Reconstruction of cervical esophagus,hypopharynx and oral cavity using free jejunal transfer

Experience with 22 cases of reconstruction of the cervical esophagus, hypopharynx and oral cavity using free jejunal transfer is presented. The method requires an experienced team with high technical competence, but the benefits related to rapid single-stage completion and low morbidity certainly justify its use.     

Reconstruction of the hypopharynx and cervical esophagus with free jejunal graft with double pedicle]

Free jejunal graft autotransplantation for reconstruction of pharyngoesophageal defects was performed in 27 cases between 1983 and 1990. Of 27 cases, 26 patients who had carcinoma of hypopharynx underwent pharyngo-laryngo-cervical esophagectomy and interposition of free jejunal autograft. In one case who had a small and early-staged carcinoma of the cervical esophagus underwent resection of the cervical esophagus without laryngectomy and free jejunal autotransplantation in order to preserve the continuity of the alimentary tract. In the first 5 cases, the autografts interpositioned in the neck had single pedicle and were revascularized by one artery and vein, like the applications in the literature. Two fistulas and one necrosis were observed in these patients. In the following 22 patients a new model of free graft was applied. Jejunal graft prepared with double pedicles in abdomen was interpositioned in the neck with the microvascular anastomosis of the 4 vessels (two arteries and two veins) belonging to both pedicles. It was observed that the blood supply and vitality of the double pedicled jejunal graft was better comparing to the jejunal graft with single pedicle. Also, the feasibility of +4 degrees C continuous perfusion from the second pedicle protected the grafts from warm ischaemia. Only one case developed a fistula and no necrosis was observed in the 22 cases with double pedicled free jejunal autografts. These results suggested that application of double pedicled jejunal grafts reduces the risk of fistula and necrosis, despite the total operation time is 45-60 minutes longer.     

Reconstruction of the hypopharynx and cervical esophagus

Hypopharynx and cervical esophageal defects are challenging problems for the reconstructive surgeon. Prior surgery and radiation therapy contribute to the difficulty in managing these patients. The surgeon must possess a reconstructive algorithm that varies depending on the defect, available donor sites, and his or her experience. The free jejunal flap is the flap used for most of these defects. The radial forearm flap is reserved for partial defects measuring less than 50% of the circumference of the pharynx. The gastric pull-up is used when an intrathoracic esophagectomy is necessary. The pectoralis flap is reserved for situations when external coverage is necessary in addition to hypopharyngeal reconstruction or when a free-tissue transfer is not appropriate. Reconstruction can offer most patients successful swallowing while minimizing complications.     

Reconstruction of the cervical esophagus with a free inferior rectus abdominis flap

An inferior rectus abdominis flap was transferred in an 83-year-old female patient with a cervical esophageal carcinoma. This flap can be a good option for pharyngoesophageal reconstruction when it is desirable to avoid laparotomy and to shorten the operating time in an elderly or high-risk patient.     

Intussusception of a transferred jejunal flap in cervical esophagus reconstruction

Although jejunal flaps have been used frequently for esophageal reconstruction, and the techniques for transfer, as well as subsequent modification, have been well described, a variety of complications still poses problems for both physicians and patients. The challenge exists in avoidance and management of complications. The purpose of this report is to present an unusual but severe complication involving a jejunal flap that was transferred to the neck for esophageal reconstruction. Intussusception of the jejunal flap occurred 1 year after flap transfer due to redundancy of the transferred segment. The patient was a child who had esophageal reconstruction for severe dysphagia that was due to a previous history of radiation injury. The disorder was successfully treated surgically with manual reduction of the intussuscepted segment, followed by shortening of the jejunal flap to prevent future recurrence. One should keep in mind that redundancy of the reconstructed esophagus may cause dysphagia due to kinking or, in this case, intussusception, which may result in necrosis of a segment of the transferred jejunum. One of the measures that should be taken during the initial reconstruction to prevent these serious complications is to perform the final inset of the jejunal flap after revascularization. This allows for proper assessment of jejunal length, which undergoes a significant change after restoration of the vascular supply.     

Reconstruction after total circular pharyngolaryngectomy: comparison between gastric interposition and free jejunal flap

AIM OF THE STUDY: To elucidate hospital mortality, morbidity and actuarial survival rates of patients with carcinoma of the hypopharynx and cervical oesophagus and to identify the technique of choice for reconstruction after pharyngolaryngectomy. PATIENTS AND METHODS: We reviewed the records of 209 patients who underwent total pharyngolaryngectomy between May 1982 and January 2000. The majority of patients had advanced cancer: hypopharyngeal in 131 cases and cervical oesophageal in 78 cases. Follow-up was complete for all patients. Chi 2 and log rank tests were used, with a limit of significance of 5%. RESULTS: The postoperative mortality and morbidity rates were 4.8% and 38.3%, respectively. Alimentary continuity was achieved using the stomach (127 patients), colon (5 patients), or free jejunal autograft (77 patients). The 1-year and 5-year survival rates were 62% and 24%, respectively. There was no significant difference with regard to the survival between gastric transposition and free jejunal autograft, but there were fewer complications in the gastric pull-up group with regard to the respiratory complications (33% vs 47.0%, p < 0.05), local recurrences (15.8% vs 33.8%, p = 0.004) and survival without dysphagia (76% vs 89%, p < 10(-5)). CONCLUSION: Surgical ablation is a viable option for advanced hypopharyngeal and cervical oesophageal neoplasms, and stomach interposition is the preferred method of reconstruction.     

Tumor of the hypopharynx: free jejunal transfer with conservation of the larynx: a case report

Resection of the hypopharynx or cervical esophagus for malignancy is always quite mutilating if reconstruction cannot be achieved with a one-stage procedure. Several techniques have been described, but they are often associated with laryngectomy. In the case reported, a free split jejunal segment transfer allowed reconstruction of the hypopharynx without laryngectomy, as the malignancy did not involve the larynx.     

Reconstruction of late esophagus perforation after anterior cervical spine fusion with an adipofascial anterolateral thigh free flap: A case report

Reconstruction of late esophageal perforation usually requires flap surgery to achieve wound healing. However, restoring the continuity between the digestive tract and retropharyngeal space to allow for normal swallowing remains a technical challenge. In this report, we describe the use of a thin and pliable free adipofascial anterolateral thigh (ALT) flap in a 47‐year‐old tetraplegic man with a history of C5–C6 fracture presented with a large posterior esophagus wall perforation allowing an easier flap insetting for a successful wound closure. The postoperative course was uneventful and mucosalization of the flap was confirmed by esophagoscopy 4 weeks postsurgery. The patient tolerated normal diet and maintained normal swallowing during a follow‐up of 3 years postoperatively. The adipofascial ALT flap may provide easier insetting due to the thin and pliable layer of adipofascial tissue for reconstructing large defects of the posterior wall of the esophagus by filling the retroesophageal space.     

Reconstruction after cervical esophagectomy using a free jejunal graft

Reconstruction after cervical esophagectomy using a free jejunal graft and forming an additional "vocal canal" are described. It is necessary to pay attention to several points, for example, selection of the jejunal graft, selection of the cervical vessels for anastomosis, technique of hypopharyngeal-jejunal anastomosis, and postoperative management of the anastomotic vessels. These contribute to the improvement of patient quality of life. Forming an additional "vocal canal" in patients who underwent radical surgery is particularly desirable. In this article, we introduce our operative method.     

Reconstruction of the large scalp defect by free flap transplantation

The reconstruction of a large scalp defect is extremely difficult on many occasions and repeated operations or a long-term hospitalization is often required. In addition, unsatisfactory results are not unusual. However, it is now possible to perform reconstruction by a one-stage operation of free tissue transplantation (free flap) using microsurgical vascular anastomosis which has rapidly developed in the past ten years. We performed reconstructions applying latissimus dorsi musculocutaneous, greater omentum, groin and scapular flaps. The advantages with the free flap are: (1) one-stage reconstruction is possible; (2) no restrictions on the postoperative position, (3) the flap, which is independent of the blood supply from the recipient, well survives on the recipient with an insufficient blood supply and (4) the damage at the donor site can be minimized. On the other hand, its disadvantages are as follows: (1) the operation requires microsurgical vascular anastomoses; and (2) recipient vessels should be normal. The above report was based on favorable results we obtained in 6 cases of reconstruction with free flap applying microvascular techniques.     

Cancer of the hypopharynx and cervical esophagus

Between 1975 and 1988 we observed 169 patients with carcinoma of the cervical esophagus, 85 with a carcinoma involving the hypopharynx and the cervical esophagus, and 27 patients with a carcinoma of the cervical esophageal region arising after laryngectomy for laryngeal cancer. The mean age was 57.5 years (range 41-73). 167 patients underwent surgical exploration (operability rate 59.5%) and in 152 cases the tumor was resected (resectability rate 91.1%). The resection was complete in 129 patients (84.5%) and palliative in 23 (14.5%). In 33 cases a segmental laryngo-pharyngo-cervical esophagectomy with free intestinal loop transplantation was performed with an operative mortality of 6.1%. 101 patients underwent total laryngo-pharyngo esophagectomy and the gastrointestinal tract was reconstructed by means of pharyngo-gastrostomy and pharyngo-colostomy in 85 and 16 cases, with an operative mortality of 12.9% and 18.3%, respectively. Total esophagectomy without laryngectomy was performed in 18 patients with a carcinoma of the distal cervical esophagus refusing laryngectomy with a hospital mortality of 5.5%. The overall 5-year actuarial survival, excluding the operative mortality, was 15.8%. After complete resection, better results were recorded with patients operated for carcinoma of the hypopharynx than with patients with carcinoma of the cervical esophagus: the 2-year and 5-year actuarial survival was 59% vs 26% and 43% vs 17%, respectively. No patient undergoing palliative resection was alive at the 3-year interval.(ABSTRACT TRUNCATED AT 250 WORDS)     

Reconstruction of the hypopharynx and cervical esophagus with bilateral pectoralis major myocutaneous flaps

A patient is presented in whom bilateral pectoralis major myocutaneous flaps, one of which was lined by a split-thickness graft, were used in the total reconstruction of the hypopharynx.     

Patch esophagoplasty with a free proximal lateral leg flap for focal stricture of the cervical esophagus: A case report

Esophageal stricture after surgery or trauma is a major reason for poor oral nutrition, body‐weight loss, and general damage to health. Patch esophagoplasty, after repeated failed dilation attempts, is recommended for focal esophageal strictures. In this report, we present a case in which a free proximal lateral leg flap was used for reconstruction of focal stricture of the cervical esophagus. A 62‐year‐old man developed progressive dysphagia after hypopharyngeal cancer ablation and adjuvant radiotherapy. He was referred for surgical interventions after repeated failed dilation attempts. Preoperative evaluation revealed a 3‐cm segment stricture of the cervical esophagus without evidence of an additional distal stricture. Patch esophagoplasty with free tissue transfer was planned. After the stricture site had been explored, the fibrotic tissue was resected. A pathology report confirmed no evidence of malignancy. The resultant defect in an otherwise healthy posterior esophageal wall was reconstructed using a proximal lateral leg flap. Recovery was uneventful and the functional outcome was satisfactory at the 6‐month follow‐up. For the radiated patients with cervical esophageal focal strictures, we introduced a novel use of the proximal lateral leg flap in patch esophagoplasty because of its unnoticeable donor site morbidity and its thin and pliable nature. © 2016 Wiley Periodicals, Inc. Microsurgery 37:426–430, 2017.     

Reconstruction of the cervical part of the esophagus using a free revascularized segment of the jejunum and microsurgical technic

The article analyses the experience in 11 reconstructions of the pharynx and cervical esophagus with a free vascularized jejunal segment employing microsurgical technique for squamous cell carcinoma of the upper digestive tract. The operative technique is described. It is noted that this operative procedure is a difficult method of surgical management of defects in the pharynx and cervical esophagus and is attended in some cases with complications. From personal experience and review of the literature, the authors conclude that autotransplantation of a free vascularized jejunal segment with the use of microsurgical technique is the best method for reconstruction of defects in the pharynx and cervical esophagus.     

游离空肠修复下咽及颈段食管肿瘤切除后组织缺损的临床分析

目的探讨游离空肠修复下咽及颈段食管肿瘤切除术后组织缺损的方法和疗效。方法对1984年9月至2004年8月收治的51例下咽、颈段食管癌及喉癌复发患者以游离空肠修复肿瘤切除术后下咽及颈段食管组织缺损的临床资料进行回顾性分析。结果51例患者中,5例游离空肠修复术后出现游离空肠坏死,46例（90％）成功修复组织缺损。修复术后1年生存率为62％,3年生存率为48％。影响预后的因素有：（1）肿瘤切除切口边缘（切缘）情况：阴性切缘患者1年生存率为75％,3年生存率为58％;阳性切缘患者的1年生存率为34％,3年生存率为0。两者比较,差异均有统计学意义（P〈0.01）。（2）肿瘤外侵情况：无甲状腺、皮肤、椎前组织、颈总动脉受侵（包括喉、气管、口咽受侵）34例,1年生存率为70％,3年生存率为42％;有甲状腺和（或）皮肤和（或）椎前组织和（或）颈总动脉受侵17例,1年生存率为44％,3年生存率为29％,两者比较,差异均有统计学意义（P〈0．05）。放疗与否、肿瘤细胞分化类型对预后的影响,差异无统计学意义。5例术后出现游离空肠坏死的患者中,1例感染死亡,其余无严重并发症。结论以游离空肠修复下咽及颈段食管部位肿瘤切除术所致缺损,并发症较少,切缘阴性及无甲状腺、皮肤、椎前组织、颈总动脉受侵患者的1年、3年生存率较高;改善了患者的进食状况;对能保证切缘阴性、肿瘤切除局部及颈部淋巴结无明显外侵的患者,可应用游离空肠修复。     

Reconstruction of cervical esophagus by using laparoscopically assisted jejunal loop harvesting and microsurgical transfer

For segmental cervical esophageal reconstruction, the free transfer of jejunal flap tends to become a standard procedure. Graft harvesting by laparotomy presumes increased morbidity at donor area level. There was described by now in the literature laparoscopic techniques for harvesting of jejunal graft, which have reduced the complications following laparotomy. We wish to present here an experimental model of laparoscopically assisted harvesting of jejunal flap used for reconstruction of cervical esophagus by free transfer. The harvesting of jejunal segment was achieved in 12 dogs; 4 cases subsequently underwent microsurgical free transfer. There are presented original contributions of authors. The harvesting average time was 115 minutes; the meantime graft ischaemia was 48 minutes in 4 cases with microsurgical transfer. Postoperative survival was 100%. Graft viability was achieved in 75% at 12 hours and 50% at 24 hours. No major operative accidents were recorded. We present a standardized experimental model, which could be an usefull guide in human therapeutics.