Free Jejunal Flap Research Articles

The Relationship Between Ischemia Time and Mucous Secretion in Vaginal Reconstruction With the Jejunal Free Flap: An Experimental Study on the Rat Jejunum.

Jejunum flap for reconstruction of the vagina provides a durable, stable coverage; patent tube passage; and natural esthetic appearance. However, excessive mucous secretion is a major drawback of the technique.We have recently presented our cases in which strict 3-hour ischemia with lower mucus secretion was applied. However, a quantitative analysis of goblet cells of the jejunum subjected to ischemia and ischemia-reperfusion injury on an animal model has not been reported to support this argument.Because goblet cells are responsible for the production and the maintenance of the mucous blanket, we aimed to determine whether goblet cell numbers decrease after ischemia and ischemia-reperfusion injury.This study was conducted on 3 groups of 10 animals. We applied to the rat jejunum only ischemia in group 1, one hour of ischemia followed by reperfusion in group 2, and 2 hours of ischemia followed by reperfusion in group 3. Histological samples taken from the jejunum exposed to ischemia and ischemia-reperfusion injury were evaluated in terms of goblet cell numbers, inflammation, apoptotic bodies, and necrosis.Goblet cell numbers significantly decreased in the group of animals exposed to ischemia and exposed to ischemia-reperfusion injury. We think that mucus hypersecretion of the jejenum can be limited by applying a longer period of ischemia time during free flap transfer in vaginal reconstruction.

Successful treatment of quintuple primary cancer, including esophageal cancer: A case report.

The present study reports the rare case of a patient with quintuple primary cancer that underwent systematic treatment, including surgical intervention. A 63-year-old male patient was initially diagnosed with primary esophageal cancer and hypopharyngeal cancer. The patient underwent total pharyngolaryngoesophagectomy using a thoracoscopic method and reconstruction using the free jejunal flap and gastric tube and was subsequently administered adjuvant chemotherapy (80 mg/m2 intravenously on day 1, cisplatin; 800 mg/m2 continuous intravenous administration on days 1-5, 5-fluorouracil). At 66 years old, the patient was diagnosed with left maxillary sinus cancer and underwent chemoradiotherapy (four 100 mg/m2 arterial cisplatin injections; 70 Gy/35 f radiotherapy, 2 Gy per day over 35 days). At 68 years old, the patient was diagnosed with gastric tube cancer and underwent gastric tube resection followed by pedicled jejunum flap reconstruction. At 69 years old, the patient was diagnosed with tongue cancer and underwent resection and reconstruction of the tongue by pectoralis major myocutaneous flap. Six years subsequent to the primary surgery, the patient remains alive, without metastasis of the lesions. To the best of our knowledge, the present study is the first report of a patient that underwent a curative procedure for the treatment of five primary multiple cancers in five organs, including esophageal cancer.

Reconstructive Trends in Post-Ablation Patients with Esophagus and Hypopharynx Defect.

The main challenge in pharyngoesophageal reconstruction is the restoration of swallow and speech functions. The aim of this paper is to review the reconstructive options and associated complications for patients with head and neck cancer. A literature review was performed for pharynoesophagus reconstruction after ablative surgery of head and neck cancer for studies published between January 1980 to July 2015 and listed in the PubMed database. Search queries were made using a combination of 'esophagus' and 'free flap', 'microsurgical', or 'free tissue transfer'. The search query resulted in 123 studies, of which 33 studies were full text publications that met inclusion criteria. Further review into the reference of these 33 studies resulted in 15 additional studies to be included. The pharyngoesophagus reconstruction should be individualized for each patient and clinical context. Fasciocutaneous free flap and pedicled flap are effective for partial phayngoesophageal defect. Fasciocutaneous free flap and jejunal free flap are effective for circumferential defect. Pedicled flaps remain a safe option in the context of high surgical risk patients, presence of fistula. Among free flaps, anterolateral thigh free flap and jejunal free flap were associated with superior outcomes, when compared with radial forearm free flap. Speech function is reported to be better for the fasciocutaneous free flap than for the jejunal free flap.

Hypopharyngeal reconstruction: a comparison of three alternatives.

This study aimed to evaluate the operative outcomes of using gastric pull-up (GPU), pectoralis major myocutaneous flap (PMMF), and jejunal free flap (JFF) to reconstruct the hypopharynx after resection of hypopharyngeal and cervical esophageal carcinoma. Retrospective clinical study. Otolaryngology Department, Zagazig University Hospital, Egypt and Surgical Department, National Cancer Institute, Cairo, Egypt. Records of 104 patients who underwent resection of carcinoma of the hypopharynx and cervical esophagus were reviewed to determine the indications for radical resection, location, and stage of the primary tumor, gross and pathological surgical resection margins, operative complications, morbidity, and mortality. Reconstruction was performed using the GPU for group (1) (n = 33), PMMF for group (2) (n = 34), and JFF for group (3) (n = 37). The hypopharynx was the most common primary tumor site for group (2) and group (3) whereas group (1) had lesions more frequently in the cervical esophagus. The overall postoperative morbidity rate was 20.2% with a perioperative mortality rate of 6.7% and there was no significant difference between the three groups. There was no graft necrosis in group (1) compared to 5.9% in group (2) and 5.4% in group (3). Pulmonary complications occurred commonly (30.3%) in group (1) compared to 11.8% in group (2) and 10.8% in group (3) The overall 3 years survival rate was 67.3% and there was no significant difference between the three groups. The outcomes of the three techniques are equally successful when used appropriately. The nature of the defect indicates the method of reconstruction. For short reconstruction above the thoracic inlet, PMMF or JFF are equally effective and in tumors requiring total esophagectomy, GPA is indicated.

Free jejunum reconstruction and laryngeal preservation for squamous cell carcinoma in the pharyngoesophageal junction

Try to use free jejunum flaps reconstruction and laryngeal preservation for squamous cell carcinoma (SCC) in the pharyngoesophageal junction. Thirteen patients who underwent resections of SCC in the pharyngoesophageal junction with free jejunal interposition from August 2007 to December 2012 were reviewed. Of them, 8 had T3 lesions, 4 had T4 lesions, and one had radiation failure with rT2 lesion. Ten patients were treated with postoperative radiotherapy with a average dosage of 56 Gy. The 3 year over all survival rate was 47.9% and disease-specific survival rate was 34.2%. The surgical complications occurred in 9 patients (9/13), including one death and one flap failure. Five patients (5/13) had permanent tracheal canulation, 10 patients (10/13) resumed oral feeding and all patients achieved reasonable speech. Free jejunum interposition can be used to reconstruct surgical defect of SCC in the pharyngoesophageal junction, thus preserving the larynx and ensuring a better quality of life for the patients.

Free jejunal flap transfer for pharyngoesophageal reconstruction in patients with intestinal malrotation: Two case reports

Intestinal malrotation results from failure of intestinal rotation and fixation during fetal life. We report two cases of esophageal reconstruction with free jejunal flaps following total laryngopharyngectomy of hypopharyngeal and cervical esophageal carcinoma in which intestinal malrotation was detected during the jejunal flap harvesting. In both cases, the ligament of Treitz was absent, and the laparotomy incision was thus extended to identify the jejunum. In case 1, harvesting an adequate length of the vascular pedicle of the flap was impossible because of the abnormal position of the pancreas; thus, a jejunal flap of maximal length was harvested for optimal pedicle positioning in the recipient site. In case 2, Ladd's ligament prohibited the release of the jejunum from the ascending colon and required its dissection. Both patients underwent successful reconstruction. When the ligament of Treitz is absent during jejunal flap harvesting, investing the whole bowel by extended laparotomy incision is recommended. When anatomical abnormality caused by intestinal malrotation is detected, releasing an adhesion of the jejunum from circumferential organs and identifying the adequate vascular pedicle of a jejunal flap are necessary. If harvesting the long vascular pedicle is impossible, a jejunal flap of maximal length should be harvested for optimal positioning for vascular anastomosis at the shortest distance in the recipient site.

Esophagectomy with gastric tube reconstruction for patients who previously underwent free jejunal transfer

Free jejunal transfer (FJT) has become one of the standard techniques used for reconstruction after total pharyngolaryngocervical esophagectomy (TPLCe); however, there are increasing concerns regarding the incidence of secondary esophageal cancer (EC) in these patients. We performed esophagectomy with gastric tube reconstruction in patients with EC who had previously undergone TPLCe with FJT. Patient 1 was a 53-year-old woman who previously received definitive chemoradiotherapy (dCRT) for middle thoracic EC. She subsequently underwent TPLCe with FJT for hypopharyngeal cancer. However, the recurrence of EC was found in the middle thoracic esophagus. Patient 2 was a 64-year-old man who previously underwent TPLCe with FJT for hypopharyngeal cancer. He subsequently underwent endoscopic submucosal dissection and dCRT for thoracic EC. He was readmitted with severe esophageal stricture following dCRT. Salvage esophagectomy with lymphadenectomy were performed. Right thoracotomy was performed in patient 1, whereas a laparoscopic transhiatal approach was used without thoracotomy in patient 2. After dissection of the thoracic esophagus, a cervical incision was made on the opposite side of the supplying vessels of the free jejunal flap (FJF) in both patients. The FJF was detected and its distal side was carefully exposed without damaging its supplying vessels or those of the permanent tracheal stoma. A gastric tube was pulled up via a posterior mediastinal route, and an anastomosis was made between the FJF and gastric tube. Postoperative recovery was uneventful in patient 1. Although minor anastomotic leakage was found in patient 2, it healed immediately with drainage treatment. The surgical approach for these patients must be chosen carefully in order to preserve the FJF, permanent tracheal stoma, and their blood supplies.

Intraoperative free jejunum flap monitoring with indocyanine green near-infrared angiography

The free jejunum flap technique has been regarded as the optimal approach during circumferential pharyngolaryngectomy reconstruction. Although classical patency tests are available, an intraoperative guarantee of the patency of anastomoses and microcirculations is inevitable. Indocyanine green near-infrared angiography (ICGA) was intraoperatively performed in six patients after reconstruction using the free jejunum flap. An adequate arterial as well as venous phase was observed. In addition to classical patency tests and doppler, we have successfully monitored the flap after total pharyngolalyngectomy intraoperatively using the ICGA. Our preliminary results implicate that this novel technique offers secure intraoperative monitoring of a free jejunum graft. This technique will provide us with advantages over regular patency test in selected cases.

The anterolateral fasciocutaneous thigh flap for circumferential pharyngeal defects—can it really replace the jejunum?

Free jejunal transfer has been used in pharyngeal reconstruction for many years, but many have criticised it as being unreliable, poorly tolerant of radiotherapy, and susceptible to stenosis and dysphagia. Recently, the trend has been to use the anterolateral thigh (ALT) flap to overcome these problems, and many authors have reported good results. At the University of Birmingham we used the jejunal free flap for pharyngeal reconstruction for many years, but in view of recent reports we changed to the ALT flap. We retrospectively analysed all patients who had pharyngeal reconstruction with an ALT flap in our unit since changing from the jejunal flap. Only circumferential defects were included. Six patients had pharyngeal resection and required reconstruction of a circumferential defect between 2007 and 2010. All the defects were reconstructed with a tubed ALT flap. No flaps failed and there was no partial necrosis. However, stricturing still occurred and the diet of many patients was restricted. Three patients required the flap to be replaced with a jejunal free flap. Although no flaps failed, we have not been able to replicate the results of other surgeons and have therefore abandoned use of the ALT flap and returned to use of the jejunal free flap for the reconstruction of circumferential pharyngeal defects.

当院における下咽頭癌に対する遊離空腸移植症例の検討

2002年7月から2011年12月までの期間に，当院において下咽頭・喉頭・頸部食道全摘術（咽喉食摘術）および遊離空腸移植を行った47例（男性40例，女性7例，平均年齢64.3歳）について，術後合併症および術後摂食機能について検討した。術前放射線照射を行っていた症例は15例であり，手術に追加する治療として節外浸潤や腫瘍切除断端が陽性であった24例に対して術後放射線照射を行った。移植した遊離空腸は全例で生着した。創部感染やリークは術前照射を受けた症例で多く，高度吻合部狭窄は術後放射線照射を受けた症例に多い傾向が見られた。高齢によるものと考えられる摂食障害は認めず，遊離空腸移植は咽喉食的術後の下咽頭再建において安全な術式であると考えられた。

Pharyngoesophageal reconstruction after resection of hypopharyngeal carcinoma: a new algorithm after analysis of 142 cases.

BackgroundThe aim of this study is to define an algorithm for the choice of reconstructive method for defects after laryngo-pharyngo-esophagectomy for hypopharyngeal carcinoma.MethodsOne hundred and forty two cases of hypopharyngeal carcinoma were included and operated on by either partial pharyngectomy, total pharyngectomy or esophagectomy. The reconstructive method was tailored according to the resected segment.ResultsPectoralis flap was used in 48 cases, free jejunal flap in 28 cases, augmented colon bypass in 4 cases, gastric pull up in 32 cases and gastric tube in 30 cases. Mean hospital stay was 12 days. Mortality rate was 10.6% and morbidity rate was 31.7%. Total flap failure occurred in 3 cases of free flap and one case of pectoralis flap. There were 23 cases of early fistula. Late stricture occurred in 19 cases, being highest with myocutaneous flap (early fistula 12/50 and late stricture 13/50).ConclusionFree jejunal flap was the flap of choice for reconstruction when the safety margin is still above the clavicle. In cases with added esophagectomy, we recommend gastric tube as a method of choice for reconstruction.

Jejunal free flap for reconstruction of pharyngeal defects in patients with head and neck cancer—the Birmingham experience

We retrospectively audited operative complications, success of flaps, and speech and swallowing outcomes in patients with head and neck cancer who had reconstruction with jejunal free tissue transfer to the pharynx. A total of 104 patients had jejunal free flaps between 1987 and 2009 at University Hospital, Birmingham. Management was by a multidisciplinary team, and the same vascular surgeon did all the anastomoses. We investigated the relations between patients, operative factors, and postoperative complications, and noted the ischaemic time of the flaps and coexisting conditions of the patients. Outcomes measured included initial and final survival rates of flaps, donor and recipient site complications, and speech and swallowing outcomes on discharge and up to 2 years postoperatively. Of the 104 patients, 14 (13%) had initial flap complications but overall flap survival was 97%. A total of 11 (11%) patients developed a fistula at a mean of 15 days postoperatively and 11 (11%) had minor donor site complications. A total of 95 (91%) were able to resume oral diet on discharge. Of the 44 who were followed up on discharge, 32 (73%) were able to maintain oral intake at 2 years and 31 (70%) could use their voice in everyday situations. The jejunal free flap enables the tumour to be removed, and reconstruction and restoration of function to be done in a single operation using tissue that is versatile. The operation is associated with low morbidity at the donor and recipient sites, and results in good speech and swallowing outcomes. The flap can also be used to reconstruct pharyngolaryngeal defects.

A two-stage operation for thoracic esophageal cancer: esophagectomy and subsequent reconstruction by a free jejunal flap

When the stomach is unavailable for esophageal reconstruction due to previous gastrectomy or synchronous gastric cancer, a pedicled jejunum or colon, with or without vascular supercharge, has been the alternative. However, these reconstructions are not free from severe complications, such as necrosis. We have introduced a new surgical technique for delayed esophageal reconstruction using a free jejunal flap. We used this technique in 11 patients. Four weeks after subtotal esophagectomy, reconstruction using free jejunal flaps was performed. A free jejunum was placed at the pre-sternum, and the internal thoracic artery and vein were usually used as the recipient vessels. There were no cases of flap necrosis and no hospital deaths. Anastomotic leakage occurred in two cases. Both leakages were cured by conservative treatment. Delayed esophageal reconstruction using a free jejunal flap can be considered to be a safe procedure when the stomach is unavailable as an esophageal substitute.

Sexual Function and Long-Term Results Following Vaginal Reconstruction with Free Vascular Jejunal Flap

Sexual adjustment and long-term results following vaginal reconstruction with free vascular jejunal flap are not well known. The study aims to investigate sexual adjustment and long-term results among patients who underwent vaginal reconstruction with free vascular jejunal flap. A total of 34 women, aged 16-31 years (mean 23.5), who underwent vaginal reconstruction with a vascular jejunal flap between 2005 and 2011 were evaluated. Indications for reconstruction included the following: Mayer Rokitansky Kuster Hauser syndrome (29 patients), isolated vaginal agenesis (2 patients), androgen insensitivity syndrome (2 patients), and (1) history of gynecologic-oncologic surgery. The study evaluates the perioperative results, complications, satisfaction with sexual function, length and width of the neovagina. All of the surgeries were completed without any intraoperative complications. Three patients required reoperation because of postoperative venous compromise in the grafts. The flap success rate was 100%, and no infection was observed for any case. The mean follow-up was 50 months (between 20 and 87 months). The mean vaginal depth and diameter were satisfactory for all cases. Postoperatively, six patients complained of jejunal hypersecretion, one patient complained of mucosal prolapse, and one patient complained of vaginal constriction. The neovaginal prolapse was repaired via minor surgery. Twenty-seven were married and sexually active. Twenty patients completed the questionnaire on sexual function. Sexual function was assessed using the Female Sexual Function Index (FSFI). Eleven patients were satisfied with their sexual lives after surgery (FSFI scores≥25). Based on our results, satisfactory sexual function was achieved using the free jejunal vascular flap.

Survival and Functional Outcomes following Total Glossectomy

Objectives: Total glossectomy is a morbid procedure offered to patients with advanced tumors of the oral cavity and oropharynx. Reconstruction of the resultant defect is typically performed immediately after resection, with regional and free tissue transfer being most commonly used. The goals of this study are to demonstrate: 1) long-term survival, 2) long-term swallowing outcomes, 3) rate of tracheostomy dependence, and 4) reconstructive techniques utilized after total glossectomy. Methods: Retrospective chart review of patients who received total glossectomy at Vanderbilt between 2000 and 2010. Survival and functional outcomes were followed from the day of the surgery to the last outpatient note. Results: 22 patients were included in this study, and 15 patients were alive 1 year post-surgery. Average length of survival after the operation was 715 days. 4 patients received concomitant total laryngectomy. 14 of 18 patients that received tracheostomy were able to be decannulated, with an average time to decannulation of 23 days. 6 of the 22 patients were able to maintain 100% of their nutrition with PO feedings at 12 months post-surgery. Reconstructive methods included 8 anterolateral thigh free flaps, 4 pectoralis flaps, 4 radial forearm free flaps, 2 scapular free flaps, 1 latissimus free flap, 2 lateral arm free flaps, and 1 jejunal free flap. Conclusions: Total glossectomy can significantly extend the lives of patients with advanced tongue cancer. However, this operation carries significant morbidity in regards to swallowing, and potentially the need for long-term tracheostomy.

Using transplant related experience in head and neck reconstruction: improving the tolerance of ischaemia by infusing free jejunal flaps with specialized transplant preservation fluid

The free jejunum flap is commonly used in the reconstruction of post ablative pharyngooesophageal defects. The sensitivity of jejunal flap to ischaemia is one of the challenges for the flap survival which has a direct impact on the time needed for flap inset and microvascular surgery. The viability of the flap is crucial from the point of maintaining the tubular continuity and preventing an anastomotic leak.

A recipient vessel modification in vaginal reconstruction with free jejunal flap

A recipient vessel modification in vaginal reconstruction with free jejunal flap

Reconstruction of large pharyngeal defects with microvascular free flaps and myocutaneous pedicled flaps

The current review will focus on the therapeutic options for reconstruction of large and complex defects of the oropharynx and hypopharynx, and the cervical esophagus following surgery for squamous cell carcinoma. The advantages and disadvantages of pedicled flaps, including the pectoralis major myocutaneous flap (PMMF) and supraclavicular artery flap (SAF), as well as the fasciocutaneous free flaps, including the radial forearm free flap (RFFF), the anterolateral thigh flap (ALT), and the jejunum free flap, are reviewed with particular emphasis on the literature from the past 2 years. For partial pharyngeal defects, several reconstructive options, that is, PMMF, RFFF, SAF, and ALT might all be appropriate. When large mucosal surfaces need reconstruction, RFFF seems to be the most utilized. Nevertheless in reviewing the literature, no specific pedicled or free flap seems superior over other options. In cases of tongue reconstruction ALT or RFFF may be appropriate. After circumferential resections of the hypopharynx and cervical esophagus, free flaps achieve a significantly lower fistula and stricture rate compared to pedicled flaps with ALT and free jejunal flaps being used most commonly. However, donor-site morbidity and the complications of jejunal harvesting can be significant. Due to its great versatility, good reported functional and oncological outcomes, and reduced overall complication rate, the ALT flap warrants consideration. Finally, transoral robotic surgery (TORS) may provide future options for reconstruction. Currently the head and neck surgeon has a diverse armamentarium available to reconstruct even large and complex pharyngeal defects. Selecting the best reconstructive option must be individualized. Fasciocutaneous free flaps, that is, RFFF and especially ALT, are assuming a greater progressive role in pharyngeal reconstruction. TORS may eventually lead to new options for reconstructive surgery.

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.

Non-occlusive mesenteric ischaemia of a free jejunal flap

Free jejunal transfer using microsurgery after oesophageal or pharyngeal cancer resection is a useful operative approach. However, the disadvantage of free tissue transfer is the risk of necrosis of the transferred tissue due to impaired blood supply. In addition, jejunal flaps are more prone to blood-flow disorders such as ischaemia and congestion compared with other types of flaps. The causes of local blood supply disorders after microsurgery are divided broadly into two classes: one is thrombosis of an artery and/or vein in the anastomotic region and the other consists of local physical factors such as compressive pressure derived from haematoma formation and the effect of infection of the vascular pedicle. In this report, two rare cases of blood-flow disorder of the transferred free jejunum are described. In both cases, no signs of significant infection or occlusion of the vascular pedicles were present and late necrosis progressed gradually. The patients showed remarkable weight loss and a poor nutritional state due to inadequate preoperative nutritional intake. The necrosis was considered to be a result of non-occlusive mesenteric ischaemia of a free jejunal flap, and the factors contributing to free jejunal necrosis were reviewed.