Early surgical techniques for reconstruction of the cervical esophagus relied on placement of rigid stents or primary closure and were complicated by high rates of postoperative complications and mortality. Gastric pull-up procedures and pedicled colon or jejunal flaps were also described for reconstruction of the cervical esophagus; however, these procedures carried significant morbidity and mortality risks because of the need for extensive dissection in the abdomen and the chest and ischemic complications in the distal portions of the flap.

In the 1920s, Gilles and Blair popularized the use of random-patterned tubed skin flaps that were “waltzed” to the site of defect by picking up blood supply from the site of insertion. These procedures were multistaged and complicated; they commonly suffered from ischemic complications. Most patients had a controlled pharyngocutaneous fistula for 6 to 12 months, and many died prior to completion of the reconstruction. Wookey⁴⁷ improved on these techniques by describing a laterally based tubed random cervical flap that decreased the time necessary for reconstruction. Although this technique was the standard of care until the mid-1960s, its use was limited owing to a relatively small amount of available skin (particularly above the hyoid bone), high rates of wound complications and fistula formation, and poor vascular supply after radical neck dissection or radiation therapy.

In 1965, Bakamjian⁴ revolutionized cervical esophageal reconstruction when he introduced the use of the deltopectoral flap. This flap, unlike other skin flaps used earlier, was based on an axial blood supply derived from perforating vessels arising from the internal mammary vessels through the second, third, and fourth intercostal spaces. This pattern of blood supply enabled reliable flap elevation that could be extended to produce large tube flaps if a delay procedure was utilized. The deltopectoral flap had the additional advantage of a remote blood supply that was not injured by radical neck dissection or previous radiation therapy. Using these flaps, Bakamjian⁴ reported a mortality rate of less than 4% and a fistula rate of approximately 30%. Although these results represented a significant advance in esophageal reconstruction, the use of the deltopectoral flap was still less than ideal because it was a multistage procedure (at least two stages if a delay was not necessary) with a controlled salivary fistula, and because the relatively poor blood supply of the distal portions of the flap did not improve wound healing in the neck.

Musculoskeletal flaps, in particular the pectoralis major myocutaneous flap (PMMF), were the next advance in cervical esophageal reconstruction because of their improved blood supply and the potential for single-stage reconstruction immediately after resection, as described by Ariyan.^2,3 The rich blood supply of these flaps had the potential to improve wound healing in the neck and decreased fistula rates as compared with skin flaps, as noted by Ariyan³ and by Theogaraj and coworkers.⁴⁴ The excessive bulk of the PMMF (particularly in women) complicated circumferential reconstruction in some patients and led to wound healing complications at the proximal esophageal anastomosis owing to the effect of gravity, making this reconstructive technique less than ideal.

In 1907, Alexis Carrel⁷ introduced the concept of microvascular tissue transfer by transferring a segment of jejunum to the cervical esophagus in a canine model. Technical difficulties, including the lack of adequate operating microscopes and microsurgical instruments, impeded the clinical use of these techniques until 1959, when Seidenberg and associates³⁸ reported the first clinical case in which a free jejunum autograft was used to reconstruct a cervical esophageal defect in a patient with recurrent laryngeal cancer. The patient survived for 5 days but died suddenly of a cerebrovascular accident. Autopsy examination at that time, however, revealed that the flap was viable. In 1961, Roberts and Douglas³⁵ reported the first successful case in which the patient was able to resume oral feeding and swallowing after microvascular jejunal transplantation. That same year, Hiebert and Cummings²³ tubularized and transferred a segment of the gastric antrum to reconstruct the cervical esophagus and pharynx. The greater curvature of the stomach together with the greater omentum was first transferred by Baudet⁵ in 1979. This flap had the advantages of an extremely long vascular pedicle (>30 cm) and avoided the erosive complications associated with acid secretion by the transplanted gastric antrum. The sigmoid colon flap was reported by Nakayama³² and associates in 1962; however, concerns about abdominal and neck contamination kept interest in this flap relatively low.

Since the late 1970s, improvements in microsurgical techniques, instrumentation, and operating microscopes have increased the rates of success with free intestinal transfers, and these techniques have become the mainstay of cervical esophageal reconstruction. Because of the technical considerations, most centers rely primarily on the free jejunal flap for cervical esophagus reconstruction.