Free Jejunal Flap Research Articles

Neoglottic formation from posterior pharyngeal wall conserved in surgery for hypopharyngeal cancer

Objective: To describe a new treatment modality of hypopharyngeal cancer consisting of total laryngectomy plus partial pharyngectomy (TLPP) conserving the posterior wall of the pharynx vertically for voice restoration. Methods: Review of hospital charts, TLPP was undertaken in 15 of 54 patients. Surgical modalities of reconstruction subsequent to TLPP were indicated on the basis of the width of posterior pharyngeal wall conserved during surgery. Posterior pharyngeal walls of width 3 cm or larger were sutured in primary closure. If the width of posterior wall was less than 3 cm, a free forearm flap or free jejunal flap was patched to the wall. Tracheo-esophageal shunt with a voice prosthesis was performed 3 weeks after surgery. Results: The Kaplan–Meier method indicated no difference in survival rate between patients with TLPP (46.4%) and the remaining patients (47.4%). Nine of 15 patients with TLPP (two patients with primary closure, three with free forearm flap, and four with free jejunal flap) were examined for voice restoration and fluoroscopy of the neopharynx. Eight of the nine patients, in whom more than 2 cm of the posterior pharyngeal wall had been conserved, demonstrated a good speech rating, maximum phonation time and neoglottic formation by the posterior pharyngeal wall. Conclusion: The combination of conservation of the posterior pharyngeal wall, patch graft and a voice prosthesis is a useful method that offers sufficient quality of phonation without deterioration of survival rate for patients with hypopharyngeal cancer.

Behavior of free jejunal flaps after early disruption of blood supply

We describe three free jejunal flaps that lost their axial blood supply in the early postoperative period—two flaps on the 7th day and the third on the 17th day. At 7 days, reestablishment of axial blood flow was essential to flap survival, whereas after 17 days, vascularization from the recipient bed was adequate to maintain viability. Based on these observations, a conservative approach to flap salvage for cases with pedicle disruption at 17 days or later is recommended.

Viability monitor of free flaps in hypopharynx reconstruction

Single-stage microvascular reconstruction of neck defects with jejunum or other free flaps are well established methods. However, these flaps usually are buried subcutaneously and viability surveillance is difficult. Alternatively to technical monitoring devices, we present a simple method using a "sentinel" part of the free jejunum flap transposed outside to the skin surface or sutured into the skin when using fasciocutaneous or myocutaneous flaps. Although this method is not new, it is rarely used. Compared to pure technical monitoring devices, it is easily performed and monitoring of buried free flaps especially in the neck region is reliable.

Voice restoration after circumferential pharyngolaryngectomy with free jejunum repair.

Speech restoration after circumferential pharyngolaryngectomy with free jejunal repair for advanced tumors of the hypopharyngo-esophageal tract remains a difficult problem to solve. We report here the results of secondary voice restoration in six patients who received a Provox 2 type prosthesis and intensive speech therapy after circumferential pharyngolaryngectomy with free jejunum repair. No patient had operative or post-operative complications due to insertion of the prosthesis. No patient had to have the prosthesis removed during the follow-up (8 to 14 months). Analysis of some acoustic parameters of voice (fundamental frequency, waveform perturbations) and qualitative characteristics of speech (intelligibility, pleasantness and acceptability) demonstrated that all the patients were able to produce satisfactory speech after tracheojejunum puncture and speech therapy and were satisfied with their own ability to communicate. Our results are reassuring and we therefore advise that in patients undergoing free jejunum flap reconstruction of the hypopharyngo-esophageal tract voice restoration should be attempted by placing a voice prosthesis through a secondary tracheo-esophageal puncture and providing intensive speech training.

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.

Pretreatment with glycine reduces the severity of warm intestinal ischemic-reperfusion injury in the rat.

Free jejunal flaps may experience adverse effects immediately after revascularization because of ischemic-reperfusion injury. In this study the authors evaluated the ability of glycine to protect the small intestine against the effects of a warm ischemic-reperfusion injury. Male Wistar rats (N = 30) were randomized to either a baseline group (no intervention), a control group (local arterial infusion with normal saline), or a glycine group (local arterial infusion with 20% glycine). Pretreatment with 20% glycine increased significantly (p < 0.05) mucosal protein and deoxyribonucleic acid content, reduced intestinal myeloperoxidase activity, and maintained mucosal glutaminase activity. These results indicate that some of the indicators of ischemic-reperfusion injury are improved by pretreatment with a 20% glycine solution.

Microsurgical reconstruction of the esophagus

The loss or stricture of the esophagus has a tremendous impact on daily life. Before the era of microsurgery, many patients had to rely on tube feeding from jejunostomy following failure of esophageal reconstruction with conventional methods. Since the application of microsurgery, almost all kinds of esophageal defects can be reconstructed successfully with microvascular transfer of jejunum, colon, and skin flaps. Microsurgery is also used to augment the blood supply for the pedicled colon and jejunum flaps. In 97.6% of cases, successful reconstruction has been achieved. The leakage rate and functional results are evaluated for each group. For the pharynx and cervical esophagus, jejunum is the best choice. For replacement of the thoracic esophagus, a pedicled colon flap is the first choice, but it can be supercharged with microvascular anastomoses to the neck vessels if necessary. We conclude that the microsurgical transfer of jejunum, colon, and skin flaps is a useful approach for reconstruction of the esophagus. With proper selection of the organ substitute and correct inset of the flap, it not only provides anatomical replacement, but also a superior functional result. Free jejunum flap transfer requires attention to flap length and duration of ischemia. Free colon flap transfer requires attention to arteriosclerotic changes and the vascular pattern. Free skin flaps require attention to leakage prevention. Semin. Surg. Oncol. 19:235–245, 2000. © 2000 Wiley-Liss, Inc.

Bilateral jejuno-mesenteric flap for reconstruction of complicated pharyngoesophageal defect

The surgical management of an infectious and fistulous wound with a pharyngoesophageal tumor is one of the greatest challenges for head and neck and plastic surgeons. The free jejunal transfer has been the standard technique for pharyngoesophageal reconstruction, and the free omental flap has been one of the most reliable methods for reconstructing contaminated wounds. A jejuno-mesenteric flap is suitable for such complicated wounds. Pharyngoesophageal defects are reconstructed by the jejunum, and contaminated and heavily irradiated neck wounds are covered with the mesenteric flaps connected with a revascularized jejunum. The technique described here possesses the advantages of both a free jejunal flap and an omentum flap. Therefore, it is a reliable method for reconstructing the pharyngoesophageal defects of complicated wounds.

Comparative study on sensory recovery after oral cavity reconstruction by free flaps: preliminary results

Anatomical restoration was once the only goal of reconstructive surgery, but now it represents only one step in the complete functional recovery process to allow resumption of physiological activity. Soft tissue and nerves play important roles in functional recovery, but the potential of these structures is not yet well known. Rehabilitation after oral cavity reconstruction by free flaps needs an interdisciplinary diagnostic and therapeutic approach, in which neurosensory recovery of transferred tissue is an important aspect.Previous studies have used clinical assessment to evaluate sensory recovery after oral reconstruction with free flaps, but these results have been subjective and not quantifiable. The aim of the present study is to evaluate the sensory recovery using objective and standardized electrophysiological data by recording the masseter inhibitory reflexes (MIR) following mental and lingual electrical stimulation.A group of 14 patients who underwent oral cavity reconstruction by transplantation of either forearm (9) or jejunal (5) noninnervated free flaps were investigated. We found that sensory recovery of fasciocutaneous radial forearm free flaps was better than that of jejunal free flaps. This could represent the starting point for further studies about sensory recovery of reconstructed anatomical structures based on standardized and objective electrophysiological data.

Microsurgical reconstruction of the esophagus.

The loss or stricture of the esophagus has a tremendous impact on daily life. Before the era of microsurgery, many patients had to rely on tube feeding from jejunostomy following failure of esophageal reconstruction with conventional methods. Since the application of microsurgery, almost all kinds of esophageal defects can be reconstructed successfully with microvascular transfer of jejunum, colon, and skin flaps. Microsurgery is also used to augment the blood supply for the pedicled colon and jejunum flaps. In 97.6% of cases, successful reconstruction has been achieved. The leakage rate and functional results are evaluated for each group. For the pharynx and cervical esophagus, jejunum is the best choice. For replacement of the thoracic esophagus, a pedicled colon flap is the first choice, but it can be supercharged with microvascular anastomoses to the neck vessels if necessary. We conclude that the microsurgical transfer of jejunum, colon, and skin flaps is a useful approach for reconstruction of the esophagus. With proper selection of the organ substitute and correct inset of the flap, it not only provides anatomical replacement, but also a superior functional result. Free jejunum flap transfer requires attention to flap length and duration of ischemia. Free colon flap transfer requires attention to arteriosclerotic changes and the vascular pattern. Free skin flaps require attention to leakage prevention. Semin. Surg. Oncol. 19:235-245, 2000.

Failure of free flap reconstruction and its prevention

In order to determine the causative factor of microvascular free flap failure and discuss its prevention, we rewiewed 126 patients undergone head and neck reconstruction by the flaps including 67 radial forearm flaps, 26 rectus abdominis myocutaneous flaps, 22 free jejunal flaps, and 11 free colon flaps at Oita Medical University. Out of the total number, 13 flaps (10%) developed a vascular complication and total free flap necrosis occurred in 8 flaps (6.3%). The incidence of diabetes mellitus, hypertension, and previous operation of head and neck was high and they were considered to be risk factors of the free flap f alure. The comlication was due to arterial failure in five flaps and venous congestion in 8 flaps. Cause of the arteial obstruction was thought to be arteriosclerosis which is intrinsic factor of artery itself. Reexploration for the rescue of flaps was attempted, but no flap could be salvaged. The trouble on veins was caused by extrinsic factors that included hematoma and the planning of microvascular anastomosis. Abnormality of the flap was found ralatively early and 5 of 8 flaps could be salvaged. In order to prevent the free flap necrosis, therefore, it was conclued as following. (1) Changing over from a free flap to a vascular pedicled flap should be considered when severe arteriosclerosis is observed during the operation. (2) Avoiding compression of the vein by hematoma and abscess et al, and appropriate planning of microvascular anastomosis are important. (3) The reexploration is initiated as soon as posible in venous congestion.

Free jejunal patch to reconstruct oral scar contracture following caustic ingestion.

Reconstruction of oral scar contracture is often a challenging problem due to the complex structures and functions of the oral cavity. This report describes the treatment of a patient who sustained extensive oral scar contracture following caustic liquid soda ingestion. Surgical release of the scar contracture formed an S-shaped, thin, long defect that was difficult to cover with a conventional flap or skin graft. A jejunal segment was transferred microsurgically as a patch to reconstruct the defect. It sustained a sufficient oral space to provide full opening of the mouth and good movement of the tongue. A free jejunal flap, used occasionally for reconstruction following oral cancer resection, has significant advantages for restoration of function after release of an oral scar contracture.

The timing and nature of neovascularization of jejunal free flaps: an experimental study in a large animal model.

The present study was designed (1) to determine whether a free jejunal transfer in a large animal model can develop collateral circulation that is adequate to maintain viability after division of the pedicle and (2) to determine the earliest time pedicle ligation is safe after transplantation. A 15-cm jejunal segment was transferred to the necks of 18 dogs weighing 25 to 35 kg. The bowel segment was inset longitudinally under the skin on one side of the neck, partially covered by the neck muscles, and the mesenteric vessels were anastomosed to recipient vessels in the neck. The proximal and distal bowel stomas were exteriorized through skin openings 12 cm apart and matured. The dogs were subjected to ligation of the vascular pedicle at different intervals: postoperative day 7 (group I, n = 3), day 14 (group II, n = 5), day 21 (group III, n = 5), and day 28 (group IV, n = 5). Blood perfusion was measured in the proximal and distal bowel stomas before pedicle division (control) and 24 hours later using hydrogen gas clearance and fluorescein dye. Bowel necrosis was analyzed using planimetry. The bowel was also stained with hematoxylin and eosin and factor VIII, and new blood vessels were counted. Mean values (+/- standard deviation) were compared with control values for each test and with normal values in the intact bowel using analysis of variance with Neumann-Keuls post-hoc test for multiple comparisons. No jejunal free flaps survived when the vascular pedicle was divided 1 week postoperatively. Bowel survival was 60 percent at 2 weeks, 83 percent at 3 weeks, and 100 percent at 4 weeks. Hydrogen gas clearance values (ml/min/100 g) were 49.6 +/- 8.7 in the mucosa of the intraabdominal jejunum and 37.9 +/- 9.4 in the jejunum that was transferred to the neck before division of the pedicle. Twenty-four hours after pedicle division, hydrogen gas clearance values were 2.8 +/- 6.4 in group I (p < 0.05), 22.4 +/- 12.4 in group II, 23.9 +/- 9.3 in group III, and 34.2 +/- 7.5 in group IV. FluoroScan readings in the transferred jejunum were 201 +/- 7.2 in the control group, 9.3 +/- 2.8 in group I (p < 0.05), 79.1 +/- 10.6 in group II, 66.2 +/- 7.3 in group III, and 164 +/- 11.9 in group IV. New vessel formation as identified by factor VIII staining correlated with increasing bowel perfusion and flap survival rate. Bowel neovascularization, perfusion, and survival increased progressively 1 week after transfer. Significant portions of the transferred bowel will neovascularize and survive as early as 2 weeks postoperatively. However, a minimum of 4 weeks before ligation of the pedicle is necessary to maximize flap perfusion and guarantee survival.

Acute Thermal Injury to the Canine Jejunal Free Flap: Electrocautery versus Ultrasonic Dissection

Electrocautery-induced thermal injury contributes to morbidity and mortality after laparoscopic surgery. Ultrasonic dissection is an alternative technique that may produce less thermal injury. We compared the amount of acute thermal injury caused to jejunal free flaps isolated with laparoscopic electrosurgical instruments with that caused by ultrasonic dissection (laparoscopic coagulating shears). Canine jejunal free flaps were isolated by electrocautery or laparosonic coagulating shears and remained viable on a vascular pedicle. After a period of ischemia and reperfusion, the flaps were resected to simulate harvesting and reimplantation. Thermal injury was observed at the site of dissection and was graded histologically. At the margin of the jejunal free flaps, the laparosonic coagulating shears produced less thermal injury (score, 2.2 at level 3) than the electrocautery grasping forceps (score, 3.7 at 35 W and 4.1 at 70 W). The laparosconic coagulating shears produced less thermal injury to a jejunal free flap than did electrocautery. Ultrasonic dissection is an alternative to the complications produced by electrocautery during laparoscopic dissection.

Reconstruction of the hypopharynx and the cervical esophagus with free jejunal flap.

Reconstruction of the hypopharynx and the cervical esophagus with free jejunal flap.

A third decade's experience with the gastric pull-up operation for hypopharyngeal carcinoma: changing patterns of use.

Gastric transposition has been used extensively in this department since 1965 for reconstruction following pharyngolaryngoesophagectomy (PLO). A previous report by Harrison and Thompson in 1986 detailed our experience with 101 cases dating back to 1965. Here we review our experience between 1986-1996. Medical records of 41 cases were examined. The primary site and stage of tumour and associated lymph nodes, patient demographics, complications, in-patient mortality and survival as demonstrated by the Kaplan-Meier method were recorded. Gastric transposition is now used for more extensive tumours: 70 per cent T4 (83 per cent pathologically T4) compared to 21 per cent in the previous report. A high proportion of 'radiation failures' remains (54 per cent). The in-hospital mortality has fallen from 11 per cent to seven per cent. The five-year-survival calculated using the Kaplan-Meier method is 11 per cent. This procedure is increasingly being used as a palliative procedure aiming to restore swallowing in the relatively young patient who has very extensive hypopharyngeal carcinoma. Long-term survival rates specific to this operation have fallen. This is attributed to patient selection for the procedure with the vast majority having disease extending into bone, cartilage or soft tissues (T4). The defect created by the resection of less extensive tumours are now increasingly reconstructed with jejunal free flaps and musculocutaneous flaps.

Reconstructive techniques currently used following resection of hypopharyngeal carcinoma.

There is no general consensus as to the best method of reconstruction following total laryngopharyngectomy for hypopharyngeal carcinoma. The aim of this study is to attempt to establish the current practice amongst British ENT Consultants and to ascertain the reasons for their choice of reconstructive technique. An anonymous questionnaire was sent to 546 consultants in the UK and the results of 363 (66.5 per cent) were analysed. One hundred and twenty-eight (35.3 per cent) consultants replied that they performed surgery for hypopharyngeal carcinoma. Sixty-five (50.8 per cent) performed a stomach pull-up procedure, 23 (18 per cent) used a jejunal free flap, 36 (28.1 per cent) used both and four (3.1 per cent) used other techniques. In the stomach pull-up group, the main reasons given for their choice were because there was no lower resection margin (48 out of 65) and because of tradition in the way they were trained (37 out of 65). In the group using the jejunal free flap, lower morbidity (18 out of 23) and mortality (14 out of 23) were the main reasons for their choice. The questionnaire also found that amongst the 60 consultants who would consider using a jejunal free flap, the majority (39) aimed for a lower clearance margin of 2-4 cm, while 17 aimed for > 4 cm clearance. This study provides a good indication of the current practice in the UK of reconstruction following resection for hypopharyngeal carcinoma. It appears that the stomach pull-up remains the most commonly used method of reconstruction, but the jejunal free flap is becoming increasingly more popular because of its lower morbidity and mortality.

Microvascular Free Flap Outcome in Head and Neck Reconstruction

To clarify the major points of head and neck reconstruction by microvascular free flap, we reviewed the complications in 78 cases of which 34 were rectus abdominis myocutaneous flaps, 28 were radial forearm flaps, 15 were free jejunal flaps and 1 scapular osteo-cutaneous flap. The analysis about post-operative complications at the recipient site was mainly performed from the point of view of the history of previous surgery and/or radiotherapy. There were 5 cases (6.4%) with major complications which required surgical repair. Out of the 5 cases, there were 3 cases with total free flap necrosis and 2 cases with abdominal complications in relation to harvesting free jejunum. The necrosis was mainly due to the plan of microvascular anastomosis and not the relationship of previous surgery and radiotherapy. It was thought to be resolved by improvement in the skill of the microvascular surgeon. There were 28 cases (35.9%) with minor complications which did not require surgical repair. Out of the 28 cases, there were 17 cases with wound infection including fistula formation, 3 cases with partial flap necrosis, and 4 cases with fluid collection. The wound infection was found to be more frequent in cases which received radical radiotherapy over 45 Gy, than in those who received pre-operative radiotherapy around 40 Gy. Careful examination was necessary to identify any wound infections for the post-operative management of free flap reconstruction in the case with radical radiotherapy.

下咽頭癌の喉頭保存手術例 下咽頭全周切除後の遊離空腸による再建術

We developed a new method of reconstruction using a free jejunal flap after nearly total hypopharyngectomy with conservation of a functioning larynx. The free jejunum was transsected longitudinally to suppress peristalsis, and then sutured back in place. To avoid compression of the reconstructed tract by the larynx, the free jejunum was connected to one side of the pharynx after resecting the lateral half of the lamina of the thyroid cartilage. The arytenoid cartilage was fixed to the cricoid cartilage in median position after extirpation of the posterior cricoarytenoid muscle and the muscular process of the arytenoid cartilage on the affected side.The surgery described above was performed for a patient with T2 carcinoma of the piriform sinus invading the anterior and posterior walls of the post-croicoid region. Bilateral radical neck dissection was combined with this surgery. The tracheal stoma was closed three months after surgery, with no disturbance in phonation, respiration or swallowing.

Laparoscopic harvesting of jejunal free flaps for esophageal reconstruction.

Endoscopic harvest of the jejunum is indicated for the reconstruction of complex defects of the head and neck and specifically the reconstruction of circumferential defects of the esophagus. However, open laparotomies are associated with systemic and local morbidity and are often seen as prohibitively invasive procedures. Laparoscopy for intra-abdominal procedures is a proven technique that yields less morbidity and provides an anatomical exposure similar to that of the open approach. We report on 11 consecutive clinical cases of free jejunal flap harvesting with the laparoscopic technique and show that the procedure is feasible.