Jejunum free flap in hypopharynx reconstruction: case series

Use of free jejunal flap as a salvage procedure in the management of high corrosive esophageal re-strictures: an institutional experience and review of literature

BACKGROUND

High pharyngo-esophageal strictures following corrosive ingestion continue to pose a challenge to the surgeon, particularly in the developing world. With the advancements and increased experience with microsurgical techniques, free jejunal flaps offer a viable reconstruction option in patients with high corrosive strictures with previous failed reconstruction. We review our experience with free jejunal flap in three cases with high pharyngo-esophageal stricture following corrosive ingestion, with previous failed reconstruction.

MATERIALS AND METHODS

A total of three patients underwent salvage free jejunal flap after failed reconstruction for high pharyngo-esophageal strictures following corrosive acid ingestion. All the three patients developed anastomotic leak and subsequent stricture, two following a pharyngo-gastric anastomosis and one following a pharyngo-colic anastomosis. The strictured segment was bridged using a free jejunal graft with microvascular anastomosis to the lingual artery and common facial vein. All patients were followed-up at regular intervals.

RESULTS AND CONCLUSIONS

The strictured pharyngeal anastomotic segment was successfully reconstructed with free jejunal flap in all the three patients. Patients were able to take food orally and maintain nutrition without the need of jejunostomy feeding. On long-term follow-up (median: 5 years), there was no recurrence of dysphagia and all the patients had good health-related quality of life.

Modified distal anastomosis between colon and thoracic esophagus for hypopharynx reconstruction using free colon flap: A comparison study

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.

Morphological analysis of ischemia-reperfusion injury in a cold ischemia model of jejunal free flap for hypopharyngeal reconstruction

BACKGROUND

Jejunal free flap (JFF) reconstruction is a popular treatment option for advanced hypopharyngeal cancer. Several factors including ischemia-reperfusion injury (IRI) can cause mucosal damage and progressive flap necrosis. We investigated the development and time-related progression of morphological and cellular changes in patients with JFF reconstruction including cold preservation of the graft.

METHODS

Eleven patients were enrolled. Biopsies were taken during surgery from normally perfused tissue, before loop isolation (T0), at the end of back-table surgery (T1), immediately before reperfusion (T2), 15' after reperfusion (T3), and at the end of the digestive anastomoses (T4) and from the external monitor daily from the 1st to the 5th postoperative day (M1-M5). Histomorphological and immunohistochemical parameters in the intraoperative and postoperative samples were evaluated and compared.

RESULTS

Delayed flap necrosis was observed in 2 patients. The cold ischemia phase did not negatively affect mucosal regeneration after reperfusion; morphological and cellular damage parameters returned to normal by the end of surgery or along the early postoperative period. Significant enterocyte replication activity was observed at the end of revascularization, which continued in the postoperative phase, leading to recovery of the epithelial morphological integrity and disappearance of apoptotic cells. An inflammatory infiltrate persisted in the M samples, and in a significant proportion of samples, mucosal fibrosis developed by the end of the postoperative observation.

CONCLUSION

Cold perfusion and preservation of the JFF can effectively limit the negative effects of IRI and to prevent short- and medium-term complications that can compromise the final outcome.

Use of the facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy: a novel technique

Reconstruction of neopharynx after total laryngectomy is a challenging task. Various locoregional flaps like pectoralis major myocutaneos/ latismus dorsi flaps and free flaps have their own limitations and advantages. To overcome this, we used facial artery-based cutaneous island flap (melo-labial flap) for reconstruction of the neopharynx following total laryngectomy (DK Gupta technique). This flap is thin, pliable, without any gravitational pull and without any risk of anastomosis failure and hence has advantage of both locoregional and free flaps and eliminates the limitations of both. It is simple, reproducible and reliable reconstructive option for neopharynx. We present a case report, review of literature and this novel technique for an excellent outcome and recommend to use it as the new workhorse of neopharyngeal reconstruction.

Successful vascularized jejunal patch graft to treat severe orad duodenal injury secondary to foreign body obstruction in a dog

OBJECTIVE

To report the surgical treatment and outcome of an adult dog with a duodenal perforation treated with a vascularized jejunal patch graft.

STUDY DESIGN

Case report.

ANIMAL

A 1-year-old castrated male boxer dog.

METHODS

Damage to a duodenal segment containing the major and minor papillae was repaired with a vascularized jejunal graft. A segment of healthy jejunum was mobilized maintaining the jejunal vessels, and a donor site anastomosis was performed. The vascularized jejunal graft was incised on the antimesenteric border creating a rectangular segment, which was trimmed and sutured to the duodenal recipient site as a patch graft to repair the defect.

RESULTS

The dog recovered well without major complications. Within 2 weeks, appetite and bowel movements were normal, with no episodes of vomiting. Infrequent regurgitation resolved without medical therapy.

CONCLUSION

A vascularized jejunal patch graft is a feasible option for successful surgical repair of duodenal injury in the dog.

CLINICAL SIGNIFICANCE

This report describes a novel surgical repair technique for treatment of gastrointestinal injuries.

Determinants of Free Fasciocutaneous Flap Outcomes in Partial Hypopharyngeal Defects

BACKGROUND

Most of the patients with hypopharyngeal cancer are still diagnosed with advanced stage, and total or partial pharyngectomy with free flap reconstruction is the mainstay of treatment. The aim of this study was to find out the possible risk factors related to surgical complications after free fasciocutaneous flap reconstruction for partial pharyngeal defect and its sequelae in the follow-up.

PATIENTS AND METHODS

We retrospectively reviewed the charts of patients with advanced hypopharyngeal cancer who received free fasciocutaneous flaps for partial pharyngeal defects reconstruction. From 2005 to 2015, 79 free fasciocutaneous flaps (59 free fasciocutaneous flaps and 20 anterolateral thigh flaps) were performed in our department. The risk factors for free flap outcome and complications were evaluated with multivariant linear regression model.

RESULTS

The mean age of patients was 60.8 years with male predominance. The mean follow-up duration was 39.6 months. Most of the cases (97.5%) were in stage III or IV. Patients with comorbidities showed significant correlation to flap failure (95% confidence interval [CI] = 0.038 to 0.264, P = 0.10). Anastomosis style (end-to-side vs end-to-end) was the only operation-related factors significantly related to flap failure rate (18.8% vs 3.2%, 95% CI = 0.031 to 0.32, P = 0.18). Flap size was significantly associated with fistula formation (95% CI = -0.005 to 0.000, P = 0.38).

CONCLUSIONS

In our experience, patients with comorbidities and end-to-side anastomosis illustrate significantly higher flap failure rate in free fasciocutaneous flap reconstruction of partial hypopharyngeal defect. Reconstruction with smaller flap size had higher possibility of fistula formation.

Fasciocutaneous free flaps for reconstruction of hypopharyngeal defects

OBJECTIVES/HYPOTHESIS

Different reconstructive options are available for defects following total laryngectomy (TL) and circumferential (CH) or partial hypopharyngectomy (PH). We evaluated the flap success, pharyngocutaneous fistula, and pharyngoesophageal stenosis rates in two groups of patients treated by different policies.

STUDY DESIGN

Comparison between two cohorts of patients treated by TL with PH/CH ± cervical esophagectomy and reconstructed according to different strategies.

METHODS

Group A (historical) was composed of 89 patients reconstructed by pectoralis major myocutaneous (PMMC), radial forearm (RF), and anterolateral thigh (ALT) flaps. A salivary bypass stent (SBPS) was not routinely applied and left in place for a maximum of 14 days. Forty-four (49%) patients received preoperative radiotherapy/chemoradiotherapy (RT/CRT). Group B (prospective) included 105 patients reconstructed by RF or ALT with long-lasting SBPS left in place for a maximum of 45 days. Sixty-one (59%) received preoperative RT/CRT.

RESULTS

In group A, flap failure occurred in four (4%) cases, and all were managed by PMMC. We encountered 22 (26%) fistulas and 14 (16%) stenoses. In group B, flap failure occurred in six (6%) cases and was managed by PMMC. We encountered seven (7%) fistulas and three (3%) stenoses. Comparing complications among the two groups, we encountered a statistically significant difference in favor of group B for both fistula (P < .001) and stenosis (P = .001). We did not evidence any significant difference in terms of flap success rate.

CONCLUSIONS

First-line application of RF and ALT free flaps with long-lasting SBPS in reconstruction after PH/CH allows obtaining reduced incidences of both fistula and stenosis.

LEVEL OF EVIDENCE

4. Laryngoscope, 127:2731-2737, 2017.

Late-onset dysphagia caused by severe spastic peristalsis of a free jejunal graft in a case of hypopharyngeal cancer

Free jejunal transfer is the main technique used for reconstructing a circumferential defect caused by total pharyngo-laryngo-cervical-esophagectomy in certain cancer cases. We report a rare case of severe late-onset dysphagia caused by autonomous spastic peristalsis, which led to complete obstruction of the free jejunal route. A 70-year-old man underwent treatment for hypopharyngeal cancer involving total pharyngolaryngectomy with free jejunal transfer. After uneventful peri- and postoperative recovery, he developed sudden-onset severe dysphagia 22 months later. Gastrografin fluoroscopy revealed abnormal peristalsis and contraction of the transferred jejunum, leading to complete obstruction. Nutritional treatment, application of depressants of peristalsis, and xylocaine injection into the outer space of the jejunal mucosa all failed to alleviate the dysphagia. Surgical treatment involving a longitudinal incision of the jejunal graft, and interposing a cutaneous flap, as a fixed wall, between the incised jejunal margins to prevent obstruction was performed. After further reconstructive surgery involving using a pectoralis major musculocutaneous flap and a split-thickness skin graft to close a refractory jejunum-skin fistula, the dysphagia was permanently alleviated. To our knowledge, this is the first report of severe dysphagia caused by peristalsis of a free jejunal graft.

Surgical treatment of hypopharyngeal cancer: a review of the literature and proposal for a decisional flow-chart

Surgical resection is one of the standard therapeutic choices for the treatment of hypopharyngeal cancer, whether or not combined with postoperative radiotherapy. The type of operation depends on the extension of the lesion and the subsites involved and often requires some form of reconstruction. Reconstructive strategies depend on whether the larynx, or part of it, has been preserved. We believe that the decisional flow-chart of the reconstructive methods after hypopharyngeal cancer resection should be based not only on the extent of resection, but also on the subsites involved. This report presents a literature review on the management of cancer of the hypopharynx and a proposal for a surgical decisional flow-chart.

Mucosal changes induced by ischemia-reperfusion injury in a jejunal loop transplanted in oropharynx

Tissues exposed to ischemia and reperfusion develop an inflammatory response. We investigate the morphological and immunological changes occurring in the mucosa of a jejunal loop transplanted in the oropharynx of a man undergoing circular pharyngolaryngectomy. Jejunal biopsies were collected during the transplantation procedures (cold and warm ischemia, reperfusion), during the 7 post-operative days through an exteriorized jejunal segment for flap monitoring, and 45 days after transplantation through an upper endoscopy. Matrix metalloproteinase (MMP)-3 and MMP-12 increase was accompanied by a parallel rise in apoptotic enterocytes, and by a concomitant reduction of surface area to volume ratio and enterocyte height. Goblet cell hyperplasia is coupled with Paneth cell disappearance at the crypt base. CD8-positive intraepithelial lymphocytes initially decrease, then they increase in accordance with the peak of enterocyte apoptosis. We identified alterations in lymphocyte infiltration, mucosal architecture and epithelial cell turnover, which may give a window to mechanisms of small bowel ischemia-reperfusion in humans.

Esophagus and hypopharyngeal reconstruction

This article reviews the literature on esophageal reconstruction. The most common methods used are gastric pull-up, pectoralis major flap, colon interposition, fasciocutaneous flaps (radial forearm free flap or anterolateral thigh flap), and free jejunum and colon flaps. The stricture rates, fistula rates, morbidity, and mortality of each flap are reviewed.

Results after U-shaped pectoralis major myocutaneous flap reconstruction of circumferential pharyngeal defects

OBJECTIVES/HYPOTHESIS

To evaluate surgical, functional, carcinologic results after circumferential pharyngolaryngectomy and reconstruction with U-shaped pectoralis major myocutaneous flap.

STUDY DESIGN

Retrospective case series.

METHODS

Forty-one patients included spanning a 6-year period.

RESULTS

General and local complications occurred in 10% and 22% of patients respectively, without early death. Swallowing and vocal functions were satisfactory for 82% and 43% of patients respectively, despite 39% of neopharynx stricture and 22% of pharyngocutaneous fistula. With a 20-month mean follow-up, cancer recurrence was present in 58% of patients. The overall survival rate was 29% at 3 years.

CONCLUSIONS

This flap is simple, reliable, and allows adequate reconstruction of the hypopharynx. However, the neopharynx stricture rate is high and the quality of voice rehabilitation is poor when compared with free flaps. This procedure, which is an option for the reconstruction of circumferential pharyngeal defects, must be considered in selected cases.

Reconstructive options after total laryngectomy with subtotal or circumferential hypopharyngectomy and cervical esophagectomy

PURPOSE OF REVIEW

The present review is focused on the main reconstructive options currently used after partial or circumferential resection of the hypopharynx and cervical esophagus. The advantages and disadvantages of pectoralis major myocutaneous (PMMC) pedicled flap, fasciocutaneous free flaps as radial forearm and anterolateral thigh (ALT), and visceral free grafts like jejunum and gastro-omental are overviewed.

RECENT FINDINGS

For partial hypopharyngeal defects with limited extension to the cervical esophagus, no specific pedicled or free flap is deemed superior over others: the patient's body habitus and surgeon's preference remain the most important factors affecting the reconstructive choice. In contrast, after circumferential hypopharyngectomy, pharyngocutaneous fistula (PCF) and stricture rates of PMMC are higher than those obtained by free flaps. In the most recent series applying ALT and jejunum, PCF and stricture occurrence is comparable, whereas reduced mortality, overall complication rate, and donor-site morbidity of ALT and its better swallowing and speech outcomes have contributed to make this option progressively more popular. On the other hand, gastro-omental seems to offer an unparalleled amount of highly vascularized tissue to manage the difficult situation of salvage surgery after chemoradiation, even though complication rates remain not negligible and this technique has not been widely adopted.

SUMMARY

The reconstructive armamentarium of head and neck surgeons involved in hypopharyngeal and cervical esophagus reconstruction should encompass every option described herein in order to appropriately deal with specific clinical needs and patient requirements. However, fasciocutaneous free flaps (especially ALT) seem to play an ever greater role in restoration of pharyngoesophageal continuity.

Reconstruction of the esophagus and voice

BACKGROUND

Esophageal defects are reconstructed using a variety of methods and tissue types. The choice depends on the location of the defect, the condition of the patient, and the flaps that are available for reconstruction. Often, patients with esophageal defects also lack a mechanism for voice production following a total laryngectomy procedure.

METHODS

A review of the literature was performed for esophagus reconstruction and voice rehabilitation following laryngectomy. Methods of voice restoration using intestinal transfers are presented based on the authors' experience.

RESULTS

Several methods of esophagus and voice restoration can achieve excellent functional outcomes.

CONCLUSION

Esophagus reconstruction and voice rehabilitation following esophageal resection and total laryngectomy are possible using a variety of flaps with good functional outcomes.

Total laryngopharyngoesophagectomy with gastric transposition reconstruction: review of long-term swallowing outcomes

Aim:

The aim of this review was to examine long-term swallowing and eating outcomes following laryngopharyngoesophagectomy with gastric pull-up reconstruction.

Methods:

Ten patients underwent clinical examination and completed the performance status scale for head and neck questionnaire and also a gastric pull-up swallowing questionnaire designed for this review. Nine of the 10 patients underwent videofluoroscopic examination of swallowing.

Results:

One patient had a stricture at the orogastric anastomosis, and one patient had bilateral tongue immobility secondary to XIIth nerve palsies. Eight participants reported eating a normal diet, and five reported not limiting their eating environment. Regurgitation, slower eating and reduced capacity were the most common functional limitations.

Conclusions:

These results support previous opinions that the gastric pull-up procedure has good swallowing outcomes, and indicate that such outcomes continue in the long term.

Functional results with advanced hypopharyngeal carcinoma treated with circular near-total pharyngolaryngectomy and jejunal free-flap repair

BACKGROUND

Patients treated by a circular pharyngolaryngectomy for advanced hypopharyngeal carcinoma have a poor prognosis and disappointing speech restoration.

METHODS

Three carefully selected patients underwent a near-total laryngectomy circular pharyngectomy with jejunal free flap repair and dynamic tracheopharyngeal shunt for treatment of advanced hypopharyngeal carcinoma. They received induction chemotherapy and postoperative radiotherapy. We assessed the functional outcome.

RESULTS

There was no major local complication. One year after the end of radiotherapy, all patients were able to eat solid diets. Two patients were able to speak immediately after the end of the treatment. After speech re-education, a high-quality tracheopharyngeal voice was restored in all three patients. Performance Status Scale for Head and Neck Cancer Patients (PSSHN) showed a mean score equal to 81/100 at 1 year.

CONCLUSIONS

In selected patients, near-total laryngectomy circular pharyngectomy with tracheopharyngeal shunt and jejunal free-flap repair offers good voice rehabilitation without impairing swallowing function.

Reconstructive and rehabilitating methods in patients with dysphagia and nutritional disturbances

As diverse as the causes of oropharyngeal dysphagia can be, as broad is the range of potential therapeutical approaches. In the past two decades, methods of plastic-reconstructive surgery, in particular microsurgically revascularised tissue transfer and minimally invasive, endoscopic techniques of every hue have substantially added to the portfolio of reconstructive surgery available for rehabilitating deglutition. Numerically, reconstructing the pharyngolaryngeal tract following resection of squamous-cell carcinomas in the oral cavity, the pharynx and the larynx has been gaining ground, as has functional deglutitive therapy performed to treat posttherapeutical sequelae. Dysphagia and malnutrition are closely interrelated. Every third patient hospitalised in Germany suffers from malnutrition; ENT tumour patients are not excluded. For patients presenting with advancing malnutrition, the mortality, the morbidity and the individual complication rate have all been observed to increase; also a longer duration of stay in hospital has been noted and a lesser individual toleration of treatment, diminished immunocompetence, impaired general physical and psychical condition and, thus, a less favourable prognosis on the whole. Therefore, in oncological patients, the dietotherapy will have to assume a key role in supportive treatment. It is just for patients, who are expected to go through a long process of deglutitive rehabilitation, that enteral nutrition through percutaneous endoscopically controlled gastrostomy (PEG) performed at an early stage can provide useful and efficient support to the therapeutic efforts. Nutrition and oncology are mutually influencing fields where, sooner or later, a change in paradigms will have to take place, i.e. gradually switching from therapy to prevention. While cancer causes malnutrition, feasible changes in feeding and nutrition-associated habits, including habitual drinking and smoking, might lower the incidence of cancer worldwide by 30 to 40% (American Institute of Cancer Research 1999).Esse oportet, ut vivas, non vivere ut edas. / Thou shouldst eat to live, not live to eat.Cicero 106 - 43 B.C.

[Hypopharyngeal cancer: analysis of the evolution and surgical results]

OBJECTIVE

Hypopharyngeal carcinoma is an aggressive malignancy that usually presents at a late stage, thereby resulting in an overall poor prognosis for these patients. The aim of this study is to determine the evolution and postoperative results of patients treated in our department for hypopharyngeal cancer.

METHODS

We retrospectively reviewed 60 patients who had undergone surgery followed by radiation therapy between 1980-1999. Most of them were advanced stage (III-IV) and 75% patients showed regional metastases at presentation.

RESULTS

The 5-year survival rate was 38.4%. The overall incidence of distant metastases and second neoplasms was 12.5% and 10.4%.

CONCLUSIONS

Hypopharyngeal cancer remains one of the most lethal ones in head and neck cancer. The poor survival rate is related primary to advanced stage disease and particularly to lymph node metastases.

The increasing use of enteral flaps in reconstruction for the upper aerodigestive tract

The enteric flaps commonly used in free tissue head and neck reconstruction include the gastro-omental flap, the omental flap, and the free jejunal flap. These flaps have demonstrated excellent reconstructive results for defects of the oral cavity, oropharynx, hypopharynx, cervical esophagus, and contouring defects of the head and neck. Their main advantages include tissue pliability, tubed shape, ease of contouring, and the ability to secrete mucus. Recent studies report outcome measurements for flap loss, fistula rates, postoperative swallowing, speech, and cosmesis. Now that experience has been gained to the point of routine use of these flaps, randomized trials are needed to determine the functional advantages of the enteric flaps compared with other reconstructive options.