Free Jejunal Transfer Research Articles

Salvage total pharyngolaryngectomy and free jejunum transfer

The objective of this retrospective study was to examine the safety and efficacy of free jejunum transfer after total pharyngolaryngectomy after radiotherapy (RT) or chemoradiotherapy (CRT) to the neck for patients with recurrent or second primary disease. Retrospective study. A total of 313 patients were divided into two groups on the basis of a history of RT to the neck: 86 patients had received RT and 227 patients had not. The patients who had received RT were subdivided on the basis of the type of previous treatment: those who had received RT alone (32 patients) and those who had undergone concurrent CRT (54 patients). Postoperative complications were compared between RT and non-RT groups and between the RT-alone and CRT groups. The rates of complications did not differ significantly between the RT and non-RT groups, but the rates of anastomotic thrombosis and carotid rupture were slightly but not significantly higher in the RT group than in the non-RT group. The overall complication rate did not differ between the RT-alone group and the CRT group. Pharyngolaryngectomy and free jejunum transfer can be performed safely, even in patients who have received RT, without significant increases in morbidity or mortality. However, a risk of carotid rupture due to pharyngocutaneous fistula remains in patients who have received RT, and prevention and early detection of fistulas are crucial. The risk of postoperative complications is not higher with CRT than with RT alone.

Free jejunal transfer for a 15-year-old girl with synovial sarcoma of the hypopharynx

Synovial sarcomas are rare, aggressive malignant soft-tissue tumours. Approximately 85-90% of synovial sarcomas occur in the extremities, with only 3% arising in the head and neck region. The hypopharynx as a site of occurrence has only rarely been reported. We describe herein our experience of free jejunal transfer for an adolescent patient with synovial sarcoma of the hypopharynx. A 15-year-old girl presented with a 2-month history of swallowing difficulties and hoarseness. Laryngoscopy revealed a mass filling the hypopharynx, almost occluding the larynx. Histological diagnosis obtained by biopsy was synovial sarcoma. The patient underwent total pharyngo-laryngo-oesophagectomy and reconstruction with a free jejunal graft. Postoperative chemotherapy and radiotherapy was performed. She has been free of recurrence or metastases for 2 years and 6 months. The patient can take a normal diet without dysphagia. Synovial sarcomas are rare, malignant, soft-tissue tumours primarily affecting the extremities, with only 3% arising in the head and neck region. The cornerstone of treatment for synovial sarcomas is complete surgical resection. Recently, total pharyngo-laryngo-oesophagectomy and free jejunal transfer have become the standard technique for patients with malignancies confined to the hypopharynx because of the minimal morbidity and mortality, favourable functional outcome and low incidence of complications associated with the donor site. We report the case of a 15-year-old girl with synovial sarcoma of the hypopharynx. We performed a total pharyngo-laryngo-oesophagectomy and reconstruction with a free jejunal graft. The postoperative course and the functional outcome were satisfactory.

Reconstruction of the jejunoesophageal anastomosis with a circular mechanical stapler in total laryngopharyngectomy defects.

Background. The aim of this study was to demonstrate the technical feasibility and potential benefits of using a circular mechanical stapler with free jejunal transfer for jejunoesophageal anastomosis in total laryngopharyngectomy reconstruction while comparing the rates of fistula and stricture. Methods. This study was a retrospective review of 12 free jejunal flaps completed with circular mechanical stapler for the jejunoesophageal anastomosis with comparison to 17 jejunal free flaps where all anastomoses were hand sewn. Results. In all, 29 patients underwent free jejunal transfer: 12 had jejunal free flap with circular mechanical stapler for jejunoesophageal anastomosis, whereas 17 patients had handsewn anastomosis. Corresponding rates of fistula and stricture were 0/12 fistulas and 3/12 strictures in the stapler cohort and 2/17 fistulas with 0/17 strictures in the hand-sewn cohort. No statistically significant difference in rate of fistula was observed between each cohort, whereas a trend toward increased rate of stricture (p 1⁄4 .06) was observed in the stapled anastomosis

Comparison of salvage and planned pharyngolaryngectomy with jejunal transfer for hypopharyngeal carcinoma after chemoradiotherapy

Salvage surgery after definitive chemoradiotherapy is often associated with a higher rate of perioperative complications and poor prognosis. The objective of this study is to examine the safety and efficacy of free jejunal transfer after salvage pharyngolaryngectomy for patients with locally recurrent hypopharyngeal carcinoma after definitive chemoradiotherapy. A retrospective analysis of patients with advanced hypopharyngeal carcinoma who underwent pharyngolaryngectomy and reconstruction using free jejunum. Forty patients who underwent pharyngolaryngectomy with jejunal transfer were included in this study. Fourteen patients underwent surgery after definitive chemoradiotherapy (the salvage-surgery group), whereas 26 patients underwent surgery after planned preoperative chemoradiotherapy (the planned-surgery group). The perioperative conditions, mortality, morbidity, functional outcomes, and oncologic outcomes in each group were compared. The patients in the salvage-surgery group lost an average of 9 kg in weight before surgery, which thus indicated a malnourished condition. However, the incidence of all perioperative complications did not differ significantly between the groups. All patients in both groups achieved oral intake without tube feeding, and the intervals to start oral intake were 12.8 days in the salvage-surgery group and 15.6 days in the planned-surgery group, which was not significantly different. The 5-year disease-free survival was 57.1% in the salvage-surgery group and 50.4% in the planned-surgery group, which was not significantly different. Salvage pharyngolaryngectomy and jejunal transfer can be performed safely and reliably for patients with locally recurrent hypopharyngeal carcinoma, and it is an excellent option after a failure of definitive chemoradiotherapy.

Blood gas analyses in doubly-vascularised free jejunal transfers

The vascular supercharge (additional microvascular anastomosis) has rarely been used for free flaps, and the blood circulation in the transferred tissue has not been recorded. We have made double vascular anastomoses during free jejunal transfer to reduce the possibility of loss of the flap from vascular occlusion. To evaluate the efficacy of additional arterial and venous anastomoses to improve the circulation in the transferred tissue, we analysed the results of blood gas measurements including venous partial pressure of oxygen ( pO 2) and carbon dioxide ( pCO 2) from the distal arcade vein. The free jejunal transfer was made using two pairs of arterial and venous anastomoses. Blood gas concentrations were analysed in samples drawn from the vein in the jejunal arcade before harvest, after the anastomosis of one paired artery and vein, after an additional arterial anastomosis, and after anastomoses of two pairs of artery/vein. The results showed that the venous pCO 2 was not changed by increasing the number of anastomosed vessels. The venous pO 2 was raised both by an additional arterial anastomosis and by two pairs of anastomoses, compared with that at the other two time points measured ( p = 0.04, p = 0.02, respectively). An additional arterial anastomosis seemed to have more effect on the pO 2 than an additional artery/vein pair. Additional arterial and venous supercharging therefore has a similar effect on hyperbaric oxygenation. This effect is mainly caused by arterial supercharging.

ハイリスク下咽頭癌症例に対する双茎遊離空腸移植の経験

We report a case of pharyngolaryngoesophagectomy and free jejunal transfer in a subject with local hypopharyngeal cancer recurrence after full-dose chemoradiotherapy. Reliable tissue transfer was also needed for early postoperative ambulation and oral ingestion. We planned the jejunal flap including two pairs of jejunal arteriovenous grafts and anastomosed them to the recipient vessel with the double-pedicled arteriovenous jejunum. The postoperative course was excellent. This approach proved useful in such severe cases with systemic complications despite longer operating time and restrictions on recipient vessels.

Double Arterialized Free Jejunal Flap

In a standard free jejunal transfer, one artery and one vein are anastomosed. However, when raising the jejunal flap, a one-segment jejunum sometimes has two arteries and one accompanying vein as a vascular pedicle. Free jejunal transfer in which two arteries and one vein are anastomosed was designed. We report on the safety and advantages of using this artery-dominant transfer when performing microvascular anastomosis. This technique was used when a one-segment jejunum had two arteries and an accompanying vein. Eight patients underwent this arterial-supercharged free jejunal transfer. All flaps survived, and no complications developed except for two cases of intraoperative thrombosis before the procedure. It is important to transfer the artery-rich graft into the same physiological environment by reconstructing the similar hemodynamics. The grafts can be transferred without harm. This artery-dominant method can be an option when conditions are unfavorable for safer jejunal transfer.

Double vascular anastomosis in the neck for reliable free jejunal transfer

To reduce the possibility of necrosis in free jejunal transfer after total pharyngolaryngo-oesophagectomy, we made a second set of arterial and venous anastomoses in addition to the usual cervical arterial and venous anastomoses. To obtain two different arterial flows (carotid and subclavian systems), the recipient arteries were the superior thyroid and the transverse cervical. For venous flow, the internal and external jugular veins were used. All flaps survived. This procedure, which is limited to the already dissected neck with no procedures in other areas, is less invasive than others. Its advantages are that when one vessel has thrombosed the other vessel functions as a safety valve, and the greater pliability of the vascular pedicles makes it easier to reach the recipient vessels. Because this method is theoretically safe and results in less possibility of losing a flap when the anastomosis is unreliable, the double-pedicled transfer can be an option for safer free jejunal transfer.

Larynx‐preserving esophagectomy and jejunal transfer for cervical esophageal carcinoma

To examine the efficacy and safety of free jejunal transfer after larynx-preserving esophagectomy in patients with cervical esophageal carcinoma, especially with a high tumor involving the hypopharynx. A retrospective analysis of patients with cervical esophageal carcinoma who underwent free jejunal transfer after larynx-preserving esophagectomy. The subjects were 32 patients who underwent larynx-preserving cervical esophagectomy and microvascular jejunal transfer. Fifteen patients had a high cervical esophageal carcinoma that involved the hypopharynx (high-tumor group), and 17 patients had a low cervical esophageal carcinoma that did not involve the hypopharynx (low-tumor group). For each group, mortality, morbidity (anastomotic leakage, wound infection, stricture, and recurrent laryngeal nerve palsy), functional outcomes (time to start oral intake, achieve complete oral intake, decannulation, and rate of larynx preservation), and oncologic outcomes (survival and local control rate) were reviewed and compared. No perioperative deaths occurred in either group. The incidence of postoperative complications did not differ between the groups. Oral intake started significantly later in the high-tumor group (14.9 days) than in the low-tumor group (10.4 days), but all patients in the high-tumor group could finally achieve oral intake without aspiration. Decannulation was possible in patients who underwent tracheostomy, and laryngeal function was completely preserved in the high-tumor group. Both survival and local control rate did not differ between the groups. Free jejunal grafts in larynx-preserving surgery can be performed safely and reliably in patients with low cervical esophageal carcinomas and in selected patients with high tumors involving the hypopharynx.

Salvage or what follows the failure of a free jejunum transfer for reconstruction of the hypopharynx?

To analyse the cases of failure of free jejunum transfer with subsequent secondary reconstruction methods after ablative surgery for malignant tumours of the laryngopharyngeal region and the cervical oesophagus with reconstruction using a jejunum interposition. Four cases in which failure of the jejunum interposition was managed with a second free or pedicle transfer were identified. The electronic files of patients were studied and analysed for patient characteristics and failure of reconstruction; type of salvage surgery and outcome; swallowing function and rehabilitation; postoperative complications; recurrence of tumour; patient survival and cause of death. Failure of the interposition occurred within 11 days in all patients, with oral bleeding being the most prominent sign. To replace the failed jejunum transfer, two new free jejunum transfers, two gastric pull-ups and one colon interposition after the second failure of a jejunum transfer were used. Three patients started swallowing rehabilitation, of which two achieved complete oral intake, defined as the redundancy of a feeding tube. The median disease-free period and overall survival was 28 and 42 months, respectively. Failure of a free jejunum transfer is a rare but inevitable complication when performed in a high-risk patient population, with oral bleeding being the most important sign of necrosis. Salvage of the buried jejunum interposition is hardly ever possible and secondary reconstruction can be performed using a new jejunum interposition or gastric pull-up procedure with considerable early postoperative complications, but relatively good results regarding swallowing rehabilitation and patient survival.

Salvage reconstruction of the oesophagus: a retrospective study of 15 cases

Salvage reconstruction of the oesophagus is still considered a challenging procedure for all head and neck surgeons. The risk of postoperative infection and delayed wound healing is high because of thick scar formation and persistent inflammation. Furthermore, recipient vessels for free tissue transfer or vascular supercharge are not always available. Alimentary tract reconstruction with skin or musculocutaneous flap may be necessary, but this method is susceptible to fistula formation.[Nakatsuka T, Harii K, Asato H, et al. Comparative evaluation in pharyngo-oesophageal reconstruction: radial forearm flap compared with jejunal flap. A 10-year experience. Scand J Plast Reconstr Surg Hand Surg 1998; 32: 307-10] In the past 10 years, we have experienced 15 cases of salvage reconstruction of the oesophagus after prior cancer treatment or aorto-oesophageal fistula; the cervical oesophagus was reconstructed in five cases and the cervico-thoracic oesophagus in 10. In four cases of cervical oesophagus and six of cervico-thoracic oesophagus we performed free jejunal transfer including two long segment transfers with double vascular pedicle. The cervico-thoracic oesophagus was also reconstructed with pedicled alimentary tract transfer (colon interposition or jejunal pull-up) with vascular supercharge in four cases. In one case, cervical oesophageal defect was reconstructed with a latissimus dorsi musculocutaneous flap. We also used a deltopectoral flap to cover the skin defect in three cases. In three cases, a second salvage operation was necessary because of flap necrosis that was caused by unreliable recipient vessels resulting from scar formation and persistent inflammation. Successful restoration of the oesophagus and oral alimentation was achieved in 11 cases. From this study, we concluded that free jejunal transfer is a useful procedure for salvage reconstruction of the oesophagus, particularly for cervical oesophagus or short oesophageal defects. Nonetheless, surgeons should know the indications and limitations of this procedure thoroughly and always be ready to choose other reconstructive options if necessary.

Artery-dominant free jejunal transfer

Although the supercharge (additional microvascular anastomosis) technique is often used in pedicled transfer of parts of the gastrointestinal tract, this is rarely performed during free jejunal transfer (FJT). The differences in blood circulation and outcomes between the usual single pedicle flap and a double pedicle flap are not well known. Therefore, we evaluated the effect of an additional arterial anastomosis in FJT. The FJT was performed using one venous and two arterial anastomoses after hypopharyngeal cancer ablation. To assess the effects of an arterial supercharge, blood-gas analysis, including the venous partial pressure of oxygen (pO(2)) and partial pressure of carbon dioxide (pCO(2)), was performed on samples drawn thrice from the jejunal vein: before harvest, after the anastomosis of a paired artery and vein and after an additional arterial anastomosis. The result revealed that the venous pO(2) was elevated by the additional arterial anastomosis, compared with the two other measuring times (P=0.04). The venous pCO(2) did not show significant changes. By being given a dominant artery, a jejunal flap can develop a physiological circulatory environment and can establish nutritional pathways without adverse effects.

Esophagectomy and Gastric Pull-Up in Patients With Previous Free Jejunal Transfer

Several options exist for reconstruction after total esophagectomy in patients with esophageal carcinoma. However, the options for a major resection after previous head and neck surgery in these patients are extremely limited. The procedure performed in 2 patients requiring esophagectomy after resection for previous head and neck malignancies is described. Both patients underwent previous chemoradiation therapy and free jejunal transfer for hypopharyngeal squamous cell carcinoma. Esophagectomy and reconstruction with a cervical gastrojejunal anastomosis combined with deltopectoral flaps were performed after the diagnosis of esophageal disease. Soft tissue defects were closed with a modified deltopectoral flap using de-epithelization. The deltopectoral flap is effective not only for cutaneous resurfacing, but also to promote delayed wound healing after radiation therapy. This report demonstrates a useful multidisciplinary approach for resection and reconstruction in patients after a previous free jejunal transfer.

Functional Outcomes and Reevaluation of Esophageal Speech After Free Jejunal Transfer in Two Hundred Thirty-Six Cases

Swallowing and communication are occasionally impaired after free jejunal transfer. Here, the relationship between surgical procedure and functional outcome was analyzed in 236 patients undergoing free jejunal transfer after total laryngopharyngectomy from 1992 through 2003. Swallowing and communication functions were also investigated with a questionnaire in 40 long-surviving patients. Although oral feeding could be resumed after surgery in most patients, anastomotic stricture and nasal regurgitation occurred in 12.7% and 29.7% of patients, respectively. Use of our standardized procedure, the tensed jejunal method, significantly reduced the incidence of stricture (P < 0.01) but increased the rate of nasal regurgitation; however, in most cases regurgitation gradually resolved. Of the 40 long-surviving patients, 17 attended a speech rehabilitation program at which 12 learned to perform esophageal speech without voice restoration procedures (11 of the 12 had received a tensed jejunal graft). Our standardized procedure helps prevent strictures and encourages esophageal speech.

Double Vascular Anastomosis for Safer Free Jejunal Transfer in Unfavorable Conditions

Free jejunum was transferred to a patient with recurrent hypopharyngeal carcinoma under unfavorable cervical conditions, caused by prior therapeutic chemoradiotherapy for hypopharyngeal carcinoma and gastric pull-up with cervical leak, resulting from treatment for thoracic esophageal cancer. The cervical recipient vessels were buried in extensively scarred fibrous tissues, so they were thought to be less reliable. Because postoperative vascular occlusion was anticipated, in addition to the ordinary single vascular anastomosis to the damaged cervical vessels, secondary vascular anastomosis to the healthy chest vessels was performed. We designed the graft to have double vascular pedicles that communicated with each other through arcade vessels. This made it possible to anastomose doubly to an intact thoracoacromial artery in the chest by elongating the vascular pedicles of the mesentery without the need for an interpositional vein graft, in addition to ordinary anastomosis in the damaged neck. The flap is nourished by the vessels from two different origins (carotid and axillary arteries, internal jugular and axillary veins) at two different places (damaged and healthy areas). This method increases the quantity of feeding vessels while improving the quality of the recipient vessels within the local area and flow sources. It is one treatment option when conditions are unfavorable for safer jejunal transfer.

The thoracoacromial artery as the recipient artery for safer free jejunal transfer in patients with irradiated, extensively scarred necks

Free jejunal transfer is considered safe when the recipient site is healthy, but when recipient vessels are associated with a serious local condition (e.g. irradiated or scarred) the risk of complications including occlusion is increased.1 We therefore considered that anastomosis to a healthy thoracoacromial artery in the healthy chest would be more reliable than anastomosis to diseased vessels in a problematic neck, if local conditions were poor.

Comparison of free jejunal graft with gastric pull-up reconstruction after resection of hypopharyngeal and cervical esophageal carcinoma

The purpose of this study is to evaluate the operative outcomes of a gastric pull-up and free jejunal graft reconstruction after resection of hypopharyngeal and cervical esophageal carcinoma. Records of all patients who underwent esophageal resection for carcinoma of the hypopharynx and cervical esophagus were reviewed. Reconstruction after esophagectomy was performed using the gastric pull-up (n = 38) or free jejunal graft (n = 14) techniques. The hypopharynx was the most common primary tumor site for the free jejunal graft group, whereas the gastric pull-up group had lesions more frequently in the cervical esophagus (P < 0.05). Both operative time and blood loss in the gastric pull-up group were significantly longer and excessive than those of the free jejunal graft group (P < 0.05). The graft survival rate was 95% (32/34) in the gastric pull-up group and 93% (13/14) for the free jejunal transfer group. The overall leakage rate was 1.9% (1/52). Three patients died (6%) in the postoperative period. There was no significant difference with regard to operative morbidity and mortality between the gastric pull-up group and free jejunal graft group. In conclusion, both free jejunal graft and gastric pull-up are safe and effective methods for the immediate restoration of alimentary continuity.

Tonometer pHi Monitoring of Free Jejunal Grafts following Pharyngolaryngoesophagectomy for Hypopharyngeal or Cervical Esophageal Cancer

Background/Aims: Graft failure is a critical complication associated with vascular occlusion in esophageal reconstruction with a free jejunal graft following pharyngolaryngoesophagectomy. In this study, we evaluated the usefulness of intramucosal pH (pH_i) measurement using a tonometer to assess the graft viability. Methods: Two consecutive studies, the early phase study and the late phase study, were performed. Nineteen patients who underwent free jejunal transfer were enrolled in the early phase study before 1999 to determine the critical pH_i value. In the late phase study after 2000 (n = 16), anticoagulant treatment to prevent graft necrosis was performed in the patients having a pH_i value under the critical level. Results: In the early phase study, vascular obstruction was not seen in 16 patients with pH_i >7.10. Of 3 patients with pH_i <7.10, 2 underwent regrafting because of jejunal graft necrosis by vascular obstruction. In the late phase study, reoperation was not required in 3 of 4 patients with pH_i <7.10. Intraoperative vascular occlusion was found in 1 patient with a decline in pH_i value and anticoagulant treatment was effective in 2 others. Conclusion: The pH_i measurement using a tonometer is useful for finding vascular problems in free jejunal grafts.

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.

Inverted, stapled J‐pouch free jejunal transfer for reconstruction of the pharynx and esophagus

Since the advent of the jejunal free flap in the early 1900s, it has become one of the most effective and widely used methods for reconstruction of circumferential defects of the esophagus, often due to malignant disease. However, as esophageal resections extend further cranially, reconstruction becomes more difficult due to the size discrepancy between the proximal jejunum and the pharygostome. Several authors have described techniques to overcome this problem, although there is, as yet, no consensus on the most effective method. Here we present our experience with an inverted, stapled J-pouch free jejunal transfer, analogous to that used in the ileoanal anastomosis after proctocolectomy for the treatment of ulcerative colitis and familial polyposis coli. In the head and neck, the inverted J-pouch provides several advantages when a resection extends into the pharynx: a closer size match to the large pharyngeal defect, a reservoir to aid swallowing, and increased conduit size proximally to aid gravity-dependent swallowing in the presence of uncoordinated peristalsis and tongue resection. This technique has served as a safe, effective, and rapid operation for this complex reconstructive problem.