Thirty-five years of single surgeon experience in the reconstruction of esophagus and voice with free ileocolon flap following total pharyngolaryngectomy

Perforator‐based chimeric anterolateral thigh flap U‐shaped insetting for total pharyngoesophageal reconstruction: Surgical technique and functional outcomes

BACKGROUND

Pharyngoesophageal reconstruction with the tubed anterolateral thigh (ALT) flap is burdened by possible strictures and pharyngocutaneous fistulae (PCF). We present our experience with the U-shaped insetting of perforator-based chimeric ALT flap focusing on surgical technique, complications and functional outcomes.

METHODS

We retrospectively included 10 patients with a total circumferential defect of the hypopharynx undergoing reconstruction with ALT flap. A perforator-based chimeric ALT flap with two independent skin paddles was harvested: the trapezoid paddle with the greater base cranially and the height oriented vertically was used for pharyngoesophageal reconstruction while the second paddle was exteriorized and used for flap monitoring and reducing tension on skin closure. Mean age was 56.4 years. Eight patients were affected by squamous cell carcinoma. Modified barium swallow radiogram and fiberoptic laryngoscopy were performed to assess strictures and PCFs. Swallowing and speech outcomes were evaluated through the Deglutition Handicap Index (DHI), M.D. Anderson Dysphagia Inventory (MDADI) and Voice Handicap Index (VHI) questionnaires.

RESULTS

Mean flap dimension was 7.9 × 6 × 9.2 cm. Mean ischemia time was 58.2 min (range 42-80). No flap loss nor flap-related complications were reported. Two PCFs were observed. Fiberoptic laryngoscopy documented a complete integration of the flap with no strictures or stenosis. Mean follow-up was 13.6 months (range 1-45 months). Mean DHI score was 33.8, mean MDADI score was 62.5, mean VHI score was 32.2.

CONCLUSIONS

The ALT flap U-shaped insetting is a reliable option for pharyngoesophageal reconstruction yielding a high success rate, low number of strictures and fistulae and good swallowing and voice outcomes.

Reconstruction of Pharyngolaryngeal Defects with the Ileocolon Free Flap: A Comprehensive Review and How to Optimize Outcomes

Several reconstructive methods have been reported to restore the continuity of the aerodigestive tract following resection of pharyngeal and hypopharyngeal cancers. However, high complication rates have been reported after voice prosthesis insertion. In this setting, the ileocolon free flap (ICFF) offers a tubularized flap for reconstruction of the hypopharynx while providing a natural phonation tube. Herein, we systematically reviewed the current evidence on the use of the ICFF for reconstruction of the aerodigestive tract. A systematic literature search was conducted across PubMed MEDLINE, Web of Science, ScienceDirect, Scopus, and Ovid MEDLINE(R). Data on the technical considerations and surgical and functional outcomes were extracted. Twenty-one studies were included. The mean age and follow-up were 54.65 years and 24.72 months, respectively. An isoperistaltic or antiperistaltic standard ICFF, patch flap, or chimeric seromuscular-ICFF can be used depending on the patients' needs. The seromuscular chimeric flap is useful to augment the closure of the distal anastomotic site. The maximum phonation time, frequency, and sound pressure level (dB) were higher with ileal segments of 7 to 15 cm. The incidence of postoperative leakage ranged from 0 to 13.3%, and the majority was occurring at the coloesophageal junction. The revision rate of the microanastomosis ranged from 0 to 16.6%. The ICFF provides a reliable and versatile alternative for reconstruction of middle-size defects of the aerodigestive tract. Its three-dimensional configuration and functional anatomy encourage early speech and deglutition without a prosthetic valve and minimal donor-site morbidity.

Free Colon Tissue Transfer for the Management of Xerostomia in Head and Neck Cancer Patients: A Bacteriological Study and Clinical Case Series

INTRODUCTION

Patients with head and neck cancer may suffer from xerostomia after repetitive surgery or radiation therapy. Free colon tissue transfer was used to restore the lubrication of the oral cavity, and a bacteriological study in mice was conducted to evaluate how the intestine transfer from the intra-abdominal to extra-abdominal locations may affect bacterial colonization.

PATIENTS AND METHODS

Twelve patients received free colon transfer for the reconstruction of their intraoral mucosal defect following trismus release. Thirty-five patients received ileocolon flap transfer to fill the pharyngeal defects. In an animal study with mice, a pedicled ileum segment was transferred to the subcutaneous space of the abdominal wall. The transferred ileum segments were biopsied for bacterial genome analysis after 3 months.

RESULTS

All but one transferred flap survived. Colon secretion was suitable for oral lubrication without the unpleasant smell 1 month postoperatively. In an animal study, genome analysis showed that the same bacterial species still existed in the transferred intestinal tissue.

CONCLUSIONS

No unpleasant smell or infections were noted in this clinical series despite the animal study showing that the bacterial spectrum did not change in the transferred intestine. Therefore, free colon tissue transfer could safely provide lubrication in patients with xerostomia.

Risks of Laparoscopic Harvest of Free Intestinal Flaps for Esophageal Reconstruction

BACKGROUND

Performing ablative surgery using an laparoscope is a common practice. However, its use in the harvest of a segment of intestine for reconstruction has 2 major challenges: risk of damage to the vascular pedicle of the flap as well as to the vessels of other parts of the intestine that remain in the peritoneal cavity and risk of damage to the intestinal flap while pulling it out through a small opening in the abdominal wall. The aim of this study was to report advantages and disadvantages of harvesting free intestinal flaps using the laparoscopic method, explaining the challenges faced and lessons learned from this experience.

PATIENTS AND METHODS

Free intestinal flaps were harvested by laparoscopy in 12 patients aged 28 to 63 years. There were 9 free jejunal flaps for the reconstruction of the cervical esophagus and 3 ileocolic flaps for the reconstruction of both the cervical esophagus and voice reconstruction.

RESULTS

In 1 patient, laparoscopy was converted to laparotomy due to previous colectomy, which resulted in compromised circulation to the rest of the colon. One jejunal flap had leakage at its pharyngeal end; therefore, a pectoralis major myocutaneous flap was used for closure. In addition, 1 ileocolic flap had partial loss of its anterior wall, and a free anterolateral flap was used as a patch for closure. Furthermore, it was very difficult to harvest 1 free jejunal flap due to the thick and fat mesentery.

CONCLUSION

Prolonged operative times, unexpected leakage at the anastomosis sites, partial loss of flaps, possible risk of vascular pedicle damage or venous compromise, demanding pedicle dissection in obese patients, and requirement of conversion to laparotomy are the major drawbacks of harvesting free intestinal flaps by laparoscopy.

Speech Performance after Anterolateral Thigh Phonatory Tube Reconstruction for Total Laryngectomy

OBJECTIVE

Traditionally, after total laryngopharyngectomy (TLP), patients cannot speak without a prosthesis or an artificial larynx. In Taiwan, most patients use a commercialized pneumatic laryngeal device (PLD). Phonatory tube reconstruction with the anterolateral thigh (ALT) flap is a novel, modified version of synchronous digestive and phonatory reconstruction involving a free muscular cutaneous flap. This study reviewed and compared speech performance between patients who underwent novel flap reconstruction and conventional PLD users.

METHOD

We retrospectively reviewed patients with laryngeal or hypopharyngeal cancer who underwent TLP from August 2017 to September 2019. The voice handicap index (VHI), speech intelligibility, acoustic and aerodynamic analysis results, and speech range profile (SRP) were compared between patients who underwent ALT phonatory tube reconstruction (ALT group) and those using PLDs (PLD group).

RESULTS

Twenty patients were included; 13 patients were included in the ALT group, and 7 patients were included in the PLD group. Compared to the PLD group, the ALT group had a better fundamental frequency range (P < .001) and semitone range (P < .001) during speech but showed worse jitter, shimmer, and harmonic-to-noise ratios. The two groups showed comparable VHI and speech intelligibility performance.

CONCLUSIONS

The ALT phonatory tube, a novel flap for reconstruction, can restore digestive and voice functions simultaneously. Compared with PLD use, ALT phonatory tube reconstruction yields an improved speech range and comparable levels of voice handicap and speech intelligibility, suggesting that the technique is a good alternative for patients after TLP.

LEVEL OF EVIDENCE

4 Laryngoscope, 131:1349-1357, 2021.

Pharyngeal Reconstruction with Microvascular Free Tissue Transfer

Reconstruction of pharyngoesophageal defects after total laryngectomies and extirpation of hypopharyngeal and upper esophageal carcinomas presents a challenging task. Goals of reconstruction include adequate voice rehabilitation and restoration of normal swallowing. The reconstructive armamentarium contains many options for reconstruction and creation of a new upper digestive tract. This review article focuses on the most commonly used free tissue transfer options for the reconstruction of these defects, with an assessment of their advantages and disadvantages.