Case report

Br. J. Surg. 1991, Vol. 78, December, 1467-1 468

Skin cancer: a late complication of skin tube oesophagus

6. P. Horvath, H. Bajusz and L. Borbely*

Departments of Surgery and *Stomatology, Albert Szent-Gyorgyi Medical University, 6701 Sieged, PO Box 464, Hungary Correspondence to: Dr 0. P. Horvhth

The first presternal skin tube oesophageal replacement was performed by Bircher' in 1894. Thirty years later in Hungary, Bakay' reported on the first successful operation. Until the 1950s this method was the only treatment for benign oesophageal stricture, which was relatively frequent in Hungary between the world wars. The first description3 of skin cancer developing in a skin tube was in 1957. Since that time about

additional patients. have been This report describes two Figure 1 Cancer perforating the skin ruhe oesophagus and extending

to the skin of the thorax

Case reports Case 1 A 63-year-old woman had accidentally drunk caustic soda in childhood. An oesophageal stricture ensued and she had been fed via a gastrostomy for 10 years. A skin tube oesophageal replacement was performed in several steps in 1941, and the stomach excluded. The patient could swallow well. In 1976 a stricture developed at the site of the cutaneojejunal anastomosis. The stricture was excised and a new anastomosis fashioned. Histological examination showed chronic inflammation and fibrosis with no malignancy but some signs suggestive of premalignant change. In January 1987 she was admitted in poor condition. At that time she could swallow only liquids. A large tumour extending to the skin of the thorax was seen in the upper third of the skin tube. A biopsy taken from the artificial oesophagus showed a well differentiated squamous cell carcinoma. The whole skin tube was removed and the jejunal loop resected with reconstruction by a presternal ileocolic oesophagoplasty. The stomach was reconnected in continuity with the gastrointestinal tract. The large skin defect was covered by a latissimus dorsi musculocutaneous flap. The patient recovered and was able to eat without difficulty.

Five months later lymph node metastases arose in the neck, accompanied by moderate difficulty in swallowing. Combined cytotoxic treatment with bleomycin, vincristine, rnethotrexate and mitolactol resulted in a 14-month remission. The patient died in February 1989 from tumour recurrence.

Case 2 A 75-year-old woman presented in 1989. In 1934 she had attempted suicide by ingestion of lye. She survived, but could not swallow because of oesophageal stricture. She had been fed via a gastrostomy for 21 years. In 1955 a skin tube was fashioned between the cervical oesophagus and a Roux loop which was pulled up presternally to the xyphoid process. In 1988 she began to complain of gradually increasing difficulty in swallowing. She was admitted in February 1989 with a perforated skin tumour in the middle third of the skin tube (Figure 1 ). Histological examination revealed a squamous cell carcinoma. The whole skin tube was removed and a presternal ileocolic oesophago- plasty performed.

The skin defect was covered by a latissimus dorsi musculocutaneous flap. The patient recovered and a subsequent barium swallow showed a free passage. She remained well 1 year after operation without evidence of tumour recurrence (Figure 2).

Figure 2 Acceptable cosmetic result 1 year afer oesophagoplasty and latissimus dorsi musculocutaneous.flap transposition to the presrernal area

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Case report

Discussion In the early decades of this century both intentional and accidental lye corrosion injury of the oesophagus was frequent in Hungary. At that time treatment generally consisted of dilatation of the stricture and/or gastrostomy. Only a few well qualified surgeons performed presternal skin oesophagoplasty, although they treated a considerable number of such patients'.

The interval between creation of the presternal cutaneous oesophagoplasty and the development of skin cancer is reported in the literature to be about 30-40 y e a r ~ ~ l ~ - ~ . In the cases described the intervals were 46 and 34 years. In the first patient the skin tube was partly resected 1 1 years before admission for cancer and at that time histology showed premalignant changes. This case was reported in 1981 lo. In that article seven clinical cases were described in which premalignant and malignant changes developed in the skin tube oesophagus after a lapse of several decades. It was assumed that these changes were caused by chronic inflammation due to chemical irritation of the skin by stagnant food, saliva and gastro-'neo-oesophageal' reflux.

In the surgical treatment of this malignant complication we recommend radical removal of the whole skin tube and presternal oesophagoplasty at one session. In both cases a considerable area of involved thoracic skin had to be removed. The colon was covered by a latissimus dorsi musculocutaneous flap which has an excellent blood supply and mobility, and provides a sufficient skin area. The transposition of this flap to the sternal area was successful and acceptable cosmetic results were obtained in both patients (Figure 2 ) .

In treating the recurrence in the first case a combination of bleomycin-vincristine-methotrexate-mitolactol was found to be very effective. After an early recurrence, remission was achieved for 14 months.

Although in recent years skin tube oesophagoplasty has rarely been performed, we can state that in benign cases it should be used as a last resort only when no other method is available'O~'z. This procedure allows patients to swallow only fluids and slops, with the assistance of downward massage of the anterior chest wall, an embarrassing performance in any society 3 .

Developments in plastic surgery have led to more frequent use of skin for replacing mucous areas in the mouth, the pharynx and the ~ e s o p h a g u s " ~ ' ~ . With the two cases described we

should like to call attention to the possible late malignant transformation of the skin used for mucosal replacement in the gastrointestinal tract.

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Paper accepted 27 August 1991

1468 Br. J. Surg.. Vol. 78, No. 12, December 1991