Secondary reconstruction of failed esophageal reconstruction

Between June 1992 and November 2002, 17 patients underwent secondary reconstruction of circumferential esophageal defects due to the failure of immediate reconstruction following ablation of thoracic esophageal cancer. Salvage reconstruction was achieved using free jejunal transfer in 13 patients (including long segment with double vascular pedicle in 2 cases), skin and/or musculocutaneous flap in 2 cases, and jejunal pull-up in 2 cases. In 5 patients, the second salvage surgery was required because of the failed first salvage. However, successful restoration of the esophagus and peroral alimentation was finally achieved in 16 of 17 patients, except 1 patient with several salvage operations using skin and musculocutaneous flap because the gut was unusable. We concluded that the preferred first choice for salvage restoration is free jejunal transfer. If the length of the esophageal defect is extensive, colonic interposition or jejunal pedicle with microvascular anastomosis for supercharging is the next option. If these procedures cannot be used, the transfer of a long jejunal segment with double vascular pedicles is recommended. Reconstruction using skin and/or musculocutaneous flap is the final option. As primary wound closure is often difficult in secondary reconstruction of the esophagus, a pectoralis major musculocutaneous flap is reliable to cover the reconstructed esophagus because skin flaps located in the neck region may be damaged by neck dissection or irradiation, and coverage of the anastomosis with muscle between the digestive tracts is effective to prevent leakage.     

Total reconstruction of the hypopharynx and cervical esophagus: a 20-year experience.

We have reviewed 145 patients who underwent 148 total reconstructions of the hypopharynx and cervical esophagus between 1970 and 1989. The types and numbers of reconstruction included 45 deltopectoral (DP) flaps, 35 musculocutaneous (MC) flaps, 19 colon interpositions, 23 gastric transpositions, and 26 free jejunal transfers. Median hospitalization was 51 days for DP flaps, 24 days for MC flaps, 28 days for colon, 30 days for gastric, and 14 days for jejunum. Median resumption of oral intake was 92 days for DP flaps, 19 days for MC flaps, 12 days for colon, 13 days for gastric, and 9 days for jejunum. Functional failure, defined as the inability to maintain adequate nutrition without tube feedings, was 40% for MC flaps, 42% for colon interposition, 17% for gastric transposition, and 20% for free jejunal transfer. Microvascular free jejunal transfer has become our method of choice for reconstruction of the hypopharynx and cervical esophagus. Gastric transposition is an alternative when resection of the thoracic esophagus is necessary.     

Free flaps for type III complex pharyngoesophageal defects after enlarged ablative surgery for advanced cancer of larynx and hypopharynx

Free tissue transfer has become a useful technique for reconstruction of type III complex pharyngoesophageal defects after enlarged laryngectomy and partial or total pharyngoesophageal resection. We present a retrospective analysis of our experience with 36 patients who received free flaps for reconstruction of complex pharyngoesophageal defects associated with skin and soft-tissue defects. Free fasciocutaneous flaps and jejunum combined with a deltopectoral flap and musculocutaneous pectoralis major flap, gastro-omental flap, and combined latissimus dorsi musculocutaneous and cutaneous scapular flaps were used for reconstruction. Adjuvant therapy included preoperative or postoperative radiotherapy. Free flap failure occurred in 2 of 36 patients. Twenty-eight patients had good swallowing function. Better results with fewer complications in reconstruction of type III complex pharyngoesophageal defects were obtained with the use of a combined latissimus dorsi and scapular flap.     

Free jejunal graft reconstruction after resection of neck cancers: Our surgical technique

Locally advanced carcinomas arising in the hypopharynx, cervical esophagus, or thyroid are traditionally treated by resection of the hypopharynx and cervical esophagus. Various methods of reconstruction aiming to achieve safety and functionality have been reported, including the myocutaneous flap and the free jejunal graft. With advances in microscopic surgery, the free jejunal transplant is now used dominantly; however, this procedure is not without major risks. In this review we examine the short- and long-term complications of this procedure. We also describe our technique of free jejunal graft reconstruction after pharyngoesophagectomy and total laryngectomy with definitive tracheostomy. We used free jejunal graft reconstruction after resection with hypopharyngeal cancer or thyroid cancers in 22 patients. Twenty-one of these patients acquired a good quality of life, but one died after loss of the jejunal graft. Thus, using a free jejunal graft for reconstruction of the hypopharynx or cervical esophagus can be very useful in improving the quality of life of patients.     

Does a vascular supercharge improve the clinical outcome for free jejunal transfer?

To clarify whether a supercharged free jejunal transfer would have a different clinical outcome from the usual transfer method, we examined clinical data from cases of esophago‐pharyngeal reconstruction. Fifty‐three patients in whom the hypopharynx and cervical esophagus was reconstructed with a free jejunal transfer were divided into two groups: 19 normal procedures and 34 supercharged. Clinical outcomes including intraoperative and postoperative events, complications and deglutition were compared statistically. There were no significant differences between the groups in terms of the rates of free flap failure, leakage, stenosis, drinking status, dysphagia, or operating time. There were no significant advantages in clinical outcomes when using a supercharge. However, supercharged flaps with an intraoperative arterial thrombosis were all rescued and survived. Thus, a supercharge in free flap is not necessary for all cases. Its indication should be limited to cases when free flaps are not reliable because of intraoperative thrombosis and arterial insufficiency. © 2012 Wiley Periodicals, Inc. Microsurgery, 2013.     

Comparative Evaluation in Pharyngo-oesophageal Reconstruction: Radial Forearm Flap compared with Jejunal Flap. A 10-year experience

We reviewed 109 consecutive patients with cancer of the hypopharynx or cervical oesophagus who underwent free flap transfer for immediate reconstruction after total pharyngolaryngo-oesophag-ectomy. The free flaps used were either free jejunal (n = 70) or radial forearm flaps (n = 39). Significantly more fistulas (3/70 compared with 15/39, p < 0.0001) and strictures (6/64 compared with 13/33, p = 0.0008) developed in the radial forearm than the jejunal flap group. However, functional donor site morbidity was minimal and there were no cases of total flap necrosis in the forearm flap group. We consider that the free jejunal flap should be the first choice for total reconstruction of pharyngo-oesophageal defects. However, the forearm flap is suitable for elderly, high risk patients, because it is less invasive and has minimal donor site morbidity, which facilitates early recovery.     

Use of the internal mammary vessels as recipient vessels for an omental flap in head and neck reconstruction

The availability of reliable recipient vessels for free flap transfer in head and neck reconstruction may be limited in cases of prior neck dissection or radiation therapy. One solution is to use the internal mammary vessels as recipients for a free omental flap. Five patients were treated with free omental flap transfer using the internal mammary vessels as recipient vessels during head and neck reconstruction. Two patients presented with a pharyngocutaneous fistula, 1 had mandibular osteomyelitis, 1 had primary esophageal cancer, and 1 had bilateral cervical radiation ulcers. All patients had received radiation therapy previously (average dose, 75.4 Gy), and 4 had undergone neck dissection (3 bilateral and 1 ipsilateral). All patients were reconstructed using a free omental flap. Four patients had a second free flap combined with the free omental flap (3 free jejunal flaps and 1 free fibular osteocutaneous flap). The mean follow-up was 26.4 months. All free flaps took entirely, the only complication ileus requiring reoperation in 1 patient. The internal mammary vessels are reliable recipient vessels for a free omental flap in head and neck reconstruction. This procedure is a good option for patients in whom previous surgery or radiation therapy has compromised local recipient vessels.     

Double vascular pedicled free jejunum transfer for total esophageal reconstruction

A double vascular pedicled free jejunum was transferred in two patients with complete esophageal defect. When the stomach and colon, which are usually employed for esophageal reconstruction, cannot be used due to previous operations or for other reasons, the jejunum is the next alternative. However, pedicled jejunal transposition is limited in length and may not reach a suitable level over the lower cervical esophagus, even if the distal portion is supercharged. Under such circumstances, a long jejunal segment with two vascular pedicles can be transferred as a free flap and used to reconstruct the whole esophagus in one stage. The paper describes two cases and discusses the advantages of double vascular pedicled free jejunum transfer.     

小腿肿瘤保肢术皮肤缺损的修复

目的：比较游离皮瓣和局部皮瓣转移对于肢体肿瘤保肢术中皮缺损修复的安全性。方法：1995年9月-1999年10月，分别用游离皮瓣移植和局部皮瓣转移修复15例小腿恶性骨肿瘤和软组织肿瘤保肢术后形成的皮缺损，9例游离皮瓣移植，6例局部旋转皮瓣。结果：游离皮瓣移植切口均一期愈合，无感染，皮瓣坏死，化疗对游离皮瓣成活无影响。6例局部皮瓣3例在术后5d出现皮瓣循环障碍，皮瓣坏死，伤口开裂，灭活的肿瘤骨外露。结论：小腿肿瘤保肢治疗中，采用局部皮瓣安全性较差。带血管蒂皮瓣游离移植是小腿肿瘤保肢术修复皮肤缺损的理想方法。     

Free jejunal flaps can be monitored by use of microdialysis

When new combinations of preoperative treatments of carcinoma of the esophagus are implemented, surgical morbidity and mortality become even more important risk factors. This study investigated whether the risk of postoperative complications caused by ischemia in the reconstructed esophagus can be reduced using microdialysis as monitoring method. This is a retrospective study of 14 patients undergoing resection of carcinoma in the upper part of the esophagus and reconstruction with a free jejunal flap. The metabolism in all 14 jejunal transfers was monitored by use of microdialysis. The data were analyzed looking for reliable parameters detecting critical ischemia. Critical ischemia was suspected in two cases. Both of these cases were surgically revised, ischemia in the jejunal flap was verified, and the jejunal flaps were revascularized. All 14 jejunal flaps survived. Using the concentration of glucose in the microdialysate, it was possible to detect the two cases of critical ischemia. Yet, the most reliable parameter seemed to be the retrospectively calculated lactate:glucose ratio; in both the ischemic flaps, the lactate:glucose ratio exceeded more than 1000% the maximum values found in all the nonischemic flaps. Microdialysis is a promising monitoring method for surveillance of free jejunal flaps.     

An effective pharyngoesophageal reconstruction with free radial forearm flaps

Summary Treatment of cancer of the cervical aerodigestive tract is challenging due in part to the difficulty in reestablishment of pharyngoesophageal continuity after resection of the involved tract. From May 1989 to August 1990, six patients underwent immediate reconstruction utilizing microvascular transfer of free radial forearm flaps following resection of pharyngoesophageal neoplasms. A small island flap connected to the radial vascular pedicle by fasciocutaneous branch was used to monitor the vascular condition of the hidden fabricated free forearm flap. Stricture is the most troublesome complication of esophageal reconstruction using a conventional free forearm flap. Two small triangular flaps were designed and inserted bilaterally in the distal anastomosis of both lateral esophageal walls to prevent circular contracture. The outer layer sutures were anchored to surrounding rigid structures to withstand shrinkage and circular contraction. The problem of stricture was solved by these procedures. This one-stage, easily monitored operation for pharyngoesophageal reconstruction is considered to be as useful as a free jejunal transfer.     

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.     

The role of fabricated chimeric free flaps in reconstruction of devastating hand and forearm injuries

Devastating hand and forearm injuries almost exclusively need free flap transfer if reconstruction is attempted. Early active and passive motion is only possible with aggressive, early, and comprehensive reconstruction. Despite recent advances in compound flaps, in selected cases it might be wise to harvest several smaller flaps and microsurgically combine them to one "chain-linked" flap "system." Four microsurgically fabricated chimeric free flaps were used in four patients for complex hand and forearm injuries. The combinations were sensate anterolateral thigh (ALT) flap plus sensate extended lateral arm flap (2x), ALT plus free fibula, and ALT plus functional musculocutaneous gracilis muscle. All flaps survived completely. Functional rehabilitation was possible immediately after flap transfer. There were no donor-site complications except two widened scars. The microsurgical fabrication of chimeric free flaps, as well established in head and neck reconstruction, can be successfully adapted to massive hand injuries as well. Individual placement of selected tissue components, early comprehensive reconstruction, and reduction of the number of operations are beneficial in cases that need more than one free flap.     

Anterolateral thigh flap: ideal free flap choice for lower extremity soft-tissue reconstruction

This article presents the authors' experience with the anterolateral thigh free flap for lower extremity reconstruction. Twenty-one consecutive anterolateral thigh flaps were transferred for reconstruction of soft-tissue defects of the lower extremity from March 2000 to May 2002. Total flap survival was 90.5 percent, with two partial failures. Venous congestion was observed in one flap (4.7 percent) and the venous anastomosis was revised immediately in the postoperative second hour. The mean follow-up time was 13.4 months (range: 5 to 26 months). The cutaneous perforators were consistently found and presented as musculocutaneous in 19 patients (90.5 percent) or septocutaneous in two other patients (9.5 percent). A thinned anterolateral thigh flap was used in 11 patients. Sensate flaps were used in four patients (19.05 percent) for the reconstruction of amputation stumps. Five flaps (23.8 percent) were used also as flow-through flaps. All patients were satisfied with the cosmetic and functional results. The anterolateral thigh flap has many advantages over other free flap donors in lower extremity reconstruction. These include a long and large caliber vascular pedicle, large and pliable skin paddle, good color and texture matching, and minimal donor-site morbidity. Moreover, the flap can be used successfully and safely as a sensate, thin, or flow-through flap. The anterolateral thigh flap can be accepted as an ideal free flap choice for lower extremity reconstruction because it has maximal reconstructive capacity and produces minimal donor-site morbidity.     

Head and neck reconstruction with the deep inferior epigastric perforator flap: A report of two cases

Rectus abdominis musculocutaneous (RAMC) free flaps are preferred for head and neck reconstruction because of the abundant blood supply to the rectus abdominis musculocutaneous. In contrast, the indications for deep inferior epigastric perforator (DIEP) free flaps in head and neck reconstruction are limited. In this report, two cases of oral cavity reconstruction with DIEP free flaps are described. In both cases, the defect was reconstructed with a DIEP free flap because it could avoid functional damage to the donor site. Successful reconstruction with a two skin‐island method was performed in both patients. Furthermore, donor site morbidity was minimal in both patients. When a DIEP free flap is used for head and neck reconstruction, elimination of dead space is the most difficult problem, because a DIEP free flap does not contain well‐vascularized muscle tissue. We compensate for this disadvantage with a flap designed to include a de‐epithelialized skin flap. Although this technique is not always the first choice for head and neck reconstruction, it is suitable for patients who wish to avoid donor site morbidity. © 2009 Wiley‐Liss, Inc. Microsurgery, 2009.     

A two-stage operation for thoracic esophageal cancer: esophagectomy and subsequent reconstruction by a free jejunal flap

When the stomach is unavailable for esophageal reconstruction due to previous gastrectomy or synchronous gastric cancer, a pedicled jejunum or colon, with or without vascular supercharge, has been the alternative. However, these reconstructions are not free from severe complications, such as necrosis. We have introduced a new surgical technique for delayed esophageal reconstruction using a free jejunal flap. We used this technique in 11 patients. Four weeks after subtotal esophagectomy, reconstruction using free jejunal flaps was performed. A free jejunum was placed at the pre-sternum, and the internal thoracic artery and vein were usually used as the recipient vessels. There were no cases of flap necrosis and no hospital deaths. Anastomotic leakage occurred in two cases. Both leakages were cured by conservative treatment. Delayed esophageal reconstruction using a free jejunal flap can be considered to be a safe procedure when the stomach is unavailable as an esophageal substitute.     

Total penile and urethral reconstruction with an expanded sensate lateral arm flap: case report

The use of cutaneous or musculocutaneous flaps for total phalloplasty requires the lack of hairy skin; otherwise urethral strictures most likely will occur. A case of simultaneous total penile and urethral reconstruction using an expanded lateral arm sensory free flap is presented. The use of an expander in a small area of hairless skin on the lateral arm results in a free flap of sufficient size. This procedure proves to be a useful addition to the reconstructive armamentarium in dealing with similar challenging cases of penile reconstruction.     

One-segment double vascular pedicled free jejunum transfer for the reconstruction of pharyngoesophageal defects

The reported success rates of free jejunal transfer are over 95%, but in cases of postoperative vascular thrombosis, the salvage of jejunal flap is often difficult because of poor ischemic tolerance of the jejunum. To reduce the incidence of jejunal necrosis due to vascular thrombosis to nearly zero, we employed one-segment double vascular pedicled free jejunal transfer. Different from conventional double pedicled free jejunal transfer (transfer of the two jejunal segments by anastomosing two pairs of jejunal root vessels), the arcade vessels are used as an additional feeder after the routine anastomosis of jejunal root vessels in our method. Between December 2004 and January 2006, 20 patients with laryngeal, pharyngeal, or cervical esophageal cancer underwent free jejunal transfer using this method. In all patients, the jejunal flap survived completely without any complication associated with vascular anastomosis or blood circulation of the flap. The disadvantage of this procedure is the approximately 1-hour prolonged operative time. Although we have experienced only 20 cases and not obtained statistically significant validity of this method compared with conventional one, we believe that the concept of our method is one of the help for safer pharyngoesophageal reconstruction, especially in patients with higher risk of vascular thrombosis.     

Foot and ankle reconstruction: An experience on the use of 14 different flaps in 226 cases

The aim of this report was to present our experience on the use of different flaps for soft tissue reconstruction of the foot and ankle. From 2007 to 2012, the soft tissue defects of traumatic injuries of the foot and ankle were reconstructed using 14 different flaps in 226 cases (162 male and 64 female). There were 62 pedicled flaps and 164 free flaps used in reconstruction. The pedicled flaps included sural flap, saphenous flap, dorsal pedal neurocutaneous flap, pedicled peroneal artery perforator flap, pedicled tibial artery perforator flap, and medial plantar flap. The free flaps were latissimus musculocutaneous flap, anterolateral thigh musculocutaneous flap, groin flap, lateral arm flap, anterolateral thigh perforator flap, peroneal artery perforator flap, thoracdorsal artery perforator flap, medial arm perforator flap. The sensory nerve coaptation was not performed for all of flaps. One hundred and ninety‐four cases were combined with open fractures. One hundred and sixty‐two cases had tendon. Among 164 free flaps, 8 flaps were completely lost, in which the defects were managed by the secondary procedures. Among the 57 flaps for plantar foot coverage (25 pedicled flaps and 32 free flaps), ulcers were developed in 5 pedicled flaps and 6 free flaps after weight bearing, and infection was found in 14 flaps. The donor site complications were seen in 3 cases with the free anterolateral thigh perforator flap transfer. All of limbs were preserved and the patients regained walking and daily activities. All of patients except for one regained protective sensation from 3 to 12 months postoperatively. Our experience showed that the sural flap and saphenous flap could be good options for the coverage of the defects at malleolus, dorsal hindfoot and midfoot. Plantar foot, forefoot and large size defects could be reconstructed with free anterolateral thigh perforator flap. For the infected wounds with dead spce, the free latissimus dorsi musculocutaneous flap remained to be the optimal choice. © 2013 Wiley Periodicals, Inc. Microsurgery 33:600–604, 2013.     

Twelve-year experience in mandibular reconstruction using osteo-muscular dorsal scapular pedicled flaps

Primary mandibular reconstruction after tumor removal or osteoradionecrosis treatment is a standard procedure. The most common reconstruction techniques are fibula, scapula, and iliac crest free flaps. Nevertheless, all patients are not eligible for microsurgery.In this study, we assess 12 years of mandibular reconstruction using an osteo-muscular dorsal scapular pedicled flap (OMDS). We included 40 patients operated on using an OMDS flap. We collected parameters such as length of hospital stay, recurrence risk, and need for secondary flap for oral cutaneous fistula (OCF) treatment. Flap bone volume was assessed by segmenting the scapula on postoperative CT-scans using dedicated software.Forty patients were included. Indications for OMDS flaps were severe cardiovascular history (27%), preoperative radiotherapy with a radiation neck and potentially unreliable blood vessel sutures (20%), previous fibula free flap failure (15%), and patient refusing free tissue transfer (8%). Aside from these medical indications, OMDS flaps were performed in 30% of cases due to organizational concerns. The mean flap length was 73±16 mm, with a maximum of 109 mm. Flap bone volume was stable over time, with negligible resorption (p = 0.761). Secondary pedicled flaps were used to treat OCF in 5 patients (12%). Secondary esthetic procedures were performed in 9 patients (22%). None of the 40 flaps were removed. None of the patients had long-term scarring complications in donor sites.OMDS flaps merit consideration for mandibular reconstruction when free tissue transfer is contraindicated or impossible due to organizational issues.