Daniel Linegar's Story

DX 7/28/98 EC adenocarcinoma, stage IIA
Transhiatal Esophagectomy - 8/17/98
Colon interposition - 1/07/99
Free flap - 1/25/99

Glendale, CA -- Hope was running out for Dan Linegar. After cancer robbed him of his esophagus, surgeons performed the standard procedure to reconstruct a swallowing tube: They pulled Linegar's stomach up and attached it where his esophagus used to be. When successful, the procedure allows esophageal cancer patients to continue eating and drinking normally.

But something went wrong in Lingear's case. For an unknown reason, the upper portion of his stomach - what doctors hoped would function as his new swallowing tube - died. Surgeons went to plan B, pulling up a portion of Linegar's right colon and reconnecting the throat and stomach. But that option, too, failed when the colon tissue also died.

For seven months Linegar, a Burbank resident, could neither eat nor drink as doctors searched for a solution to his medical crisis. A feeding tube connected directly to his lower bowel kept him alive, but in a constant state of weakness.

"It was a period of very limited energy for me", Linegar said, "just to be able to taste something, I would swish apple or orange juice around in my mouth. But, of course, I couldn't swallow it. It's amazing how much you miss being able to swallow something, even a glass of water".

A Radical Solution

Having exhausted the standard option for esophageal reconstruction. Linegar's surgeon, Sam Carvajal, M.D., turned to a colleague at Glendale Adventist Medical Center for a radical solution to the vexing problem. Norick Bogossian, M.D., is a plastic surgeon at the Medical Center with specialized training in microvascular surgery - which proved to be the key to turning around Linegar's dismal prognosis.

Using a surgically advanced technique called microvascular tissue transfer, or free flap reconstruction, Dr, Bogossian removed a 9 1/2 strip of skin-along with an underlying artery and the vein-from Linegar's left forearm, rolled it into a tube, placed it behind Linegar's sternum (breastbone) and stitched it in place. Two flaps of skin from Linegar's thighs covered the exposed tissue on his forearm. To keep the transferred tissues alive, Dr. Bogossian had to sew 2 mm artery and the vein under the operating microscope with sutures that have 1/4 thickness of human hair.

However, as instrumentation and surgical techniques became more sophisticated, plastic surgeons were able to completely remove "composite tissue" skin, muscle, bone and blood vessels and reestablish the blood supply at the transplant site, that was the true emancipation Dr. Bogossian said.

Because blood vessels are only about two millimeters in diameters-less than the diameter of angel hair pasta-surgical microscopes and specialized instrumentation had to be developed. And, along with the equipment, plastic surgeons had to learn new techniques in order to operate on a microscopic level.

There are about two dozen sources for free flaps on the human body, Dr. Bogossian said, However, less than 10 of those sources are commonly utilized for microvascular reconstruction. Plastic surgeons choose the source based upon the transplant location and function the tissue will need to perform in its new location. Some tissues, for instance, may need to be elastic and mobile, while other tissues may need to be rich in nerve endings to maintain sensation in the transplant location.

Making the Microsurgery Decision

Microvascular tissue transfer is not necessarily the best option for every case, and is often not the first choice. Plastic surgeons decide on which technique to use based on what Dr. Bogossian calls the reconstructive ladder.

The surgeon looks at the defect, then determines what is the simplest solution and least taxing for the patient. Sometimes the best solution is microvascular tissue transfer.

However, I he said, in certain situations of reconstruction, free flap transfer is not a luxury; it is, instead, the gold standard. Without the availability of microsurgical reconstruction, these particular procedures could not be done.

As in Dan Linegar's case, body parts lost to cancer are often prime candidates for microvascular tissue transfer. In addition, body parts lost from accidents or other serious trauma can often be successfully reconstructed using free flap techniques.

The first patient at Glendale Adventist Medical Center to undergo microvascular tissue transfer was a 56 year old man whose diabetes had left him with a large, infected ulcer involving his heal bone that would not respond to conventional treatment even after 3 1/2 years of treatment with antibiotics. Because there is no suitable site on the lower one-third of the leg for a local flap (the type of flap that remains partially attached), the patient was facing the prospect of having his foot amputated.

Using the microvascular tissue transfer, Dr. Bogossian was able to attach a price of abdominal muscle, along with its blood supply, to the area on the main foot that had been destroyed by the infection. The procedure was a huge success, and the man who would have had part of his leg missing is now walking on his completely healed foot.

Rewards and Challenges

Just like many advanced surgical techniques, microvascular tissue transfer has some significant advantages over other procedures, but also has limitations.

The greatest advantage of the technique is that it allows for blood vessels to be moved and reestablished. As a result of microvascular tissue transfer, the transplanted tissue typically heals faster, is more resistant to infection and looks and functions better than other alternatives, including prosthetic devices. In addition, although the initial costs of free flap surgery are higher than other alternatives, studies have shown that the faster healing time and lower rate of infection results in a lower overall cost.

However the procedure can only be performed in facilities that have an operating room microscope available, as well as the specialized instruments to perform the surgery.

Most importantly, the plastic surgeon must have training and expertise in microsurgery. A few major medical centers across the country offer six to twelve-month fellowships in microsurgery for board-eligible plastic surgeons.

Doctor Bogissian received his training in plastic surgery at Cornell University and Memorial Sloan-Kettering Hospital in New York City. He trained in microsurgery at UCLA, and completed a second fellowship in craniofacial surgery (pertaining to the bones of the face) at the University of Miami. He has been in practice for four years since completing his training.

The Sweat Taste of Success

For Dan Linegar, the results of his free flap surgery were nothing short of miraculous. He remembers well the day in the hospital when his surgeon, Dr. Sam Carvajal, brought him a glass of apple juice and watched as he drank it. That was the first drink I had in I don't know how long, Linegar said.

The next day, he enjoyed a treat from Diary Queen, and has been progressing in his ability to drink and eat solid food since then. Although his artificial esophagus is only the diameter of a thumb and there are a few other lingering issues, Linegar said the inconveniences are minor compared with the joy of being able to swallow again. It's nice to be eating again and to be free from cancer he said, and I know that a lot of the other things I'm dealing with during my recovery will go by the wayside as I progress.

Successfully completed LA Aids Walk (10K) Sept 1999

Daniel's comments: As the story states, my esophagus was uniquely reconstructed, but what is not that clear is that food now reaches my stomach by passing through my throat, the free flap, the surviving portion of my colon, and then into the surviving portion of my stomach. I was in the hospital for the majority of the time from August 17, 1998, and March 3, 1999. I returned to work part-time July 1999 and then resumed full time in February 2000.

I had a checkup with my oncologist in June 2000, and there is no sign of the cancer. Thankfully, I have not needed chemo or radiation. Even though my passageway is very restricted it hasn't caused me any problems, so I have not yet had to be dilated.

Write Dan at dlinega@sprintmail.com