Free Jejunal Flap Reconstruction Research Articles

Subtotal esophagectomy and concurrent reconstruction with free jejunal flap for primary esophageal cancer after pancreatoduodenectomy.

Pancreatoduodenectomy and subtotal esophagectomy are widely considered the most invasive and difficult surgical procedures in gastrointestinal surgery. Subtotal esophagectomy after pancreatoduodenectomy is expected to be extremely difficult due to complicated anatomical changes, and selecting an appropriate intestinal reconstruction method will also be a difficult task. Therefore, perhaps because the method is considered impossible, there have been few reports of subtotal esophagectomy after pancreatoduodenectomy. A 73-year-old man with a history of pancreatoduodenectomy was diagnosed with superficial thoracic esophageal squamous cell carcinoma. Definitive chemoradiation therapy was recommended at another hospital; however, he visited our department to undergo surgery. We performed the robot-assisted thoracoscopic subtotal esophagectomy. There were some difficulties with the reconstruction: the gastric tube could not be used, the reconstruction was long, and the organs reconstructed in the previous surgery had to be preserved. However, the concurrent reconstruction was achieved with the help of a free jejunal flap and vascular reconstruction. All reconstructions from the previous surgery, including the remnant stomach, were preserved via regional abdominal lymph node dissection. After reconstruction, intravenous indocyanine green showed that circulation in the reconstructed intestines was preserved. On postoperative day 1, no recurrent nerve paralysis was observed during laryngoscopy. The patient could start oral intake smoothly 2weeks after surgery and did not exhibit any postoperative complications related to the reconstruction. The patient was transferred to another hospital on postoperative day 21. Owing to the free jejunal flap interposition method, we safely performed one stage subtotal esophagectomy and concurrent reconstruction, preservation of the remnant stomach, and pancreaticobiliary reconstruction in patients with a history of pancreatoduodenectomy. We believe that this method is acceptable and useful for patients undergoing complicated reconstruction.

Background Factors Associated with Postoperative Complications in Patients with Advanced Hypopharyngeal Cancers Undergoing Total Pharyngolaryngoesophagectomy Followed by Free Jejunal Flap Reconstruction

AbstractWe retrospectively analyzed background factors associated with postoperative complications in patients with advanced hypopharyngeal cancers who underwent total pharyngolaryngectomy followed by free jejunal flap reconstruction. A total of 23 participants, including 21 men and 2 women aged 49 to 83 years (average 72.3 years) were enrolled in this study. Mild and moderate/severe complications occurred in five and seven cases, respectively. The most common complication was stricture of the esophagojejunal anastomosis (nine cases). Other complications included two tracheostomal stenosis, one each for pneumonia and chyle leakage. The free jejunal flap survived in all cases. The disease-free survival rate was 47.8% at 52 weeks after surgery. The platelet count was significantly lower (18.8 ± 1.9 × 104/mL vs. 27.7 ± 1.8 × 104/mL; p = 0.008) in patients with moderate/severe complications than in those without. The percentage of stage IV cases and intraoperative blood loss tended to be higher in patients with complications than in those without. Knowledge of these potential risk factors for the development of postoperative complications to satisfactorily manage the clinical course of patients with advanced hypopharyngeal cancers is necessary.

Factors Associated with Complications after Total Pharyngo-Laryngo-Esophagectomy and Free Jejunal Flap Reconstruction

Introduction: Free jejunal flap (FJF) reconstruction is a standard procedure for pharyngeal and cervical esophageal defects resulting from head and neck cancer resection. However, improvements in patients’ quality of life after surgery require a further statistical approach. Methods: An observational, retrospective, multivariate analysis was designed to report the incidence of postoperative complications and their association with clinical factors in 101 patients who underwent total pharyngo-laryngo-esophagectomy and FJF reconstruction for head and neck cancer at a university hospital between January 2007 and December 2020. Results: Postoperative complications were observed in 69% of patients. In the reconstructive site, anastomotic leak, observed in 8% of patients was associated with vascular anastomosis in the external jugular vein system (age-adjusted odds ratio [OR]: 9.05, p = 0.044) and anastomotic stricture, observed in 11% of patients was associated with postoperative radiotherapy (age-adjusted OR: 12.60, p = 0.02). Cervical skin flap necrosis was the most common complication (34%) and was associated with vascular anastomosis on the right cervical side (age- and sex-adjusted OR: 4.00, p = 0.005). Conclusion: Although FJF reconstruction is a useful procedure, 69% of patients suffer a postoperative complication. We suppose that anastomotic leak is related to the low blood flow resistance of the FJF and inadequate drainage of the external jugular venous system, and anastomotic stricture is related to the vulnerability of the intestinal tissue to radiation. Furthermore, we hypothesized that the location of the vascular anastomosis may affect the mesenteric location of the FJF and the dead space in the neck, leading to the development of cervical skin flap necrosis. These data contribute to increasing our knowledge about postoperative complications related to FJF reconstruction.

Segmental cervical esophagectomy with free jejunal flap reconstruction for cervical esophageal cancer in patients with previous history of gastric surgery: a report of two cases.

Although free-flap jejunal reconstruction is frequently performed after cervical esophagectomy for cervical esophageal cancer, the procedure after gastric surgery has not been reported. We encountered two patients with esophageal cancer and previous gastric surgeries who eventually underwent segmental esophagectomy with free-flap jejunal reconstruction. Case one involved a 75-year-old man who underwentabdominal abscess and duodenal ulcer perforation surgeries (abdominal drainage and subsequent gastrojejunal bypass). A type 0-IIa tumor was located posterior to the cervical esophagus's right wall, 21cm from the incisor, without lymph node swelling or distant metastasis. The left lobe of the thyroid gland was mobilized to ensure an oral resection margin. Severe abdominal adhesions required careful adhesiolysis to harvest the jejunum (20cm long) 40cm from the jejunojejunostomy. An end-to-side and side-to-end esophagojejunostomy were performed for the proximal and distal ends, respectively. Case two involved a 75-year-old male with a history of distal gastrectomy with Billroth I reconstruction for early gastric cancer. A submucosal tumor-like lesion was located on the cervical esophageal wall on the left side, 21cm from the incisor. The distal esophagus requiredadditional segmental resection because the anal resection line was close to the tumor. Jejunum (10cm long) 30cm from Ligament of Treitz was harvested. An end-to-side and end-to-end esophagojejunostomy for the proximal and distal ends, respectively, was performed. This surgery requires a thorough preoperative examination to ensure an adequate surgical margin and a careful free-flap harvest based on post-gastric surgery anatomy.

613. DOUBLE LUMEN JEJUNAL FREE FLAP RECONSTRUCTION AFTER PROXIMAL ESOPHAGEAL RESECTION FOR MALIGNANCY

Abstract Malignancies located at the level of the upper esophageal sphincter pose a challenge due to the proximity to pharyngeal, laryngeal, and upper esophageal anatomic structures. Poorly differentiated tumors in this area can pose both diagnostic and therapeutic dilemmas, and patients with prior neck radiation may require surgery. In cases that are treated with laryngectomy, pharyngectomy, and proximal esophagectomy, jejunal free flap reconstruction can restore gastrointestinal continuity and function. A single institution early experience with multidisciplinary complex head and neck reconstruction requiring pharyngectomy and proximal esophagectomy was reviewed. Charts were reviewed for demographic details, operative details, and 30 day perioperative occurrences. Radiographic, clinical, and endoscopic records were reviewed. Method and approach for jejunal harvest and abdominal complications were obtained. Location of microvascular anastomoses were recorded for implantation of the jejunum. Length of small bowel utilized was recorded along with details of operative technique and methods for both proximal and distal anastomoses. Pre-operative and post-operative pathology reports were reviewed and compared. The initial 4 cases of pharyngeal and esophageal resection requiring jejunal free flap reconstruction were reviewed. Mean age was 65.3 (50-74), mean BMI was 31.7 (21.7-49.8), and 75% of patients were female. Median length of stay was 13.5 days (8-14) after the index operation. Flap survival rate was 100%, and there was 0% leak rate. Three patients had previous neck surgery, 75% survived to 30 days with 1 patient opting for palliative care. All flaps were harvested using a laparoscopic approach. There were no abdominal donor site related complications. Pathology 50% SCC, mucoid epidermoid carcinoma, and anaplastic thyroid carcinoma. Reconstruction of complex pharyngeal and proximal esophageal defects after oncologic resection for malignancy involving the proximal esophagus abutting the upper esophageal sphincter poses a complex challenge. These proximal esophageal defects are managed effectively with jejunal free flap reconstruction utilizing microvascular anastomoses. A double lumen jejunal free flap should be considered to restore pharygo-esophageal continuity, provides good pharyngeal size match, and can also be safely performed in patients with a re-operative field or prior neck radiation.

Postoperative serum C-reactive protein dynamics after pharyngolaryngectomy with jejunal free-flap reconstruction.

Pharyngolaryngectomy with jejunal free-flap (JFF) reconstruction can be offered for locally advanced hypopharyngeal cancer. However, the procedure carries significant morbidity. Postoperative serial serum C-reactive protein (CRP) has been shown to be a marker predicting postoperative complications, and the aim of this study was to describe the dynamics and value of CRP in this patient group. Retrospective analysis of pharyngolaryngectomies with JFF reconstruction was performed in our institution. Daily postoperative CRP values were analysed within the first 14 days, as were complications. Twenty-one cases were included. Total morbidity was 57.1% including 14.3% (temporary) anastomotic leaks and 14.3% flap failures. Patients in the normal group showed peak CRP levels around postoperative day 2 (2.2). Increased CRP levels on or after day 4 were associated with complications (p<0.01) with a sensitivity of 83.3% and specificity of 77.8%. In keeping with CRP kinetics from other surgical studies, peak CRP values on day 2 or 3 are expected, followed by a decline. Peaks in CRP on day 4 or later raise the suspicion of complications. CRP is not specific for any one complication but rather can help guide early appropriate clinical assessment and management. The natural postoperative CRP response peaks around postoperative day 2 (2.2) and declines thereafter. Rising CRP levels after postoperative day 3 are suspicious of surgical complications (p<0.01) with positive and negative predictive values of 83.3% and 77.8%, respectively. Therefore, serial postoperative CRP can be used as an adjunct to monitor outcomes in this group.

A survey of feeding and swallowing function after free jejunal flap reconstruction in cases of head and neck cancer.

Reconstructive surgery using the free jejunum flap for locally advanced head and neck cancer is effective in preserving the swallowing function; however, it does not allow normal oral intake in all patients. A total of 47 patients underwent surgery at Nara Medical University between Jan 2010 and Dec 2019. The patients' ages ranged from 48 to 86 years. Sites were the hypopharynx (33 cases), larynx and cervical esophagus (5 cases each) and oropharynx (4 cases). Swallowing function was assessed using videofluorography, from the start of oral intake to discharge, as well as meal form at discharge. Lateral-retropharyngeal-lymph node dissection (LRPLND), preoperative radiation therapy, extended resection to the nasopharynx and incidence of stenosis in the jejuno-esophageal anastomosis were examined. Significant differences were revealed in the scores of pharyngeal residues of contrast medium and pharyngeal contraction, with and without preoperative radiotherapy. LRPLND did not affect swallowing function; dissection group cases had lower scores for soft palate elevation. Overall, resection extended to the nasopharynx, and the anastomosis method did not affect scores of swallowing function.

Analysis of various defects and reconstructive methods after invasive thyroid carcinoma resection

ObjectiveThe thyroid gland adjoins the trachea, pharynx, esophagus, carotid artery and cervical skin. Most thyroid carcinomas have been treated at lower stages; however, in some cases the carcinomas have invaded the surrounding organs. After resecting invasive thyroid carcinomas, the defects vary depending on the invasion area and organs affected; subsequent reconstructive methods vary depending on the size of defect and its components. This study analysed the pattern of defects and the reconstructive methods used following invasive thyroid carcinoma resection. MethodsFrom April 2011 to March 2021, 665 patients in Saitama Cancer Center (Saitama, Japan) were diagnosed with thyroid carcinoma and subsequently underwent thyroidectomies. In the 25 patients (3.8%), the thyroid carcinoma invaded surrounding organs and any reconstructive surgery—including end-to-end tracheal anastomosis and simple pharynx closure—was performed after thyroid carcinoma resection. The patients’ records were retrospectively reviewed, and the defects and subsequent reconstructive methods were analysed. ResultsWhen our new classification system was applied to the defects, the number of cases for each type was totaled: Tr0: 1; Tr1a: 3; Tr2b: 5; Tr3a: 1; La-Tr3b+PE2: 7; La-Tr3b+PE2+S2: 1; PE1: 1; PE1+S1: 2; S1: 2; S2: 2. For Tr0, a tracheal fenestration was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr1a defect, a tracheal fenestration was performed with cervical skin after the tumor resection and the tracheal fenestration was closed with a deltopectoral flap or pectralis major musculocutaneous flap. In one recent patient, the tracheal fenestration was reconstructed using free forearm flap and cervical skin, and the fenestration was closed with a hinge flap. For Tr2b defect, free forearm flap and costal cartilage graft reconstruction was performed after the tumor resection and the fenestration was closed with a hinge flap. For Tr3a defect, end-to-end anastomosis was performed in one patient. For La-Tr3b+PE2 defect, total pharyngolaryngectomy with free jejunal flap reconstruction was performed. For PE1 defect, a simple closure was performed in one patient and a PMMC muscle flap was used for covering the suture line in two patients. For S1 and S2 defect, PMMC flap or DP flap was used. ConclusionOur analysis of defects and reconstructive methods defines the complex defect patterns occurring after invasive thyroid carcinoma resection, describes the patterns of subsequent reconstructive methods.

Postoperative Complications and Swallowing Function after Jejunal and Skin Flap Reconstruction for Hypopharyngeal Carcinoma-A Multicenter Retrospective Study.

This study compared the incidence of perioperative complications and swallowing function between free jejunal flap reconstruction and cutaneous free tissue flap construction. We included 223 patients who underwent hypopharyngeal reconstruction using free flap. At discharge, +the free jejunal flap was associated with a Functional Oral Intake Scale (FOIS) score of 1–6 in 132 cases (70%) and a score of 7 in 56 cases (30%). Regarding the cutaneous free tissue flaps, FOIS scores of 1–6 were observed in 18 cases (51%), and a score of 7 was noted in 17 cases (49%). Donor site complications occurred in 12% of the patients who underwent free jejunal flap procedures and in none of the patients who underwent cutaneous free tissue flap procedures. We found that the free jejunal flap had a regular dietary intake rate in 56 patients (30%), whereas cutaneous free tissue flaps had a regular dietary intake rate in 17 patients (49%). Cutaneous free tissue flaps had a significantly higher regular dietary intake rate at discharge and a significantly lower incidence of donor site complications than free jejunal flaps. In conclusion, free-flap reconstruction may be a better method than free jejunal flap reconstruction for the treatment of hypopharyngeal cancer.

Total Pharyngo-Laryngo-Cervical-Esophagectomy with Jejunal Free Flap Reconstruction in a Developing Country: A Case Report from Vietnam

Patient: Male, 52-year-old Final Diagnosis: Hypopharyngeal cancer Symptoms: Dysphagia Medication:— Clinical Procedure: Surgery and radiotherapy Specialty: Oncology • Surgery Objective: Rare disease Background:Esophageal invasion in hypopharyngeal cancer is an uncommon lesion and has a poor prognosis. Total pharyngo-laryngo-esophagectomy is the most effective treatment option. Reconstruction of the gastrointestinal tract in the same period of surgery is required. There are many different options, such as pedicle flap, gastric pull-up, pedicled transverse colon flaps, and free flap. In cases where only cervical esophagectomy is required, with benefits for patients, jejunal free flap is the first choice to reconstruct the esophagus. However, the extensive surgical resection requires interdisciplinary collaboration among surgical specialities, which is not always available.Case Report:A 52-year-old male patient came to us with a chief concern of dysphagia, which first appeared 3 months ago. Rigid fiberoptic and direct laryngoscopes indirectly observed the tumor at the posterior wall; it had passed the esophagus opening and infiltrated to the cervical esophagus, with the rightmost part spread into the right pyriform sinus. Histopathology studies of the tumor showed a squamous cell carcinoma. The patient underwent total pharyngo-laryngo-cervico-esophagectomy, reconstructed with a jejunal free flap, and adjuvant radiation therapy after surgery. At follow-up 1 year after surgery, the patient was significantly recovery with no signs of tumor recurrence, no difficulties of oral intake, and his speech was restored by electrolarynx.Conclusions:We reported the case of a patient with hypopharyngeal cancer who underwent total pharyngo-laryngo-cervicoesophagectomy and esophagus reconstruction using a jejunal free flap, performed for the first time in Vietnam. As expected, with good oncological and functional results, the degree of invasiveness and sequelae of the surgery can be well tolerated.

Primary pharyngolaryngectomy with jejunal free flap reconstruction: a single centre's evolving experience.

Head and neck squamous cell carcinoma, and in particular hypopharyngeal squamous cell carcinoma, has long been associated with disfiguring treatment options, significant morbidity and limited long-term survival outcomes. Total pharyngolaryngectomy (TPL) with free flap reconstruction followed by post-operative radiation therapy or chemoradiotherapy is a widely accepted treatment of choice for advanced disease of the hypopharynx. Our unit undertook a 11-year review of all primary TPL patients aiming to provide an update on survival outcomes, morbidity, post-operative complications and evolving management strategies. We report one of the largest single-centre series to date with 89 patients undergoing primary TPL between 2003 and 2013, and compare these outcomes to 180 patients undergoing TPL at the same facility in the previous 23 years. Between study periods, we saw a shift in patient population towards higher stage disease (T-stage 3 or 4 97% 2003-2013; 68% 1979-2002) and increased nodal involvement (node positive 88% 2003-2013; 70% 1979-2002) without a subsequent reduction in 5-year disease-specific survival (52% 2003-2013; 52% 1979-2002) or 5-year overall survival (32% 2003-2013; 33% 1979-2002).

Swallowing disorders following free jejunal flap reconstruction of circumferential pharyngeal defect: Does Botox help?

Free jejunal flap for circumferential pharyngeal reconstruction is associated with late-onset dysphagia, regurgitation and prolonged transit time. This study aims to assess the feasibility and efficacy of Botulinum toxin A (Botox) in alleviating such swallowing dysfunction. Twenty-six consecutive patients underwent free jejunal flap for circumferential pharyngeal reconstruction between January 2012 and December 2018. Outcomes were compared at 6, 12 and 24months. In the non-Botox group (n=13), video-fluoroscopic and manometry studies demonstrated asynchronous contractions and retrograde propulsion. All patients complained of nasal regurgitation on thin fluids at 6, 12 and 24months. Bolus residue accumulation along jejunal mucosal folds resulted in prolonged transit time. In the Botox group (n=13), amplitude of asynchronous contractions were lower: 25.4mmHg vs. 52.1mmHg (p=0.037) for thin fluids at 12months. Three patients complained of nasal regurgitation on thin fluids at 6months. All 3 were asymptomatic at 12months. Transit time was shortened overall. Functional Oral Intake Scale was higher. MD Anderson Dysphagia Inventory global (72.5% vs 45.7%, p=0.003) and functional (62.0% vs 40.6%, p=0.012) subscales were significantly improved at 24months. Botox safely and effectively alleviates swallowing dysfunction associated with free jejunal flap for circumferential pharyngeal reconstruction.

Dysphagia following pharyngo-laryngectomy and free jejunal flap reconstruction with dissection of retropharyngeal lymph node

Dysphagia following pharyngo-laryngectomy and free jejunal flap reconstruction with dissection of retropharyngeal lymph node

Abstract: Swallowing Outcomes of Hypopharyngeal Reconstruction with Free Jejunal Flap - Retrospective Statistical Analysis of 83 Consecutive Cases in Japanese Single Institution -

INTRODUCTION: Total pharyngo-laryngo-esophagectomy (TPLE) and free jejunal flap (FJ) reconstruction has been a widely used procedure for extensive hypopharyngeal or laryngeal cancer. There are several reports that assess swallowing outcomes of hypopharyngeal reconstruction with FJ flap. Pre/postoperative irradiation, chemotherapy and resection of lateral retropharyngeal (Rouviere) lymph nodes are known factors to influence postoperative swallowing outcomes in Caucasian people. However, to date, little is known regarding the influential factors in Asian people. In the current report, we retrospectively analyze postoperative functional outcome of patients in one institution in Japan and statistically assessed influential factors for swallowing outcome. PATIENTS and METHODS: From January of 2007 to October of 2017, 83 cases that underwent FJ transfer for hypopharyngeal reconstruction in Nagoya University hospital are included in the study. The patients were 58 males and 25 females, with a mean age at the operation of 66.2 years. Indication for the operation included 67 hypopharyngeal cancers, 10 laryngeal cancers and 6 esophageal stenoses due to irradiation or operative scar formation. Pre/postoperative chemoradiotherapy, operative technique as well as postoperative complication are listed for possible influential factors associated with postoperative outcomes. Swallowing functions were extracted from medical records. Statistical analysis was performed utilizing (SAS 9.4, SAS Institute, United States), and univariate regression analysis as well as multivariate regression analysis were performed. P value under 0.05 was considered as statistically significant. RESULTS: FJ flap failure resulted from venous thrombosis in one patient and was rescued with staged pectoralis major flap transfer. 3 months post-operatively, 55.6 % of patients could tolerate normal diet. This rate was 66.1 % at 6 months and 76.9 % at 12 months after the operation. Anastomotic stapler was found to be a risk factor for dysphagia at 3 and 6 months postoperatively, but was not a risk factor at 12 months. Neither preoperative nor postoperative radiotherapy was found to be risks for dysphagia. DISCUSSION: Swallowing outcome is a result of a complex relationship of multiple factors such as age, pre/postoperative chemoradiotherapy, surgical intervention and rehabilitation. In this study, the anastomotic stapler was found to be a risk factor for dysphagia in the early postoperative phase; however, this relationship disappeared at one year. Balloon dilation procedure or rehabilitation might have improved the outcome during the course. These analysis may help to improve operative procedure to achieve best postoperative functional outcome.

Morbidity and Functional Outcomes following Free Jejunal Flap Reconstruction for Head and Neck Cancer

Aim: To evaluate the morbidity and fundamental functional outcomes (swallow and speech) after free jejunal flap (FJF) reconstruction following total pharyngolaryngo-esophagectomy (PLE) in China. Methods: 18 patients with FJF reconstruction after total PLE were retrospectively reviewed. Scheduled barium swallow test was performed 7-10 days postoperatively. Rehabilitation of swallowing and speech for patients was assessed by the Performance Status Scale for Head and Neck Cancer Patients. Results: 8 patients died of tumor recurrence and 2 patients died of other reasons (cerebrovascular disease and respiratory disease, respectively). The 1-year, 2-year, and 3-year survival rates were 70.5, 49.4, and 33.8%, respectively. 83.3% of all patients could tolerate soft chewable foods, such as cooked vegetables, fish, hamburger, and small pieces of meat. 2 patients with early stenosis at upper anastomotic sites were with good swallowing function; while 2 patients with early stenosis at lower anastomotic sites were found to have difficulty in oral diet. 2 (11.1%) patients with larynx-preserving pharyngo-esophagectomy showed no compromise in speech. Only 2 (11.1%) patients underwent primary tracheoesophageal puncture for inserting an indwelling voice prosthesis for speech, and both patients achieved functional tracheoesophageal speech. The remaining 14 (77.8%) patients with total PLE did not resume functional speech. Conclusion: Postoperative barium swallow examination is helpful to predict long-term anastomotic stenosis. Good functional swallow rehabilitation is achieved following FJF reconstruction after total PLE or a larynx-preserving procedure. However, the speech outcomes are not satisfactory. It raises the demand of enhancement of functional recovery so that quality of life can be improved for these patients in China.

Multi-disciplinary treatment increases the survival rate of late stage pharyngeal, laryngeal or cervical esophageal cancers treated by free jejunal flap reconstruction after cancer resection

To investigate the survival status of patients with pharyngeal, laryngeal or cervical esophageal cancers, who received free jejunal flap (FJF) to repair the defects following tumor resection, and to analyze the effect of multi-disciplinary treatment on their survival. Fifty-eight patients with pharyngeal, laryngeal or cervical esophageal cancer underwent free jejunal flap (FJF) reconstruction after cancer resection between 2010 and 2013. All their clinical records were reviewed and analyzed. The success rate of flap transplantation was 91.4% (53/58). The 2-year overall survival rates (OSR) of cervical esophageal cancer and hypopharyngeal cancer patients were 67.5% and 49.3%, respectively, both were significantly better than that of laryngeal cancer. The main causes of death were local recurrence and distant metastases. The group with no short-term complications had a better two-year OSR (59.0%) than the group with short-term complications (46.6%), however, the difference between them was not significant (P=0.103). The 2-year survival rate of the initial treatment group was 65.0%, better than that of the salvage treatment group (49.4%), but the difference was not significant (P=0.051). For the stage III and IV patients, the multi-disciplinary treatment group had a significantly better 2-year OSR (64.7%) than the single or sequential treatment group (37.0%, P=0.016). Free jejunal flap reconstruction is an ideal option for repairing the cervical digestive tract circumferential defects caused by tumor resection with a high success rate and a low mortality. Compared with the single or sequential treatment, multi-disciplinary treatment can significantly improve the survival rate of late-stage hypopharyngeal and cervical esophageal cancer patients.

Safety of intra‐operative vasopressor in free jejunal flap reconstruction

Microvascular surgeons always hold strong belief against the use of vasopressors during free flap surgery. Our aim is to study the safety of intra-operative vasopressors on free jejunal flap reconstruction. A retrospective chart review was performed on patients undergoing free jejunal flap reconstruction, aiming at investigating the intra-operative use of vasopressors and the potential complications associated. Between 1984 and 2012, 110 free jejunal flaps were performed for reconstruction of circumferential pharyngeal defects created after resection of cancers of the hypopharynx. Intra-operative vasopressor was given in 81 (73.6%) patients. The most common vasopressors used were ephedrine (42.7%), phenylephrine (14.5%) or both (42.8%). They were administered to the patients before the start of flap harvesting (n = 32, 29.1%), during the flap harvesting (n = 30, 27.3%), during microvascular anastomosis (n = 20, 18.2%), or they were given more than once during the whole operation (n = 28, 25.4%). The incidence of intra-operative re-anastomosis due to thrombosis was 4.5% and the post-operative flap failure rate was 5.4%. There was no significant relationship between the administration of vasopressor during surgery and the need for intra-operative re-anastomosis, post-operative flap failure and the timing of flap failure. Similarly, there was also no relationship between the timing of vasopressor administration and the above variables. The long-term stricture rate was 2.7%, the risk of which was not increased by the intra-operative use of vasopressors. The intra-operative use of vasopressors is safe in free jejunal flap reconstruction.

Early prediction of anastomotic leakage after free jejunal flap reconstruction of circumferential pharyngeal defects

Anastomotic leakage from the free jejunal flap, if diagnosed late, can result in catastrophes. Our study aims to look for clinical parameters that allow early identification of leakage so that appropriate interventions can be taken. Between 1980 and 2011, consecutive patients with free jejunal flap reconstruction of circumferential pharyngeal defects were included. A retrospective chart review was then performed comparing the clinical parameters (body temperature, heart rate, serum albumin, haemoglobin and white cell count) between patients with no leakage and those with clinical and radiological leakage. 4. Ninety-six patients were included in the study. The median age was 62 years. Majority (69.8%) of the defects were created after resection of tumours in the hypopharynx. Five (5.2%) patients had clinical leakage and 12 (12.5%) had radiological leakage. There was no significant difference in body temperature, heart rate, incidence of atrial fibrillation and haemoglobin level between those with and without leakage. The serum white cell count was higher in the patients who leaked, but it became statistically significant only after day 7 postoperatively. The serum albumin level was significantly lower in patients with anastomotic leakage starting as early as day 3 after surgery, and the difference persisted until the leak was controlled. However, there was no significant difference in the plasma albumin level between those with clinical or radiological leak. Both serum albumin level and white cell count identified the presence of anastomotic leakage from the free jejunal flap. Serum albumin allows early prediction of leakage so that early interventions can be taken to avoid the damage resulting from the delay in diagnosis.

Jejunal free flap reconstruction of the pharyngolaryngectomy defect: 368 Consecutive cases

The Jejunal Free Flap (JFF) was first described by Seidenberg in 1957 for the reconstruction of pharyngolryngectomy defects. Historically, its outcome profile has been better than alternative reconstructions. Recently, the use of tubed Fasciocutaneous Free Flaps (FCFF) has been increasing as series reporting outcomes superior or equivalent to JFF are published. Our experience with JFF has been more positive than recently published reports suggest. This study aims to provide an accurate and up-to-date assessment of outcomes in JFF reconstruction of pharyngolaryngectomy defects and to compare these results to those of contemporary alternative techniques. 368 Consecutive free jejunum reconstructions were performed for pharyngolaryngectomy defects between 1977 and 2010. All patients had been assessed by a multidisciplinary Head and Neck Clinic prior to surgery. A systematic review of recent literature pertaining to pharyngolaryngectomy reconstruction outcomes was undertaken for comparison with our dataset. 70.9% of tumours in this series were T-grade 3 or 4. Perioperative mortality was 3.8% and flap failure occurred in 2.98%. The incidence of anastomotic leak was 8.2% and stricture occurred in 10.9%. A full oral diet was maintained by 91.6% of patients by day 12 on average. 70.6% underwent primary tracheo-oesophageal puncture and of these 78.1% had effective speech. Overall, our data compares favourably with other series. The strengths of the JFF reconstruction are the capacity to maintain an oral diet, low stricture and leak rates and the versatility to reconstruct long segment defects. We have observed variability in leak rates throughout the study period, which may be operator dependant. The gap between outcomes for FCFF and JFF reconstructions has narrowed but the latter remains our reconstruction of choice for pharyngolaryngectomy defects.

Surgical Management of Pharyngocutaneous Fistula After Total Laryngectomy

The increased use of radiation in the primary management of laryngeal carcinoma has resulted in an increase in pharyngocutaneous fistula (PCF) formation after salvage laryngectomy. The impact of this practice on surgical management strategies has been analyzed. A retrospective review of 177 patients treated by total laryngectomy for laryngeal or hypopharyngeal squamous cell carcinoma was performed. PCF formation was documented and management strategies were analyzed. Preoperative radiation therapy (XRT) was administered to 86 patients (48.6%). Postoperative PCF developed in 47 patients (26.5%), including 30 (34.9%) who had received preoperative XRT versus 17 (18.6%) who had not received XRT (P = 0.015). Spontaneous PCF closure occurred in 23 patients (48.9%). Two patients died with persistent, untreated PCF. Surgical closure of PCF was performed in 22 patients (46.8%), including 17 who had received preoperative radiation (77.3%). Reconstructive methods included 9 local flaps, 17 pectoralis major (PM) flaps, and 2 free jejunal flaps. Seven of the 9 (77.8%) patients treated with local flaps had received XRT. Three patients had successful fistula closure including 2 who had not received radiation. Six of 9 patients (66.7%) developed recurrent fistulization after local flap closure necessitating PM flap closure. Overall, 14 patients (82.4%) had received preoperative XRT prior to PM flap closure. Six patients (35.3%) who had received XRT developed recurrent fistulization and 5 of these fistulas eventually closed with local wound care. The remaining patient succumbed to a carotid artery rupture. Two patients required a completion pharyngectomy and free jejunal flap reconstruction. PM flaps were used in both cases to provide soft-tissue coverage. Preoperative XRT increases the risk of PCF after laryngectomy and the need for surgical closure. Local flap closure has a limited role in the surgical management of PCF. PM flap reconstruction has a high complication rate including recurrent fistulization in the setting of preoperative radiation.