Reply

Abstract

Sir:FigureWe thank the authors for their article entitled “The Use of Jejunal Mesentery to Provide Additional Soft-Tissue Coverage in Esophageal Reconstruction with a Free Jejunal Flap: The Mesenteric Wrap.” We are pleased that our work has stimulated conversation and action by other units in preventing the potentially catastrophic event of an orocutaneous fistula. We would like to respond to a handful of comments Drs. Pennington et al. have made. We agree that preventing orocutaneous fistulas is an integral part of esophageal reconstruction and also ensures minimal donor-site morbidity. It is encouraging in their small series that there have not been any complications; however, we have been made aware recently of other surgeons who have used the mesenteric wrap in cases in which a small fistula has developed. The idea is clever, but we have reservations about the practicality. Our experience is that the mesentery (unlike the omentum) is not a straightforward sheet and is not extensive or robust, as is highlighted in the intraoperative photograph in the authors' article where the proximal anastomosis wrap appears very thin. Also, harvest of a long segment of jejunum would be necessary and would require quite careful planning, which the authors admit. Our concern would be getting the entire circumference of both anastomoses covered with the wrap. A key limitation is that the mesentery occurs in loops based on the vascular pedicle such that it does not necessarily unfold in the manner that the diagrammatic drawing suggests. We consider that it is a useful concept to consider, but it is unlikely that one could rely on it routinely. We consider that a principal reason for our small fistula rate is the use of the CEEA stapler (Covidien, Mansfield, Mass.); we had no leaks in 48 anastomoses. In fact, as a result of our review, even if the patient has been exposed to preoperative radiotherapy, we consider not harvesting a pectoralis major flap if both anastomoses are stapled. We thank Dr. Pennington and St. Vincent's Hospital for their constructive comments and the addition to the techniques available for reducing orocutaneous fistulas, and we look forward to further publication of their work in the coming years. Pouria Moradi, F.R.A.C.S.(Plast.), M.R.C.S.(Eng.) Simon H. Wood, F.R.C.S. Peter Clarke, F.R.C.S. Operative Unit of Plastic and Reconstructive Surgery, Charing Cross Hospital, London, United Kingdom