Bowel Preparation before Microvascular Free Colon Transfer for Head and Neck Reconstruction: Is It Necessary?

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.

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.

Free microvascular transfer of the reverse ileo-colon flap with ileocaecal valve valvuloplasty for reconstruction of a pharyngoesophageal defect: indication and usage of the ‘funnel flap’

The authors have designed a method of reconstruction for high pharyngeal and oesophageal defects that potentially avoids many of the disadvantages related to size mismatch at the proximal and distal end of oesophageal defects that are encountered with the use of free jejunal and colon flaps, respectively. An ileo-colon flap was used to reconstruct this type of defect where the ascending colon was anastomosed to the pharyngeal end and the ileum was anastomosed to the oesophageal end. Both sides were perfectly matched in circumference and minimal manipulation was necessary at both ends of the flap. A detailed description of the surgical technique is depicted and a case presented. While this procedure solves some of the problems encountered when dealing with this type of defect, it nevertheless does have some disadvantages and technical nuisances that are detailed and discussed in this report.

Free microvascular transfer of the vermiform appendix for creation of a tracheo-oesophageal fistula: A new method of voice reconstruction

BACKGROUND

Voice rehabilitation following laryngectomy can take many forms. As its basic premise, vibrating air must be transferred to the mouth where articulation takes place and speech can be produced. It requires a source of air, a conduit for transfer, and a mechanism for prevention of regurgitation and aspiration. Creating a tracheo-oesophageal fistula and maintaining it with a vascularised appendix has been the intention of this report.

METHODS

Three patients with an average age of 53 years underwent the procedure of free transfer of the appendix for voice restoration during the months of September 2004 through December 2004. All patients had laryngectomies and one had total cervical oesophageal reconstruction with a pedicled pectoralis major flap. Voice evaluation, swallowing function, and presence of aspiration were evaluated.

RESULTS

All flaps survived without complications. The results of swallowing function were unaltered from preoperative levels. All flaps remained patent at an average follow-up period of 8 months. All three patients could produce loud voice, which was intelligible at a reasonable distance. Maximal phonation time was 4s in two patients and 5s in one patient. Voice rehabilitation using the free appendix flap can achieve a phonation time which is low and words and short phrases that are intelligible but limited so far to this level. The donor site morbidity is low and aspiration was not present. The results of this study indicate that this method may have a potential role in voice reconstruction but requires more experience and refinement of this technique.