Double Vascular Pedicled Free Jejunum Transfer for Total Esophageal Reconstruction

Hypopharyngeal reconstruction: a comparison of three alternatives

This study aimed to evaluate the operative outcomes of using gastric pull-up (GPU), pectoralis major myocutaneous flap (PMMF), and jejunal free flap (JFF) to reconstruct the hypopharynx after resection of hypopharyngeal and cervical esophageal carcinoma. Retrospective clinical study. Otolaryngology Department, Zagazig University Hospital, Egypt and Surgical Department, National Cancer Institute, Cairo, Egypt. Records of 104 patients who underwent resection of carcinoma of the hypopharynx and cervical esophagus were reviewed to determine the indications for radical resection, location, and stage of the primary tumor, gross and pathological surgical resection margins, operative complications, morbidity, and mortality. Reconstruction was performed using the GPU for group (1) (n = 33), PMMF for group (2) (n = 34), and JFF for group (3) (n = 37). The hypopharynx was the most common primary tumor site for group (2) and group (3) whereas group (1) had lesions more frequently in the cervical esophagus. The overall postoperative morbidity rate was 20.2% with a perioperative mortality rate of 6.7% and there was no significant difference between the three groups. There was no graft necrosis in group (1) compared to 5.9% in group (2) and 5.4% in group (3). Pulmonary complications occurred commonly (30.3%) in group (1) compared to 11.8% in group (2) and 10.8% in group (3) The overall 3 years survival rate was 67.3% and there was no significant difference between the three groups. The outcomes of the three techniques are equally successful when used appropriately. The nature of the defect indicates the method of reconstruction. For short reconstruction above the thoracic inlet, PMMF or JFF are equally effective and in tumors requiring total esophagectomy, GPA is indicated.

Supercharged jejunum flap for total esophageal reconstruction: single-surgeon 3-year experience and outcomes analysis

BACKGROUND

Esophageal reconstruction after total esophagectomy remains a formidable task irrespective of the conduit chosen. Historically, the gastric pull-up and colonic interposition have served as primary choices for such defects. However, where the stomach and colon are unavailable or unsuitable, the jejunum serves as a reliable alternative for the reconstruction of total esophageal defects.

METHODS

The authors performed an outcomes analysis of a single surgeon's surgical technique and experience. Patients who received supercharged pedicled jejunum flaps for reconstruction of total esophageal defects over a 3-year period were included in this study. Data were collected prospectively evaluating operative technique, length of hospital stay, operative time, complications, postoperative diet, and quality-of-life outcomes analysis.

RESULTS

Five patients underwent supercharged pedicled jejunal flap surgery during this study period. All flaps had complete viability and no microvascular complications. One patient had a radiographic anastomotic leak detected by barium swallow that was reexplored and closed primarily and reinforced with a pectoralis advancement flap with subsequent resolution. All patients are currently tolerating a regular diet and there are no symptoms of reflux or dumping. No conduit strictures or redundancy has been found to date, and there has been no need for reoperation in the long term.

CONCLUSIONS

The supercharged jejunum flap is a reliable alternative to the gastric pull-up and colonic interposition for total esophageal reconstruction. In our experience, the key maneuver in this technique is a substernal tunnel for the jejunal conduit and exposure of recipient vessels and the esophageal stump by means of a manubriectomy, clavicle resection, partial first rib resection and, occasionally, a second rib resection.

Salvage reconstruction of the oesophagus: a retrospective study of 15 cases

Salvage reconstruction of the oesophagus is still considered a challenging procedure for all head and neck surgeons. The risk of postoperative infection and delayed wound healing is high because of thick scar formation and persistent inflammation. Furthermore, recipient vessels for free tissue transfer or vascular supercharge are not always available. Alimentary tract reconstruction with skin or musculocutaneous flap may be necessary, but this method is susceptible to fistula formation.[Nakatsuka T, Harii K, Asato H, et al. Comparative evaluation in pharyngo-oesophageal reconstruction: radial forearm flap compared with jejunal flap. A 10-year experience. Scand J Plast Reconstr Surg Hand Surg 1998; 32: 307-10] In the past 10 years, we have experienced 15 cases of salvage reconstruction of the oesophagus after prior cancer treatment or aorto-oesophageal fistula; the cervical oesophagus was reconstructed in five cases and the cervico-thoracic oesophagus in 10. In four cases of cervical oesophagus and six of cervico-thoracic oesophagus we performed free jejunal transfer including two long segment transfers with double vascular pedicle. The cervico-thoracic oesophagus was also reconstructed with pedicled alimentary tract transfer (colon interposition or jejunal pull-up) with vascular supercharge in four cases. In one case, cervical oesophageal defect was reconstructed with a latissimus dorsi musculocutaneous flap. We also used a deltopectoral flap to cover the skin defect in three cases. In three cases, a second salvage operation was necessary because of flap necrosis that was caused by unreliable recipient vessels resulting from scar formation and persistent inflammation. Successful restoration of the oesophagus and oral alimentation was achieved in 11 cases. From this study, we concluded that free jejunal transfer is a useful procedure for salvage reconstruction of the oesophagus, particularly for cervical oesophagus or short oesophageal defects. Nonetheless, surgeons should know the indications and limitations of this procedure thoroughly and always be ready to choose other reconstructive options if necessary.

Secondary reconstruction of failed esophageal reconstruction

Between June 1992 and November 2002, 17 patients underwent secondary reconstruction of circumferential esophageal defects due to the failure of immediate reconstruction following ablation of thoracic esophageal cancer. Salvage reconstruction was achieved using free jejunal transfer in 13 patients (including long segment with double vascular pedicle in 2 cases), skin and/or musculocutaneous flap in 2 cases, and jejunal pull-up in 2 cases. In 5 patients, the second salvage surgery was required because of the failed first salvage. However, successful restoration of the esophagus and peroral alimentation was finally achieved in 16 of 17 patients, except 1 patient with several salvage operations using skin and musculocutaneous flap because the gut was unusable. We concluded that the preferred first choice for salvage restoration is free jejunal transfer. If the length of the esophageal defect is extensive, colonic interposition or jejunal pedicle with microvascular anastomosis for supercharging is the next option. If these procedures cannot be used, the transfer of a long jejunal segment with double vascular pedicles is recommended. Reconstruction using skin and/or musculocutaneous flap is the final option. As primary wound closure is often difficult in secondary reconstruction of the esophagus, a pectoralis major musculocutaneous flap is reliable to cover the reconstructed esophagus because skin flaps located in the neck region may be damaged by neck dissection or irradiation, and coverage of the anastomosis with muscle between the digestive tracts is effective to prevent leakage.