Mesenteric flap in free jejunal transfers: a versatile technique for head and neck reconstruction

Stripped Mesenteric Flap: A Novel Option for Preventing Anastomotic Leakage in Circumferential Pharyngeal Reconstruction

Reconstruction of a circumferential pharyngeal defect with a free jejunal flap is a well-established procedure. However, anastomotic leakage often occurs, which can lead to abscess formation, pharyngocutaneous fistula formation, and carotid rupture. Previous reports have described covering the anastomotic site with a mesenteric flap to prevent anastomotic leakage. However, the mesentery is covered by a serosal membrane, which interferes with adhesion and vascular communication. Therefore, we stripped off the serosal membrane to accelerate adhesion to the anastomotic site. We retrospectively studied patients who had a history of radiotherapy and who had received a stripped mesenteric flap in a circumferential pharyngeal reconstruction procedure. We collected the following data: operative time, blood loss, postoperative complications, interval to resumption of oral intake, and duration of hospital stay. We obtained data for 11 patients. The jejunal flap failed in one patient because of arterial thrombosis. One of the other 10 patients developed anastomotic leakage caused by congested mucous membrane necrosis. The patient was treated conservatively and showed no clinical symptoms of infection or inflammation. The 9 remaining patients had no anastomotic leakage. In the present series, although anastomotic leakage was observed in one of 10 patients who underwent circumferential pharyngeal reconstruction using a stripped mesenteric flap, the severity of the leakage was minimized.

The Use of the Sternocleidomastoid Flap Helps Reduce Complications After Free Jejunal Flap Reconstructions in Total Laryngectomy and Cervical Esophagectomy Defects

PURPOSE

Esophageal reconstruction after tumor extirpation or ingestion injury is a difficult problem for the reconstructive plastic surgeon. Free tubed fasciocutaneous flaps and intestinal flaps have become the mainstay for reconstruction. The free jejunal flap has the advantage of replacing like-with-like tissue and having lower fistula rates. Additionally, the "mesenteric wrap" modification and prophylactic pectoralis major muscle have been described to further decrease anastomotic leaks and fistulae. The purpose of this study was to describe the use of the prophylactic pedicled sternocleidomastoid (SCM) flap for prevention of anastomotic leaks and fistulae.

METHODS

A retrospective review of patients who underwent reconstruction of circumferential pharyngoesophageal defects with a free jejunal flap by a single surgeon from 2008 to 2012 was performed. Those who received a prophylactic pedicled SCM flap to reinforce one of their jejunal anastomoses were selected for this study, and their outcomes were analyzed. Patients' demographics, comorbidities, complications, and clinical outcomes were collected and analyzed.

RESULTS

Three patients underwent reinforcement of one jejunal anastomosis with a pedicled SCM flap. The mean age was 60 years, and average follow-up was 27 months. Two patients received postoperative radiation, and one patient received both preoperative and postoperative radiation. The recipient vessels included the facial artery, internal jugular vein, and facial vein. The flap survival rate was 100%. There was 1 stricture and 1 fistula that occurred at the anastomoses without the SCM muscle reinforcement. There were no complications at the jejunal anastomotic sites that were reinforced with the SCM muscle. Of the 6 anastomotic sites in 3 patients, there was a 0% fistula rate and 0% stricture rate at the sites reinforced with the SCM muscle versus a 33% fistula rate and a 33% stricture rate at the sites without the SCM muscle flap. One patient was diagnosed with local tumor recurrence and eventually succumbed to the progression of their disease. All patients were able to tolerate an oral diet without supplemental feeds. All patients were able to achieve intelligible speech via an electrolarynx or esophageal speech.

CONCLUSION

Reconstruction of pharyngoesophageal defects can be technically challenging and requires extensive planning and careful execution. The free jejunal flap restores alimentary continuity with good functional outcomes. Fistula rates may be decreased with the use of a prophylactic SCM flap to reinforce the jejunal anastomosis.

[Strategy in the treatment of hypopharyngeal and cervical esophageal carcinoma]

In the period between January 1st, 1978 and January 1st, 2003, 82 unselected patients with hypopharyngeal and cervical esophageal squamocellular carcinoma were treated at the Department of Esophagogastric Surgery, First University Surgical Hospital, Clinical Center of Serbia. In 43 (52.4%) patients operated with curative intent, radical surgical en-block resection and functional neck dissection has been performed. In 26 (60.5%) patient reconstruction was performed with stomach, in 11 (25.6%) left colon, and 6 (14%) free jejunal transfer. The overall 2-year and 5-year survival rate were 55.88% (19 patients) and 26.47% (9 patients), respectively. No patient undergoing nutritive gastrostomy and radiotherapy was alive after two years. At present surgery looks like the treatment of choice for hypopharyngeal and cervical esophageal carcinoma, providing a definitive palliation of dysphagia and better long-term survival. Free jejunal transfer has become the standard technique for reconstruction of the pharynx and hypopharynx especially with proximal lesions, whereas, gastric tube interposition is the technique of choice for reconstruction of the hypopharynx and cervical esophagus when the resection extends below the thoracic inlet or when there is a presence of synchronous carcinoma of theesophageal.

Use of tubed gastro-omental free flap for hypopharynx and cervical esophagus reconstruction after total laryngo-pharyngectomy

In case of total laryngo-pharyngectomy (TLP), replacement of the pharyngoesophageal segment is more often done with jejunal flap; however, in some cases, this flap doesn't represent the best surgical technique of reconstruction. The tubed gastro-omental free flap (TGO) offers an alternative procedure in selective cases. The objective of the study was to assess the TGO as a method of pharyngoesophageal reconstruction. Our study was based on a literature review and a retrospective study of six consecutive cases of TGO reconstruction after TLP. Six patients aged from 52 to 70 years underwent TGO reconstruction after TLP. Five patients had previously received systemic chemotherapy and external irradiation at curative doses, and three had undergone previous surgery. No abdominal complication occurred. Partial necrosis of the gastric flap occurred in one case. Except for this case, the feeding tube could be removed after 15 days. One patient was successfully treated with pneumatic esophageal dilatation for stricture 2 months after surgery. Four patients died of loco-regional tumor evolution or distant metastatic disease. For both of the patients who survived (mean follow-up, 40 months), a normal diet and an esophageal voice were obtained. The TGO offers a safe method of reconstructing the pharyngoesophageal segment in a surgical field compromised of previous multimodal therapy.

Jejunum free flap in hypopharynx reconstruction: case series

BACKGROUND

Surgical treatment of hypopharyngeal cancers with extension to the retrocricoid region generally requires a circumferential pharyngolaryngectomy followed by a reconstruction of the removed segment of the upper digestive tract. Historically, many techniques have been used in order to achieve a safe and functional reconstruction. Jejunum interposition is generally considered the best reconstructive technique.

METHODS

This study examines the details of the surgical technique, the complications, the oncological and the functional results in a series of 29 consecutive patients submitted to circumferential pharyngoesophageal resection for advanced hypopharyngeal cancer followed by reconstruction with a free flap of jejunum.

RESULTS

Three of the transplants failed because of venous thrombosis. The overall success rate was 90%. There were no general complications. A good swallowing has been preserved in all our patients. All our patients where a phonatory prosthesis was positioned (20/29) were able to achieve speech following speech therapy and all were satisfied with their own capacity to communicate.

CONCLUSIONS

The prognosis of hypopharyngeal tumours (18-40% at 5 years) remains poor, but jejunum autografts are being shown to be an excellent choice for the reconstruction of the cervical hypopharyngo-oesophagus offering the patient fast rehabilitation and a reasonable quality of survival. Our experience confirm that this kind of reconstruction is safe with a good results in improving oncologic controls and restoring a good quality of life.

Bilateral Jejuno-mesenteric flap for reconstruction of complicated pharyngoesophageal defect

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

The free radical forearm flap: a reliable method for reconstruction of the laryngohypopharynx after in-continuity resection

Between 1992 and 1996 14 patients with a squamous cell carcinoma of the laryngohypopharynx underwent tumour resection and primary reconstruction with the free volar forearm flap. Tumour resection was performed by a head and neck surgeon and reconstruction by a plastic surgeon. Preoperative radiotherapy was given to 13 patients and postoperative radiation to one patient. Thirteen patients were male and one patient was female, with a mean age of 66 years (range 53-79 years). The flap was harvested from the left forearm in 12 cases and from the right in two. The mean operation time was 12 h (range 11-20 h), and the mean intraoperative bleeding volume was 700 ml (range 400-1,000 ml). Twelve of 14 flaps survived. One flap was totally lost 3 weeks postoperatively and another was partially lost 2 weeks after surgery. Overall revisional surgery was carried out in six patients. Infections and fistulae at the neck occurred in six of the 14 patients. Six of the 14 patients were alive at follow-up. One patient died of an acute haemorrhage from an oesophageal ulcer 2 months after surgery, one patient died of a second primary oesophageal cancer and six patients developed recurrences. The mean survival time was 26 months (range 2-43 months).

Use of intraperitoneal vessels in reconstructive microsurgery: an account of 117 cases

The purpose of this study was to evaluate our experience of microvascular anastomosis of intraperitoneal vessels. Between 1985 and 1994, 117 microsurgical reconstructions were done using intraperitoneal vessels. These included oesophageal reconstruction (n = 106), reconstruction of the hepatic arterial, superior mesenteric arterial, or portal venous system (n = 8), and reconstruction of the chest or abdominal wall (n = 3). We used 129 intraperitoneal arteries and 117 intraperitoneal veins. Of a total of 246 intraperitoneal vessels, five hepatic arteries, seven splenic, 14 gastroepiploic, six superior mesenteric, 178 jejunal, 30 ileocolic, four middle colic arteries or veins, and two portal veins were used for microvascular anastomosis. The overall successful rate for these reconstructive cases was 97% (114/117). Microsurgical use of intraperitoneal vessels is a safe and developing procedure in plastic and reconstructive surgery.