Free Jejunal Transplantation Research Articles

Free jejunal transplantation in a patient with short neck, cervical spondylosis, and vascular calcification: A case report

Free jejunal transplantation in a patient with short neck, cervical spondylosis, and vascular calcification: A case report

Occult Early Squamous Cell Carcinoma in Zenker's Diverticulum Treated With Diverticulectomy Followed by Additional Esophagectomy With Free Jejunal Reconstruction: A Case Report

A 63-year-old man was evaluated for a 20-year history of dysphagia and vomiting. Barium-swallow esophagography showed a Zenker's diverticulum at the upper end of the esophagus. Esophagogastroduodenoscopy revealed the diverticulum about 20 cm from the incisors. There was no mucosal inflammation or irregularity in the diverticulum. Computed tomography showed that the diverticulum was about 8 cm in size. There was no lymphadenopathy around the esophagus. Because the patient's symptoms were worsening, we performed diverticulectomy using a linear stapling device and cricopharyngeal myotomy. The mucosa of the resected specimen had no macroscopically abnormal lesions. However, an area unstained by iodine that widely involved the surgical margin was recognized at pathologic examination. Pathologic findings revealed squamous cell carcinoma invading the lamina propria mucosa with inflammatory cell infiltration. In addition, the pathologic surgical margin was widely positive. However, a remnant tumor lesion was not detected by postoperative esophagogastroduodenoscopy. Biopsies near the staple line were negative. After obtaining informed consent, we performed resection of the cervical esophagus including the proximal stump of the diverticulum and cervical lymphadenectomy approximately 4 months after the primary operation as an additional surgery. Reconstruction was performed by free jejunal transplantation with microvascular anastomosis. The patient was discharged on postoperative day 45. Pathologic examination revealed no malignant lesion in the resected specimen, and radical cure was confirmed.

PS01.141: TREATMENT STRATEGY FOR THORACIC ESOPHAGEAL CARCINOMA COMPLICATED WITH HEAD AND NECK CANCER

Abstract Background The frequency of complication of head and neck cancer to thoracic esophageal cancer is high, and treatment methods and their order will be determined from the viewpoints of curability and quality of life. Methods We review the course of three cases we experienced and give some consideration. Results [Case 1] A 68-year-old man with cT2N0M0 Mt esophageal cancer and cT2N0M hypopharyngeal cancer. Two courses of DCF (DOC + CDDP + 5 FU) made the hypopharyngeal lesion CR. After thoracoscopic subtotal esophagectomy with three fields lymph nodes dissection, one course of DCF was added, and CRT (60 Gy/30 fr) combined with weekly CBDCA was administered to the neck. The case is alive without recurrence for 5 years and 9 months from the start of treatment. [Case 2] A 72-year-old man with cT2N0M0 Mt esophageal cancer and cT3N2bM0 hypopharyngeal cancer. Three courses of TCS (DOC + CBDCA + TS-1) made the hypopharyngeal lesion CR. After thoracoscopic subtotal esophagectomy, CRT (60 Gy) combined with biweekly CDDP was administered to the neck. The case is alive without recurrence for 5 years and 7 months. [Case 3] A 63-year-old man with LtMt multiple esophageal cancer (4 lesions, cT3N2M0) and cT2N1M0 hypopharyngeal cancer, and cT1bN0M0 gastric cancer. Though the hypopharyngeal cancer remained in PR after 2 courses of DCF, aiming at larynx preservation, thoracoscopic subtotal esophagectomy was performed, and gastric lesion was excised at the time of creating the stomach tube. After the operation, CRT (70 Gy) combined with weekly CBDCA made the hypopharyngeal lesion CR. Another cancer was demonstrated in the residual esophagus in 1 year and 3 months and surgical resection of the residual esophagus and the larynx with reconstruction with free jejunal transplantation was performed. The case is alive without recurrence for 2 years and 5 months after reoperation. Conclusion Salvage surgery may be necessary for metachronous multiple cancer cases, non-CR cases, and local recurrence cases as in case 3. We think that we can aim at compatibility of curability and maintenance of quality of life by treatment method which aims at preservation of larynx, combining with chemoradiotherapy and esophagectomy. Disclosure All authors have declared no conflicts of interest.

PS02.144: ESOPHAGOPLASTY WITH FREE JEJUNUM FLAP AFTER COLON-ESOPHAGUS CONDUIT ISCHEMIA

Abstract Background Colon interposition is mainly used as a second line treatment, when the stomach has to be resected for oncological or technical reasons, or when the stomach is deliberately kept intact for benign and congenital diseases in patients with long-life expectancy. Colon provides extended conduit length, reliable blood supply and low incidence of reflux. However, the early and late postoperative ischemic complication rate is 5–15%. Methods Colon ischemia can frequently cause anastomosis complications, which can be safely treated with dilation or surgery. The most serious but rare complication is the acute conduit necrosis. More severe cases of necrosis require conduit take down with proximal esophageal diversion and placement of an enteral feeding tube. An uncommon complication is the colonic stricture due to chronic ischemia, which can be treated with conservative methods such as dilation and stenting. Surgery is indicated since the impaired deglutition can compromise the quality of life. Supercharged or free jejunal interposition is a suitable alternative conduit for esophageal replacement in patients with otherwise limited delayed reconstructive options. Good functional outcomes can be achieved despite the formidable technical challenges in this group of patients. Results In three such cases, we could successfully use a free jejunal flap for reconstruction; the replacement type was different, using substernal, presternal and sternotomy routes. The arterial blood supply was provided by the internal mammary artery. Saphenous graft was used to interconnect to external jugular or innominate vein to reestablish the venous drainage. All three patients survived without further complication. Conclusion Overall, it can be stated that free jejunal graft transplantation can be used to resolve complicated cases that cannot be reconstructed with any other methods and jejunum offers a good swallowing function and quality of life. Disclosure All authors have declared no conflicts of interest.

Free jejunal segment transplantation to reconstruct the esophageal defect caused by tumor resection and fol- low-up observation by endoscopy

Objective To investigate the method and curative effect of the posterior cervical esophageal de- fect after the reconstruction of lower pharyngeal carcinoma by dissociation of the lower pharyngeal carcinoma. Methods From August, 2015 to June, 2017, we used the jejunum segment. to reconstruct five patients’ esophageal defect in the neck segment enlarged after the enlargement of the hypopharyngeal carcinoma. The length of the jejunum was 8.0 -15.0 cm, We used microvascular stapling to anastomosis vein in surgery. The morphological and functional changes of the graft tube were observed by endoscopic follow-up. Results All 5 patients were discharged from the hospital with an average of 12 days in hospital. The mean time of heat ischemia was 8 minutes, and the average oper- ation time was 5.2 hours. After endoscopic follow-up for 12 months, no stricture or anastomotic leakage occurred in the transplanted bowel, and the intestine moves downward autonomously, the morphological and functional remodeling of transplanted intestinal tract was observed. Conclusion Free jejunal reconstruction of hypopharyngeal carcinoma resection for cervical esophageal is a safe method with a good outcome in morphological and functional remodeling. It’ s one of the ideal methods to reconstruct cervical esophageal defect. Key words: Free jejunal transplantation; Reconstructive; Hypopharyngeal neoplasms; Esophagus

Left brachiocephalic vein injury during esophagectomy

Left brachiocephalic vein injury has not yet been reported during reconstruction after esophagectomy. A 58-year-old male patient was diagnosed with cervical esophageal squamous cell carcinoma and subsequently underwent subtotal esophagectomy followed by neo-adjuvant chemotherapy. The left brachiocephalic vein was accidentally injured when making a retrosternal space. The brachiocephalic vein was ligated followed by rapid sternotomy, and cervical esophagostomy without tumor resection and jejunostomy were performed for damage control. Complete resection of the cervical esophageal tumor and free jejunal transplantation for reconstruction were performed 55 days after the initial surgery. The patient is now well and has survived for more than 34 months after the reconstruction. Surgeons should consider left brachiocephalic vein injury when making a retrosternal space. Damage control surgery and preparation for a second surgery may be important in cases of accidental major vascular injury during esophagectomy.

Reconstruction of hypopharyngeal circumferential and cervical esophageal defects with free jejunal interposition in 112 cases

To investigate the results of reconstruction of hypopharyngeal circumferential and cervical esophageal defects with free jejunal transfer. Retrospective review of 112 patients who underwent pharyngoesophageal reconstruction with free jejunal interposition. Analysis was confined to the patients with advanced hypopharyngeal, esophageal or recurrent laryngeal squamous cell cancer. Kaplan-Meier method was used to identify the accumulative survival rate. The free jejunal success rate was 94.6% (106/112). The pharyngocutaneous fistula rate and anastomoses narrow rate were 8.9% (10/112) and 12.5% (12/96) respectively. The perioperative mortality rate was 1.8% (2/112). Except 1 case of dead, 6 cases with flap failure and 2 cases with laryngeal preservation, other 103 cases had resumed oral feeding. The success rate of free jejunal transplantation is high and free jejunal interposition is an ideal reconstruction method for patients who have hypopharyngeal circumferential and cervical esophageal defects after tumor resection.

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.

Functional and Radiological Evaluation of Free Jejunal Transplant Reconstructions After Radical Resection of Hypopharyngeal or Proximal Esophageal Cancer

Cancer of the pharyngoesophageal junction (PEJ) is associated with late onset of symptoms, high morbidity, and a dismal prognosis. Radical surgery with pharyngolaryngectomy and reconstruction with a free vascularized jejunal transplant has been increasingly practiced in the treatment of these patients. This strategy is not devoid of challenges, and the present study is aimed at evaluating the long-term functional outcome among patients who have undergone such surgical treatment. Ten patients (mean age 59 years) with a mean follow-up time of 54 months were included. Clinical assessment, health-related quality of life (HRQL) questionnaires, and a standardized radiography examination were used for evaluation. The Karnofsky index ranged from 60 to 90 (mean 82). Global QL scores (EORTC QLQ-C30) had a mean value of 74, and the mean scores for dysphagia-related items of the EORTC QLQ OES-18 questionnaire were within the lower range. Radiographic signs of disturbed bolus transport through the jejunal transplant were found in all patients examined despite the grading of dysphagia from 0 to 1. The Watson dysphagia score varied between 0.5 and 45.0 (mean 16.2). No correlations were found between radiographic findings and the clinical evaluations or the outcomes assessed by the HRQL questionnaires. HRQL was found to be generally good after cancer of the PEJ and jejunal transplant insertion. Most patients reported mild dysphagia. Radiologic signs of disturbed bolus passage were common, but their clinical impact seemed questionable.

The blood supply of third intestinal artery to the free jejunal transplantation: an applied anatomical study

目的 以第3支小肠动脉为蒂灌注观察,了解其有效供血的空肠范围,为移植手术提供解剖依据.方法 对32例固定小肠、21例新鲜小肠标本解剖测量及醋酸乙酯、ABS血管灌注观察.结果 两组标本血管变异在可接受范围内.在第1～5小肠动脉中,以第3支小肠动脉管径较粗.以第3支小肠动脉血供分布区域,肠壁、系膜血管吻合交通丰富,血液循环较好.灌注后均匀红染的空肠游离缘长度为(142.2±62.3)(69.0～206.6)cm;ABS有效分布的动脉弓长度为(30.8±7.3)(23.0～37.3)cm.结论 以第3支小肠动脉为蒂作游离空肠移植,有足够长度的有效血管弓及足够长度血供的肠管,可满足临床作食管重建的需要。

Dysphasia due to solitary jejunal diverticulumafter free jejunal transfer for reconstructionof the cervical oesophagus

The free jejunal flap has been widely used in clinical practice for the restoration of the cervical oesophagus, but a variety of complications still pose problems. The purpose of this report is to present a rare complication of the jejunal flap. A diverticulum of the jejunal segment, causing severe dysphagia, occurred 4 years after flap transfer in a 50-year-old man who underwent oesophageal reconstruction due to severe stricture following caustic ingestion. The patient was treated successfully by resection of the diverticulum. When examining a patient with unidentified symptoms in the neck or dysphagia after cervical oesophageal reconstruction with free jejunal transplant the possibility of small bowel diverticula should be borne in mind in order to prevent serious life-threatening complications that may arise from it.

Functional Long-Term Outcome of a Free Jejunal Transplant Reconstruction following Chemoradiotherapy and Radical Resection for Hypopharyngeal and Proximal Oesophageal Carcinoma

Background/Aims: To evaluate the functional outcome of a reconstruction by a free vascularized jejunal transplant combined with a voice prosthesis after chemoradiotherapy and surgery for proximal oesophageal or hypopharyngeal cancer. Methods: Seven patients (6 men, mean age 52 years, range 28–70) with squamous cell cancer in the proximal oesophagus (n = 6) or the hypopharynx received preoperative chemoradiotherapy (40.8 Gy, cisplatinum and 5-FU) followed by a circumferential pharyngolaryngectomy and resection of the proximal oesophagus. A single-stage reconstruction was carried out with a free jejunal transplant using a microsurgical technique. A tracheojejunal puncture and insertion of a voice prosthesis (Provox I) was performed after 3 months in suitable cases. Results: All operations had a per- and postoperative uneventful course. Five patients were alive after a mean follow-up time of 5 years and 7 months after surgery (range 3 years 4 months to 7 years 10 months), while 2 patients died from metastases within 2 years after surgery. Postoperative examination showed histopathological down-staging in all cases. Relief of dysphagia was achieved in most cases. Good or average speech was recorded in 3 patients. Conclusion: Reconstruction after radical resection for proximal oesophageal and hypopharyngeal cancer can be carried out with low mortality, acceptable morbidity and a promising functional outcome.

Retrosternal pedicled jejunum interposition: an alternative for reconstruction after total esophago-gastrectomy.

If the colon cannot be used for reconstruction after total esophago-gastrectomy, alternatives have to be sought. From 1990 to 2001, retrosternal jejunum loop interposition was performed in 35 patients (male/female: 29:6; mean age 59.2, range 16-83 years) due to cancer in 32 cases and to esophageal perforation in three cases. In all patients reconstruction with stomach or colon, respectively, was impossible on behalf of the underlying histology, of previous resection of the stomach and impedient colonic diseases. A jejunal segment with abundant arcades was chosen, preserving a strong, distal arteriovenous mesenteric pedicle, while 2-3 proximal mesenteric vessels were severed. The loop was pulled up retrosternally, establishing a cervical end-to-side esophagojejunostomy. A Roux-en-Y anastomosis was done in a convenient position. Two patients died perioperatively due to mediastinitis and consecutive multiorgan failure (one Boerhaave's syndrome, one suicidal ingestion of acid). In one case the oral part of the loop developed venous congestion and was replaced by a free jejunal transplant. The perioperative course of 32 patients was uneventful. Seventeen patients are up and well (1-8.5 years). Sixteen patients died of metastatic disease. The functional results are satisfactory. In about 50% of patients recurrent dilatations became necessary due to anastomotic scars. However, none of the patients complained about severe dysphagia. In cases of impedient colonic diseases, the pedicled, retrosternal jejunal loop with cervical anastomosis is an alternative for reconstruction after total esophagogastrectomy.

Surgical management of carcinoma of the hypopharynx and cervical esophagus: analysis of 209 cases.

Free jejunal transfer has become the standard technique for reconstruction of the pharynx and hypopharynx, especially with proximal neoplastic lesions, whereas gastric tube interposition is the technique of choice for reconstruction of the hypopharynx and cervical esophagus when resection extends below the thoracic inlet. Surgical ablation is a viable option for advanced hypopharyngeal and cervical esophageal neoplasms, with stomach interposition a safe and preferred method of reconstruction. Retrospective analysis. University hospital that is a regional referral institution for esophageal cancer treatment and complex digestive reconstructions after esophagectomy. We reviewed the records of 209 patients who underwent total pharyngolaryngectomy between May 1982 and July 1999. The majority of patients had advanced cancer: hypopharyngeal in 131 cases and cervical esophageal in 78 cases. Pharyngolaryngectomy and total esophagectomy with pharyngogastric anastomoses (n = 127); pharyngolaryngectomy, cervical esophagectomy, and reconstruction with free jejunal transplant (n = 77); and pharyngolaryngectomy and total esophagectomy with pharyngocolic anastomoses (n = 5). Postoperative mortality and morbidity, long-term survival, and prognostic factors influencing survival. The postoperative in-hospital mortality rate was 4.8% (10 patients), with a postoperative morbidity rate of 38.3%. 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 (33% vs 47%, P<.05). The significant adverse factors affecting survival were tumor cervical localization, postoperative complications, disease stages pT3 and pT4 for the cervical esophageal tumors, microscopic pharyngeal penetration, or incomplete resection. The significant beneficial factors were tumor hypopharyngeal localization and postoperative radiotherapy. Surgical ablation is a viable option for advanced hypopharyngeal and cervical esophageal neoplasms, with stomach interposition the preferred method of reconstruction. Although the prognosis is poor, satisfactory short-term palliation can be achieved. The significant adverse factors affecting survival should be taken into account to select the candidates for surgery.

Multicentricity in pharyngoesophageal tumors: Argument for total pharyngolaryngoesophagectomy and gastric transposition

Background Pharyngoesophageal tumors pose a challenge to surgical management, and there is controversy in the literature as to the best procedure to be used. Advantages and disadvantages are mentioned for total pharyngolaryngoesophagectomy and gastric transposition (PLE>), free jejunal transplants, and free forearm flaps. One of the arguments for PLE> is the persistence or subsequent occurrence of multiple primaries in a field cancerization region. Multiple tumors in the head and neck/esophagus/lung axis have been reported. However, despite extensive investigation, there is little information on specific multicentricity in patients treated with PLE> for pharyngolaryngoesophageal carcinomas. Methods A clinicopathological study was undertaken in 35 consecutive patients who underwent PLE> for pharyngoesophageal cancer to evaluate synchronicity, multicentricity, and metachronicity. Only in situ and invasive carcinomas were considered. The findings were compared with the reports in the literature. Results Thirty-eight tumors were diagnosed preoperatively, with the main indications for PLE> being tumors located in the esophagus or hypopharynx (32 patients) and larynx (three patients). After the surgical treatment, 21 patients had single primaries (60%) and 14 (40%) had 25 multiple primaries in addition to their main primaries (total of 60 tumors in the whole group). Synchronous, previous metachronous and subsequent metachronous carcinomas occurred in 26%, 17%, and 8.5% of the instances, respectively. Twenty of the 25 multicentric carcinomas were invasive (80%). Either the main primaries or the multicentric carcinomas were located in the esophagus or hypopharynx (91.5% and 60%, respectively). Other sites included the larynx, oropharynx, oral cavity, and lung. Conclusion The incidence of multicentric tumors in patients with pharyngoesophageal carcinomas may favor total PLE> as the procedure of choice, because it includes all the condemned upper pharyngolaryngoesophageal mucosa. © 2000 John Wiley & Sons, Inc. Head Neck 22: 156–163, 2000.

Complications following esophageal surgery.

Chronologically, complications can be classified as intraoperative, early, and late. The authors analyze complications according to this classification on the basis of more than 400 esophageal operations and related literary data. As regards intraoperative complications, they deal only with those occurring at transhiatal esophagectomy (e.g., tracheal tear, bleeding, pneumothorax, laryngeal nerve injury). Among the early complications, they survey the incidence of transplant necrosis and related mortality, further sequelae ensuing from subacute ischemia of the replaced organ and analyze in detail the questions which arise regarding anastomotic leakage. Firstly, they deal with those causative factors that influence the frequency of anastomotic insufficiency, such as the technical "know-how" of anastomosis making (e.g., one layer vs two layers; stapling or manual suture; interrupted or running suture), the way of replacement using whole stomach or tube-stomach and the consequences originating from the route of replacement (e.g., anterior or posterior mediastinal route). Incidence and management of chylothorax are also dealt with. While dealing with late complications, the authors give a detailed comment on anastomotic strictures and also other factors facilitating the development of late dysphagia, such as peptic stricture and tumor of the organ remnant. Finally, some cases successfully treated by surgery are presented (skin-tube formation in cases following transplant necrosis; abolition of a pharyngogastric anastomosis stricture using a free jejunal transplant and surgical solution of an anastomotic stricture from median sternotomy approach).

Reconstruction of the oropharynx with special reference to the free jejunal autograft and transplants from the scapular area

Reconstruction of the oropharynx with special reference to the free jejunal autograft and transplants from the scapular area

Vaginal Reconstruction with Free Jejunal Flap

Congenital absence of a vagina is a rare but outstanding anomaly of plastic surgery. Although many methods are described for reconstruction of vaginal agenesis, there is not a method yet to be approved as a perfect solution to this problem. With the aim of solving the problems faced with conventional methods, free jejunal transplantation was planned to construct a neovagina. For this method, we isolated a 15-cm jejunal segment, with its pedicle, transferred it to the preprepared vaginal pouch, and anastomosed the donor vessels of the mesentery to the inferior epigastric vessels. In the postoperative sixth month, problems of intercourse or the need to use any lubricator or stent were still not experienced and reported. In this paper, we judge and compare our approach by reviewing others.

200 freie Jejunumtransplantationen: Lohnt der große operative Aufwand?*

From 1983 to 1992, 216 free jejunal transplants were performed after resection of malignant tumours for reconstructing the upper oesophageal tract. In two patients reconstruction was performed secondarily and in four cases within the framework of recurrence treatment. In 25 cases the jejunal transplant was sewn in tubular form to the circular insert of the hypopharynx, whereas in the remaining 188 cases the jejunum transplant was sewn as patch. A jejunum transplant was most frequently employed in the tonsillar region (n = 75). Reconstruction of the body of the tongue was performed in 42 cases and of the hypopharynx in 29 cases. Of the 213 patients treated, 175 were irradiated postoperatively. The most severe complications were in 5 cases death from the sequels of the operating, abdominal complications in 15 cases and complete loss of the transplant in 22 cases. Protracted inability to swallow occurred in 15 cases and pneumonia in 16 patients. The five-year survival probability was 39% for the 42 patients suffering from carcinomas of the oral cavity, 53% for the 90 patients with oropharyngeal carcinoma in stage III and 33% in stage IV, as well as 40% with the 29 patients suffering from hypopharyngeal carcinomas. An essential advantage of the free jejunum transplants were the excellent functional reconstruction results. This is demonstrated by examples of various cases. Since the number of treated patients is still too low, it is at present not yet possible to compare this approach with other therapeutic concepts, such as enoral laser surgery resection or radiochemotherapy.

Gross morphologic and functional effects of postoperative radiation on free jejunal autografts.

Twenty adult mongrel dogs underwent free jejunal transplants to the neck; 10 either died of or had to be sacrificed as a result of postoperative complications, 5 received a 55-Gy-equivalent dose of radiation after 3 weeks, and 5 were followed as controls. Serial manometric and endoscopic evaluations were performed over a 9-month period. Progressive deterioration of the quality and amplitude of peristalsis of the jejunal autografts was observed only in the radiated group. In addition, all dogs in the radiated group developed severe jejunal circumferential constriction and stricture formation. These delayed effects of irradiation on revascularized jejunal autografts should be considered in planning the method of pharyngoesophageal reconstruction as well as the timing of adjuvant radiotherapy.