Simple reconstruction of large pharyngeal defects with free jejunal transfer

Reconstruction techniques using free jejunal transfer for total pharyngolaryngectomy with total glossectomy

BACKGROUND

Total pharyngolaryngectomy is sometimes combined with total glossectomy for advanced hypopharyngeal or cervical esophageal cancers involving the tongue base. The optimal reconstruction method for total pharyngolaryngectomy with total glossectomy has not been established due to a considerable diameter mismatch between the floor of mouth and the esophageal stump. This report describes two reconstruction methods using free jejunal transfer.

METHODS

Five consecutive patients who underwent total pharyngolaryngectomy with total glossectomy were included, with a mean age of 67.0 (range 55-75) years. Primary tumors included tongue, hypopharyngeal, cervical esophagus, and laryngeal cancers. The mean defect size was 17.0 (16-19) × 6.8 (6-7) cm. Surgical techniques involved either a simple incision or a two-segment method to address the size mismatch between the jejunum and the floor of mouth. In the simple incision method, a longitudinal cut was made to the antimesenteric or paramesenteric border of a jejunum wall to expand the orifice. In the two-segment method, a jejunal graft was separated into two segments to reconstruct the floor of mouth and the cervical esophagus, and these segments were connected with a longitudinal incision to the cervical esophageal segment to form a funnel-shaped conduit.

RESULTS

Of the five patients, three underwent the simple incision method and two the two-segment method. Postoperative pharyngoesophagography showed a smooth passage for all patients. Postoperative courses were uneventful except for one flap loss due to arterial thrombosis. Four patients achieved oral feeding, while one became gastric-tube dependent. At a mean follow-up of 22.1 (4-39) months, one patient required tube feeding, two tolerated full liquid, and two consumed a soft diet.

CONCLUSIONS

Both the simple incision and two-segment methods achieved satisfactory swallowing function. The choice between these reconstruction methods may depend on the extent of resection of the posterior pharyngeal wall.

Efficacy of Tensed and Straight Free Jejunum Transfer for the Reduction of Postoperative Dysphagia

Background:

Free jejunal transfer (FJT) is a standard method of reconstruction after total pharyngo-laryngo-cervical esophagectomy (TPLE) in patients with advanced head and neck cancer. However, it is related to various degrees of postoperative swallowing dysfunction. This study aimed to assess whether the tensed and straight FJT method results in a reduced rate of postoperative dysphagia compared with historical controls.

Methods:

Patients who were undergoing FJT after TPLE for squamous cell carcinoma of the hypopharynx or cervical esophagus were enrolled. The primary endpoint was the rate of not developing dysphagia within 6 months of the surgery, and we compared this value with that obtained from historical data of patients who underwent FJT. The secondary endpoint was the rate of developing surgical complications.

Results:

Although 128 patients were registered between August 2012 and July 2015, 7 were excluded based on the exclusion criteria. Of the remaining 121 patients, FJT with the craniocaudally tensed and straight method was performed in all patients. The rate of not developing dysphagia and its 95% confidence interval (CI) were 66.1% and 57.0–74.5%, respectively. The lower limit of the CI was higher than the prespecified threshold value of 50.0%. The rate of developing complications of total necrosis of the jejunum was 3.3%, cervical infection was 9.9%, and major anastomotic leakage was 4.1%.

Conclusions:

Our findings revealed that the proportion of postoperative dysphagia decreased in patients who underwent tensed and straight FJT. This method may become the standard surgical method in reconstruction of defects after TPLE.

Evaluation of routine contrast swallow following total pharyngolaryngectomy and free jejunal transfer

OBJECTIVE

Anastomotic leakage is a serious complication following total pharyngolaryngectomy (TPL) and free jejunal transfer (FJT). Although routine radiological assessment using contrast swallow is widely performed postoperatively for the detection of anastomotic leakage before oral intake, the accuracy remains unclear. We evaluated the clinical usefulness of routine contrast swallow for screening of anastomotic leakage.

STUDY DESIGN

Retrospective chart review.

METHODS

We retrospectively reviewed 232 patients who had undergone TPL and FJT from 2009 to 2013. Initial contrast swallow was performed near the seventh postoperative day in patients without a history of radiation for head and neck region preoperatively and near the 14th postoperative day in patients with a history. The accuracy of routine contrast swallow was calculated.

RESULTS

Clinical anastomotic leakage occurred in 12 patients (5.2%); of these, anastomotic leakage was detected by initial contrast swallow in six patients. The sensitivity and specificity of contrast swallow were 50.0% and 99.1%, respectively.

CONCLUSION

Contrast swallow has low sensitivity and a high false-negative rate for the diagnosis of clinical leakage after TPL and FJT, and routine contrast swallow was insufficient for the screening of anastomotic leakage. Therefore, contrast swallow should be performed in a targeted fashion for patients with clinical signs of anastomotic leakage.

LEVEL OF EVIDENCE

4.

Standardization of Free Jejunum Transfer After Total Pharyngolaryngoesophagectomy

OBJECTIVE

Our latest free jejunum transfer procedure was reviewed and compared with previous procedures to standardize the operation.

METHODS

This was a retrospective study of 269 patients who had undergone total pharyngolaryngoesophagectomy and free jejunum transfer from 1992 through 2004. The patients were divided into two groups: a late group, in which surgery was performed with our latest standard procedure from 2000 through 2004, and an early group, in which various procedures had been used from 1992 through 1999. Surgical times, postoperative progress, and complications were evaluated.

RESULTS

The mean surgical time was shortened from 3 hours 25 minutes in the early group to 3 hours 9 minutes in the late group, and ischemic time was shortened from 2 hours 44 minutes to 2 hours 20 minutes. For recipient vessels, branches of the external carotid artery and the internal jugular vein were more often used in the late group. Length of hospitalization decreased from 31.7 days in the early group to 24.4 days in the late group, although the start of drinking was similar (15.4 days versus 12.1 days). The rates of complications were significantly reduced in the late group, particularly those associated with the enteric anastomosis such as minor leakage (18.2-5.2%) and stenosis (17.6-3.0%).

CONCLUSION

Our latest method of free jejunum transfer reconstruction has become reliable and expeditious through simple and stable minor revisions of procedures.