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Gasteratos K, Vlachopoulos N, Kokosis G, Goverman J. Efficacy and Safety of Microsurgical Pharyngolaryngeal and Pharyngoesophageal Reconstruction: A Systematic Review of the Literature. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2023; 11:e4958. [PMID: 37124383 PMCID: PMC10146040 DOI: 10.1097/gox.0000000000004958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Accepted: 03/06/2023] [Indexed: 05/02/2023]
Abstract
Restoration of function and complication management after pharyngolaryngectomy remains a challenging task. The aim of our study was to compare the functional and clinical outcomes of pharyngolaryngeal and pharyngoesophageal reconstruction using free flaps, namely jejunal (FJF), anterolateral thigh, and radial forearm, and describe a reconstructive approach for these defects following tumor resection. Methods We performed a systematic literature review on PubMed (Medline), Embase and Cochrane Library over the last two decades for articles reporting the surgical reconstructive modalities available after total or partial pharyngeal and/or laryngeal resection using a structured search strategy and strict inclusion and elimination criteria. Results Our search identified a total of 677 articles, 112 full texts were fully reviewed for eligibility, and 39 met the inclusion criteria. The use of both FJF and fasciocutaneous flaps is safe. The FJF has optimal swallowing outcomes and a low incidence of major recipient-site complications. Nevertheless, free fasciocutaneous flaps exhibit comparable functional results, while they seem linked with fewer cases of perioperative mortality and flap failure. However, none of the currently available techniques can combine all potential benefits. Conclusions Despite these procedures being mainly palliative in nature, the advent of microvascular techniques and utilization of fasciocutaneous free flaps has allowed optimal restoration of function combined with a reduced rate of perioperative and longterm complications. Both FJF and fasciocutaneous flaps can be viable treatment options, depending on the expertise of the surgeon and patient selection, to ensure the best outcomes.
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Affiliation(s)
| | | | - George Kokosis
- Division of Plastic and Reconstructive Surgery, Rush University Medical Center, Chicago, Ill
| | - Jeremy Goverman
- Sumner M. Redstone Burn Center, Department of Surgery, Massachusetts General Hospital, Boston, Mass
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2
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Schmidt F, Ward M, Repanos C. Postoperative serum C-reactive protein dynamics after pharyngolaryngectomy with jejunal free-flap reconstruction. Ann R Coll Surg Engl 2023; 105:263-268. [PMID: 35904323 PMCID: PMC9974345 DOI: 10.1308/rcsann.2021.0315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/25/2021] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION 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. METHODS 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. RESULTS 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. CONCLUSIONS 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.
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Affiliation(s)
- F Schmidt
- Portsmouth Hospitals University NHS Trust, UK
| | - M Ward
- Portsmouth Hospitals University NHS Trust, UK
| | - C Repanos
- Portsmouth Hospitals University NHS Trust, UK
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Mohan AT, Mahajan NN, Mardini S, Blackmon SH. Outcomes of Standardized Protocols in Supercharged Pedicled Jejunal Esophageal Reconstruction. Ann Thorac Surg 2023; 115:210-219. [PMID: 35718204 DOI: 10.1016/j.athoracsur.2022.05.048] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Revised: 05/02/2022] [Accepted: 05/25/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND This study evaluated clinical and patient-reported outcomes (PROs) of long-segment supercharged pedicled jejunal (SPJ) interposition after implementation of a dedicated multidisciplinary pathway and technical refinements. METHODS This study was a 6-year review of consecutive patients who underwent complex esophageal reconstruction with SPJ interposition. Clinical data were abstracted, and PRO data were collected prospectively by using the Upper Digestive Disease mobile application (UDD App). This standardized questionnaire comprised domains for mental and physical health, pain, dysphagia, reflux, hypoglycemia dumping, and gastrointestinal dumping symptoms. Operative refinements were comprehensively established by 2018. RESULTS A total of 19 patients were included in the study, 15 of whom had a history of esophageal malignant disease and neoadjuvant chemoradiation. Most patients (18; 95%) underwent delayed reconstruction after diversion. There was no 90-day mortality or flap loss. Most patients (18; 95%) achieved an enteral diet. Seven patients (37%) experienced early complications (<90 days) requiring procedural intervention. The incidence of any medical or surgical complication was similar in the earlier (2015-2017) and late (2018-2020) cohorts, but aspiration events, surgical site infections, anastomotic leak rates, and median hospital stay (reduced from 15 days [IQR, 10-21 days] to 9 days [IQR, 9-13 days]) improved in the contemporary cohort. PRO data were collected in 14 of 15 (93%) living patients. Severe symptoms in at least 1 domain were reported by most patients (11; 79%) and improved over time. CONCLUSIONS Dedicated care pathways allow standardization of complex procedures, and targeted modifications may optimize recovery and patient outcomes. This cohort of patients may report severe symptoms that require ongoing monitoring and intervention.
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Affiliation(s)
- Anita T Mohan
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Nandita N Mahajan
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Samir Mardini
- Division of Plastic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota
| | - Shanda H Blackmon
- Division of General Thoracic Surgery, Department of Surgery, Mayo Clinic, Rochester, Minnesota.
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Rebrikova IV, Vorotelyak EA, Rogovaya OS, Polyakov AP, Mordovskiy AV, Ratushny MV, Kaprin AD, Vasiliev AV. Hypopharyngeal reconstruction using prelaminated autologous bio-engineered pectoralis major flaps. RUSSIAN JOURNAL OF TRANSPLANTOLOGY AND ARTIFICIAL ORGANS 2022. [DOI: 10.15825/1995-1191-2022-4-135-144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
After removal of metastatic malignant tumors of the hypopharynx and larynx, hypopharyngeal defects are formed. To restore the hypopharynx, a mucosa and a muscular component are needed.The objective of this study is to develop a hypopharyngeal reconstruction technique using prelaminated pectoralis major flap with mucosal epithelium analogue from autologous epithelial layers.Materials and methods. Nine patients underwent reconstruction of the hypopharynx using bioengineered prelaminated pectoralis major flaps. The mucosa was restored by tissue-engineered autologous epithelial cell layers that were obtained by culturing in vitro cells isolated from skin biopsies that were previously obtained from patients.Results. Oral nutrition was restored in all cases. Pharyngeal stenosis was detected in one (11%) patient. A stratified squamous epithelium on the pectoral fascia was revealed in 67% of cases at week 2 after prelamination, in 89% of cases at week 4 after reconstruction and in 100% of cases at month 3, 6, 12 and 24 after reconstruction.Conclusion. Reconstruction using prelaminated bioengineered flaps allows recreating the anatomical integrity and function of the hypopharynx.
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Affiliation(s)
- I. V. Rebrikova
- National Medical Research Radiological Centre; RUDN University
| | | | | | - A. P. Polyakov
- National Medical Research Radiological Centre; RUDN University
| | | | | | - A. D Kaprin
- National Medical Research Radiological Centre
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5
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Yildirim MEC, Mousavi SA, Chen S, Lu T, Weng H, Chen H. Development of a benign colon tumour in the free colon flap after the oesophageal reconstruction. SURGICAL PRACTICE 2022. [DOI: 10.1111/1744-1633.12592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Affiliation(s)
- Mehmet Emin Cem Yildirim
- Department of Plastic Surgery Demiroglu Science Unıversity Florence Nightingale Hospital Istanbul Turkey
| | | | - Shih‐Heng Chen
- Department of Plastic Surgery Chang Gung Memorial Hospital Taipei Taiwan
| | - Ting‐Yu Lu
- Department of Thoracic Surgery China Medical University Hospital Taichung Taiwan
| | - Hui‐ching Weng
- Institute of Gerontology National Cheng Kung, University Tainan Taiwan
| | - Hung‐chi Chen
- Department of Plastic Surgery China Medical University Hospital Taichung Taiwan
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6
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Role of Total Laryngopharyngoesophagectomy with Gastric Pull Up in the Management of Locally Advanced Hypopharyngeal Cancers. Indian J Otolaryngol Head Neck Surg 2022; 74:127-135. [DOI: 10.1007/s12070-020-01806-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Accepted: 01/22/2020] [Indexed: 11/26/2022] Open
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Kim SD, Kim IG, Tran HN, Cho H, Janarthanan G, Noh I, Chung EJ. Three-Dimensional Printed Design of Antibiotic-Releasing Esophageal Patches for Antimicrobial Activity Prevention. Tissue Eng Part A 2021; 27:1490-1502. [PMID: 33847168 DOI: 10.1089/ten.tea.2020.0268] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Pharyngoesophageal defects can cause exposure to various bacterial flora and severe inflammation. We fabricated a biodegradable polycaprolactone (PCL) patch composed of both thin film and three-dimensional (3D) printed lattice, and then investigated the efficacy of pharyngoesophageal reconstruction by using 3D printed antibiotic-releasing PCL patches that inhibited early inflammation by sustained tetracycline (TCN) release from both thin PCL films and printed rods implanted in esophageal partial defects. PCL was 3D printed in lattice form on a presolution casted PCL thin film at ∼100 μm resolution. TCN was loaded onto the PCL-printed patches by 3D printing a mixture of TCN and PCL particles melted at 100°C. TCN exhibited sustained release in vitro for over 1 month. After loading TCN, the patches showed decreased tensile strength and Young's modulus, and less than 20% TCN was slowly released from the 2.5% TCN-loaded PCL patches over 150 days. Cytotoxicity tests of extract solutions from patch samples demonstrated excellent in vitro cell compatibility. Antibiotic-releasing PCL patches were then transplanted into partial esophageal defects in rats. Microcomputed tomography analysis revealed no leak of orally injected contrast agent in the entire esophagus. Tissue remodeling was examined through histological responses of M1 and M2 macrophages. In particular, the 1% and 3% TCN patch groups exhibited significant muscle layer regeneration by desmin immunostaining. Further histological and immunofluorescence analyses revealed that the 1% and 3% TCN patch groups exhibited the best esophageal regeneration according to reepithelialization, neovascularization, and elastin texture around the implanted sites. Our antibiotic-releasing patch successfully consolidates the regenerative potential of esophageal muscle and mucosa and the antibacterial activity of TCN for 3D esophageal reconstruction. Impact statement Anastomosis site leakage and necrosis after pharyngoesophageal transplantation inevitably causes mortality because the mediastinum and neck compartments become contaminated. Herein, we present antibiotic-releasing pharyngoesophageal patch that prevents saliva leakage and has an antimicrobial effect. We have demonstrated antibiotic release profile and mechanical properties for esophageal transplantation. Upon esophageal transplantation of antibiotic-releasing polycaprolactone patches, antimicrobial effects and muscle regeneration around the graft sites were clearly identified in the group containing 1% and 3% of tetracycline. The esophageal graft led to the remarkable recovery throughout reepithelialization, neovascularization, and elastin texture of around the implanted sites. We believe that current system is capable of various applications that require antibacterial in vivo.
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Affiliation(s)
- Seong Dong Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, National Medical Center, Seoul, Republic of Korea
| | - In Gul Kim
- Department of Otorhinolaryngology-Head and Neck Surgery, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hao Nguyen Tran
- Department of Chemical and Biomolecular Engineering, Seoul National University of Science and Technology, Seoul, Republic of Korea
| | - Hana Cho
- Department of Otorhinolaryngology-Head and Neck Surgery, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Gopinathan Janarthanan
- Department of Chemical and Biomolecular Engineering, Seoul National University of Science and Technology, Seoul, Republic of Korea
- Convergence Institute of Biomedical Engineering and Biomaterials, Seoul National University of Science and Technology, Seoul, Republic of Korea
| | - Insup Noh
- Department of Chemical and Biomolecular Engineering, Seoul National University of Science and Technology, Seoul, Republic of Korea
- Convergence Institute of Biomedical Engineering and Biomaterials, Seoul National University of Science and Technology, Seoul, Republic of Korea
| | - Eun-Jae Chung
- Department of Otorhinolaryngology-Head and Neck Surgery, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
- Department of Otorhinolaryngology-Head and Neck Surgery, College of Medicine, Seoul National University, Seoul, Republic of Korea
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Spaulding SL, Ansari E, Xing MH, Sandler ML, O'Malley QF, Ho R, Spitzer H, Levy J, Ganz C, Khorsandi AS, Mundi N, Urken ML. Diagnosis and management of pharyngoesophageal stenosis: A comprehensive approach to prophylactic, endoscopic, and reconstructive treatment options. Am J Otolaryngol 2021; 42:103003. [PMID: 33894689 DOI: 10.1016/j.amjoto.2021.103003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2021] [Accepted: 03/15/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Pharyngoesophageal stenosis (PES) is a serious complication that substantially impacts functional outcomes and quality of life (QOL) for up to a third of head and neck cancer patients who undergo radiotherapy. Dysphagia is often multifactorial in nature and is a devastating complication of treatment that impacts patients' QOL, general health and overall wellbeing. The authors detail the clinical presentation, risk factors, imaging characteristics, preventive measures, and multimodality treatment options for PES. METHODS The authors present a comprehensive management algorithm for PES, including treatment by dilation, stenting, spray cryotherapy and dilation, and reconstructive treatment options utilizing different pedicled and free flaps. RESULTS The authors advocate for a thorough assessment of the extent and degree of pharyngoesophageal involvement of PES to determine the optimal management strategy. CONCLUSIONS The development of post treatment dysphagia requires appropriate imaging and biopsy, when indicated, to rule out the presence of persistent/recurrent cancer. Multidisciplinary management by a team of physicians well-versed in the range of diagnostic and therapeutic interventions available for PES is critical to its successful management.
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Affiliation(s)
- Sarah L Spaulding
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Edward Ansari
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
| | - Monica H Xing
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America.
| | - Mykayla L Sandler
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Quinn F O'Malley
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Rebecca Ho
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Hannah Spitzer
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Juliana Levy
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Cindy Ganz
- The Thyroid, Head, and Neck Cancer (THANC) Foundation, New York, NY 10003, United States of America
| | - Azita S Khorsandi
- Department of Radiology, New York Eye and Ear Infirmary, New York, NY 10003, United States of America
| | - Neil Mundi
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
| | - Mark L Urken
- Department of Otolaryngology-Head and Neck Surgery, Icahn School of Medicine at Mount Sinai, New York, NY 10003, United States of America
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9
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Bouhadana G, Azzi AJ, Gilardino MS. The ideal flap for reconstruction of circumferential pharyngeal defects: A systematic review and meta-analysis of surgical outcomes. J Plast Reconstr Aesthet Surg 2021; 74:1779-1790. [PMID: 33931325 DOI: 10.1016/j.bjps.2021.03.042] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2020] [Revised: 02/10/2021] [Accepted: 03/11/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND There is a lack of consensus regarding the superiority of the common free flaps for the reconstruction of circumferential pharyngeal defects. METHODS A systematic literature search was conducted to identify studies reporting the complications of circumferential pharyngeal reconstruction between 2005 and 2020. Anterolateral thigh free flaps (ALTFF), jejunal free flaps (JFF), and radial forearm free flaps (RFFF) were compared. Various complications were compared by meta-analysis. Primary endpoints were fistula and stricture rates. RESULTS Forty studies were included (2230 patients). Stricture rate was similarly low with tubed ALTFF (13.3%, n = 36/270) and JFF (13.2%, n = 176/1334). Fistula rate was the lowest with JFF (9.2%, n = 58/634). ALTFF was associated with the lowest rates of partial and complete flap failure (3.8%, n = 6/157, and 2.8%, n = 5/178), infection (2.8%, n = 3/106), donor site morbidity (3.9%, n = 5/130), and mortality (0%, n = 0/101) within 30 days. A meta-analysis demonstrated that there was no statistically significant difference in stricture and fistula rates between ALTFF and JFF. Moreover, JFF was associated with a significantly lower fistula rate than that of RFFF (p < 0.001). ALTFF was associated with a significantly lower infection rate than that of JFF (p = 0.013). CONCLUSIONS The data suggest the use of ALTFF for circumferential pharyngeal defects. In the absence of randomized, prospective data, the authors hope the results presented can be used as an evidence-based reference.
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Affiliation(s)
| | - Alain J Azzi
- Division of Plastic and Reconstructive Surgery, McGill University, 1650 Cedar Avenue, Montreal H3G 1A4, Quebec, Canada.
| | - Mirko S Gilardino
- Division of Plastic and Reconstructive Surgery, McGill University, 1650 Cedar Avenue, Montreal H3G 1A4, Quebec, Canada
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10
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Tubed Anterolateral Thigh Free Flap for Pharyngoesophageal Reconstruction. PLASTIC AND RECONSTRUCTIVE SURGERY-GLOBAL OPEN 2020; 8:e3046. [PMID: 33133931 PMCID: PMC7544307 DOI: 10.1097/gox.0000000000003046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 06/22/2020] [Indexed: 11/25/2022]
Abstract
Caustic ingestions can severely injure the upper and lower aerodigestive tract, resulting in detrimental mucosal changes both acutely and chronically. Injuries are most severe following alkaline ingestion. Esophagectomy is often recommended in patients with high-grade esophageal injuries to mitigate the risk of perforation. Esophageal reconstruction after these injuries is often delayed, and staged, allowing adequate tissue stabilization before further manipulation. Here, we report on a 25 year-old woman who presented with a high-grade caustic esophageal injury following the ingestion of an alkaline drain cleaner. She underwent an emergent thoracic esophagectomy, gastrectomy and a cervical salivary esophagostomy. Post-operatively, she developed supraglottic and hypopharyngeal strictures, but maintained a functional larynx. She subsequently underwent a staged, extrathoracic total esophageal reconstruction using an anterolateral thigh (ALT) myocutaneous free flap with laryngeal preservation. Although serial esophageal dilatations and trans-oral laser procedures for pharyngeal strictures were required, she was able to maintain the ability to swallow.
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11
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Sert G, Chen SH, Chen HC. Repair of the marginal artery with an interpositional vein graft during colon interposition for esophageal reconstruction. Microsurgery 2020; 40:823-824. [PMID: 32533784 DOI: 10.1002/micr.30618] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2020] [Revised: 04/13/2020] [Accepted: 05/29/2020] [Indexed: 11/07/2022]
Affiliation(s)
- Gokhan Sert
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Shih-Heng Chen
- Department of Plastic and Reconstructive Surgery, Chang-Gung Memorial Hospital, Taipei, Taiwan
| | - Hung-Chi Chen
- Department of Plastic Surgery, China Medical University Hospital, Taichung, Taiwan
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12
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Chilgar RM, Nicoli F, Baljer B, Ciudad P, Manrique OJ, Sacak B, Orfaniotis G, Chen HC. Modified distal anastomosis between colon and thoracic esophagus for hypopharynx reconstruction using free colon flap: A comparison study. Asian J Surg 2020; 43:907-912. [PMID: 31959573 DOI: 10.1016/j.asjsur.2019.11.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2018] [Revised: 02/27/2019] [Accepted: 11/20/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND Free colon flap is the preferred method of hypopharynx reconstruction when the defect is substantial, or simultaneous voice reconstruction is planned. Most of the complications in free colon flaps are located at the anastomosis between colon and thoracic esophagus due to size mismatch of the lumen. We present our experience comparing a modified anastomosis technique and a conventional anastomosis technique at the distal end of interposed colonic segment. METHODS In this retrospective review, 94 patients, divided into two groups, underwent hypopharynx reconstruction. Group A (18 patients), conventional anastomoses between colon and thoracic esophagus was performed, while in Group B (76 patients), underwent the modified method of anastomosis. RESULTS The average follow-up period was 46 months in group A and 54 months in group B. Fistula formation was found in 2 patients from Group A, and 1 patient from Group B. Strictures were observed in 4 patients from Group A, and 1 patient from Group B. Difference between both groups regarding complications of leakage and stricture formation was statistically significant (p < 0.05). CONCLUSION Modified method for anastomosis between colon and thoracic esophagus was found to be effective in the reduction of complications associated with the use of a free colon flap for hypopharyngeal reconstruction. Further advances of this technique could gain momentum in the future.
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Affiliation(s)
- Ram M Chilgar
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Fabio Nicoli
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan; Department of Plastic and Reconstructive Surgery, University of Rome "Tor Vergata", Italy; Department of Plastic and Reconstructive Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom.
| | - Bence Baljer
- Department of Plastic and Reconstructive Surgery, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, United Kingdom; Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Pedro Ciudad
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Oscar J Manrique
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan; Division of Plastic and Reconstructive Surgery, Mayo Clinic Minnesota, Rochester, MN, USA
| | - Bulent Sacak
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan
| | - Georgios Orfaniotis
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan; Department of Plastic and Reconstructive Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Hung-Chi Chen
- Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.
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13
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Sokoya M, Vincent A, Cohn JE, Kadakia S, Kohlert S, Ducic Y. Comparison of radial forearm free flap and gastric pull-up in pharyngo-oesophageal reconstruction. Clin Otolaryngol 2019; 44:405-407. [PMID: 30618077 DOI: 10.1111/coa.13279] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2018] [Revised: 10/01/2018] [Accepted: 10/17/2018] [Indexed: 11/29/2022]
Affiliation(s)
- Mofiyinfolu Sokoya
- Department of Otolaryngology, University of Colorado School of Medicine, Aurora, Colorado
| | | | - Jason E Cohn
- Department of Otolaryngology-Head and Neck Surgery, Philadelphia College of Osteopathic Medicine, Philadelphia, Pennsylvania
| | - Sameep Kadakia
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
| | - Scott Kohlert
- Department of Otolaryngology - Head and Neck Surgery, University of Ottawa, Ottawa, ON, Canada
| | - Yadranko Ducic
- Otolaryngology and Facial Plastic Surgery Associates, Fort Worth, Texas
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14
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Pegan A, Rašić I, Košec A, Solter D, Vagić D, Bedeković V, Ivkić M. TYPE II HYPOPHARYNGEAL DEFECT RECONSTRUCTION - A SINGLE INSTITUTION EXPERIENCE. Acta Clin Croat 2018; 57:673-680. [PMID: 31168205 PMCID: PMC6544115 DOI: 10.20471/acc.2018.57.04.10] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
SUMMARY – There are several options for hypopharyngeal reconstruction depending on defect size. Reconstructive options include primary closure, local flaps, regional axial flaps or regional intestinal flaps, and free flap transfer with skin or intestinal free flaps. The preferred method of reconstruction should minimize early postoperative complications that prolong hospital stay and/or become life threatening, ensure early restoration of function and decrease donor site morbidity. The purpose of this study was to evaluate functional outcomes of different flap reconstruction methods in type II hypopharyngeal defects. In this non-randomized retrospective cohort study, data on 31 (27 male and four female) patients were collected over a 10-year period of single institution type II hypopharyngeal defect reconstructions. The following measures of functional outcome were extracted from patient medical histories: postoperative complications (flap failure, fistula formation, donor site related complications), hospital stay in days and swallowing function after 14 days, 1 month and 6 months. There were nine patients in the radial forearm free flap (RFFF) reconstruction group, seven in the jejunum reconstruction group, and 15 in the gastric tube reconstruction group. In the RFFF group, three patients experienced flap failure; in the jejunal transfer group, no donor site morbidity was observed; whereas three patients from the gastric tube reconstruction group had minor abdominal skin wound dehiscence. Out of the 3 different reconstructive methods, RFFF was most likely to fail. The mean duration of hospital stay was 22.6 days, being shortest in the RFFF group. There were no significant differences in early postoperative swallowing function among the groups. The choice of flap used for hypopharynx reconstruction should be driven by donor site factors and functional outcomes. When assessing type II hypopharyngeal defect reconstruction results, the findings of this study suggest that free jejunal flaps and gastric tubes offer superior functional results in comparison with RFFFs.
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Affiliation(s)
| | - Ivan Rašić
- University of Zagreb, School of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Andro Košec
- University of Zagreb, School of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Darko Solter
- University of Zagreb, School of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Davor Vagić
- University of Zagreb, School of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Vladimir Bedeković
- University of Zagreb, School of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
| | - Mirko Ivkić
- University of Zagreb, School of Medicine, Department of Otorhinolaryngology and Head and Neck Surgery, Sestre milosrdnice University Hospital Centre, Zagreb, Croatia
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15
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Cuthbert R, Deutsch C, Roy A, Stimpson P, Patel H. Postoperative monitoring of the free jejunal flap: use of colour duplex and systematic review of available techniques. Ann R Coll Surg Engl 2018. [PMID: 29543049 DOI: 10.1308/rcsann.2018.0043] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Introduction The free jejunal flap represents the gold standard for circumferential defects in upper digestive tract reconstruction. It is a technically demanding procedure with significant failure rates. Unrecognised failure leads to flap necrosis and potentially fatal sequelae, including sepsis and carotid artery bleed. Despite these catastrophic consequences, however, there remains no consensus on an optimum method for postoperative flap monitoring. Our unit has pioneered the use of external colour duplex ultrasound to monitor flap vascularity. We describe this technique and systematically review other published monitoring systems. Materials and methods A patient underwent oesophageal reconstruction using a jejunal free flap. Monitoring commenced immediately via external application of a colour duplex probe over the flap's vascular pedicle to facilitate flow volume assessment. Further bi-daily assessments were successfully used to monitor the postoperative viability of the flap. The systematic review was conducted in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Results Six alternative monitoring techniques were identified: exteriorised jejunal segment, implantable Doppler probe, watch window, microdialysis, microendoscopy and reflectance photoplethysmography. Discussion Exteriorised jejunal segment and implantable Doppler probe are most commonly described, yet both are associated with high false positive rates, which is particularly significant in a patient demographic facing increased general anaesthetic risk. Most other techniques remain experimental. External colour Doppler ultrasound provides the surgeon with immediate reassurance following the reconstruction, requires minimal training to use, and eliminates the need for revisional procedures. Conclusion Our initial experience suggests that external colour Doppler ultrasound has exciting potential as an efficient and noninvasive technique for monitoring the free jejunal flap.
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Affiliation(s)
- R Cuthbert
- Department of Plastic and Reconstructive Surgery, Barts Health NHS Trust, Royal London Hospital , London , UK
| | - C Deutsch
- Department of Plastic and Reconstructive Surgery, Barts Health NHS Trust, Royal London Hospital , London , UK
| | - A Roy
- Department of Radiology, Barts Health NHS Trust, Royal London Hospital , London , UK
| | - P Stimpson
- Department of Ear, Nose and Throat, Barts Health NHS Trust, Royal London Hospital , London , UK
| | - H Patel
- Department of Plastic and Reconstructive Surgery, Barts Health NHS Trust, Royal London Hospital , London , UK
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16
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Özkan Ö, Özkan Ö, Amoroso M. Temporary Banking of the Jejunal Flap for a Difficult Esophageal Reconstruction. Ann Thorac Surg 2016; 103:e1-e3. [PMID: 28007257 DOI: 10.1016/j.athoracsur.2016.06.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2015] [Revised: 04/18/2016] [Accepted: 06/06/2016] [Indexed: 10/20/2022]
Abstract
In this report, we describe a case of difficult esophageal reconstruction using temporary banking of a jejunal free flap. This flap was temporarily placed on the patient's chest wall using the internal mammary vessels (IMVs) as recipient vessels. After 15 days, the jejunal flap was transferred to the neck region, and permanent coverage was provided using a pedicled latissimus dorsi musculocutaneous flap.
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Affiliation(s)
- Ömer Özkan
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Akdeniz University School of Medicine, Antalya, Turkey.
| | - Özlenen Özkan
- Department of Plastic, Reconstructive, and Aesthetic Surgery, Akdeniz University School of Medicine, Antalya, Turkey
| | - Matteo Amoroso
- Department of Plastic Surgery, Sahlgrenska University Hospital, Gothenburg, Sweden
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17
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Zhang Z, Guo Y, Liang C, Feng H, Liu D. Free jejunum interposition as salvage surgery after cervical esophagus injury. J Thorac Dis 2016; 8:E513-6. [PMID: 27499985 DOI: 10.21037/jtd.2016.05.06] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
In rare cases when stomach could not be suitable for esophageal replacement, the jejunum should probably be suitable for esophageal reconstruction. However, the widespread prevalence of jejunal interposition is precluded because of its complexity. Here we present a case of a 74-year-old female who underwent free jejunal interposition as salvage surgery. In this case, cervical esophagus was injured during thyroidectomy. Nine months later, replacement of injured part of esophagus with free jejunum was performed. End-to-end and end-to-side anastomosis were used for esophagus-jejunum and vascular-to-vascular anastomosis respectively. This patient was discharged from hospital 15 days postoperatively. No severe postoperative complication happened. Only minor late operation complication (anastomotic stricture) occurred during 13 years of annual follow-up.
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Affiliation(s)
- Zhenrong Zhang
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
| | - Yongqing Guo
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
| | - Chaoyang Liang
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
| | - Hongxiang Feng
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
| | - Deruo Liu
- Department of General Thoracic Surgery, China Japan Friendship Hospital, Beijing 100029, China
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18
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Ki SH, Choi JH, Sim SH. Reconstructive Trends in Post-Ablation Patients with Esophagus and Hypopharynx Defect. Arch Craniofac Surg 2015; 16:105-113. [PMID: 28913234 PMCID: PMC5556778 DOI: 10.7181/acfs.2015.16.3.105] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 10/13/2015] [Accepted: 10/14/2015] [Indexed: 12/18/2022] Open
Abstract
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.
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Affiliation(s)
- Sae Hwi Ki
- Department of Plastic Surgery, Inha University School of Medicine, Incheon, Korea.,Department of Plastic Surgery, Inha University Hospital, Incheon, Korea
| | - Jong Hwan Choi
- Department of Plastic Surgery, Inha University Hospital, Incheon, Korea
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19
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Bonavina L, Chirica M, Skrobic O, Kluger Y, Andreollo NA, Contini S, Simic A, Ansaloni L, Catena F, Fraga GP, Locatelli C, Chiara O, Kashuk J, Coccolini F, Macchitella Y, Mutignani M, Cutrone C, Poli MD, Valetti T, Asti E, Kelly M, Pesko P. Foregut caustic injuries: results of the world society of emergency surgery consensus conference. World J Emerg Surg 2015; 10:44. [PMID: 26413146 PMCID: PMC4583744 DOI: 10.1186/s13017-015-0039-0] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2015] [Accepted: 09/15/2015] [Indexed: 01/10/2023] Open
Abstract
INTRODUCTION Lesions of the upper digestive tract due to ingestion of caustic agents still represent a major medical and surgical emergency worldwide. The work-up of these patients is poorly defined and no clear therapeutic guidelines are available. PURPOSE OF THE STUDY The aim of this study was to provide an evidence-based international consensus on primary and secondary prevention, diagnosis, staging, and treatment of this life-threatening and potentially disabling condition. METHODS An extensive literature search was performed by an international panel of experts under the auspices of the World Society of Emergency Surgery (WSES). The level of evidence of the screened publications was graded using the Oxford 2011 criteria. The level of evidence of the literature and the main topics regarding foregut caustic injuries were discussed during a dedicated meeting in Milan, Italy (April 2015), and during the 3rd Annual Congress of the World Society of Emergency Surgery in Jerusalem, Israel (July 2015). RESULTS One-hundred-forty-seven full papers which addressed the relevant clinical questions of the research were admitted to the consensus conference. There was an unanimous consensus on the fact that the current literature on foregut caustic injuries lacks homogeneous classification systems and prospective methodology. Moreover, the non-standardized definition of technical and clinical success precludes any accurate comparison of therapeutic modalities. Key recommendations and algorithms based on expert opinions, retrospective studies and literature reviews were proposed and approved during the final consensus conference. The clinical practice guidelines resulting from the consensus conference were approved by the WSES council. CONCLUSIONS The recommendations emerging from this consensus conference, although based on a low level of evidence, have important clinical implications. A world registry of foregut caustic injuries could be useful to collect a homogeneous data-base for prospective clinical studies that may help improving the current clinical practice guidelines.
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Affiliation(s)
- Luigi Bonavina
- />Department of Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097 San Donato Milanese (Milano), Italy
| | - Mircea Chirica
- />Department of Digestive Surgery, Saint-Louis Hospital, Paris, France
| | - Ognjan Skrobic
- />Department of Surgery, University of Belgrade, Belgrade, Serbia
| | - Yoram Kluger
- />Department of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | | | | | - Aleksander Simic
- />Department of Surgery, University of Belgrade, Belgrade, Serbia
| | - Luca Ansaloni
- />General Surgery I, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fausto Catena
- />Emergency Surgery Department, Maggiore Parma Hospital, Parma, Italy
| | - Gustavo P. Fraga
- />Department of Surgery, University of Campinas, Campinas, Brasil
| | - Carlo Locatelli
- />Institute of Toxicology, University of Pavia, Pavia, Italy
| | | | - Jeffry Kashuk
- />Department of Surgery, University of Jerusalem, Jerusalem Rehovot, Israel
| | | | - Yuri Macchitella
- />Department of Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097 San Donato Milanese (Milano), Italy
| | | | - Cesare Cutrone
- />Department of Otolaryngology, Azienda Ospedaliera, Padova, Italy
| | - Marco Dei Poli
- />Intensive Care Unit, IRCCS Policlinico San Donato, San Donato Milanese, Italy
| | - Tino Valetti
- />Department of Anesthesiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Emanuele Asti
- />Department of Surgery, IRCCS Policlinico San Donato, University of Milan Medical School, Piazza Malan 1, 20097 San Donato Milanese (Milano), Italy
| | - Michael Kelly
- />Department of Surgery, Wagga Wagga Hospital, Wagga Wagga, Australia
| | - Predrag Pesko
- />Department of Surgery, University of Belgrade, Belgrade, Serbia
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20
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Hackl C, Popp FC, Ehehalt K, Dendl LM, Benseler V, Renner P, Loss M, Dolderer J, Prantl L, Kühnel T, Schlitt HJ, Dahlke MH. Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report. BMC Surg 2014; 14:78. [PMID: 25319372 PMCID: PMC4202252 DOI: 10.1186/1471-2482-14-78] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2013] [Accepted: 10/08/2014] [Indexed: 12/18/2022] Open
Abstract
Background Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system. Case presentation A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion. Conclusions This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | - Marc H Dahlke
- Department of Surgery, University Medical Center Regensburg, Regensburg 93042, Germany.
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