Esophageal reconstruction by jejunal transfer

Technical challenges of total esophageal reconstruction using a supercharged jejunal flap

OBJECTIVE

To review our experience and technique of the supercharged jejunal flap for total esophageal reconstruction.

BACKGROUND

A gastric pull-up is the first choice for total esophageal reconstruction. When this fails or when the stomach is unavailable, a supercharged jejunal flap may reestablish alimentary tract continuity.

METHODS

We performed a retrospective review of 51 patients who underwent a supercharged jejunal flap for total esophageal reconstruction between March 2000 and September 2009 at a single institution. Patient characteristics, technical details, and outcomes were analyzed.

RESULTS

Thirty-six men and 15 women patients were included with a mean age of 55 (28-74) years. An immediate reconstruction was performed in 34 (67%) patients and delayed in 17 patients. The jejunal conduit was passed through a substernal route in 31 (60%) patients and a retrocardiac route in 20 patients. Most common recipient arteries were the internal mammary and transverse cervical. Most common recipient veins were the internal mammary and internal jugular. The overall success rate was 94% with 3 flap failures. A total of 33 patients experienced 1 or more complications with abdominal wound infection and pulmonary complications being the 2 most frequent. Mean length of hospital stay was 21.5 ± 14.0 days. Forty-four (90%) patients were able to achieve a regular diet and 39 (80%) patients discontinued their tube feeds.

CONCLUSION

This technically challenging operation requires a multidisciplinary approach and careful planning, yet can be successfully performed with good long-term function and acceptable morbidity. An algorithm delineating the operative strategy is presented.

Long-segment, supercharged, pedicled jejunal flap for total esophageal reconstruction

OBJECTIVE

Many patients with cancer have limited esophageal reconstruction options when the stomach is unavailable as a replacement conduit or when long-segment discontinuity exists. Jejunum has been used as an alternative conduit, both as a pedicled or free flap interposition; however, reports of this are usually limited to short-segment repairs. Microvascular augmentation of a pedicled jejunal flap allows creation of a longer conduit, making it possible to replace the entire esophagus with jejunum. Few reports describe this technique in patients with cancer. We report our initial experience with "supercharged" pedicled jejunum as an alternative conduit for total esophageal reconstruction.

METHODS

Review of a prospectively collected departmental database was performed to identify those patients who underwent total esophageal reconstruction with supercharged pedicled jejunum. Data regarding their perioperative course and postoperative function were gathered from the prospectively collected clinical data, review of hospital records, and patient interviews.

RESULTS

Total esophageal reconstruction with supercharged pedicled jejunum was attempted in 26 patients (age range, 37-74 years) between March 2000 and April 2004. Twenty-four of 26 patients were ultimately discharged with an intact supercharged pedicled jejunum flap, for an overall success rate of 92.3%. One patient experienced intraoperative flap loss caused by technical difficulties harvesting the flap and never had the flap interposed. One other flap loss occurred in the early postoperative period in a patient who had multisystem organ failure after a prolonged reconstruction. Cervical anastomotic leaks occurred in 19.2% (5/26) of the patients. Two midconduit leaks occurred that were suspicious for iatrogenic perforation from nasogastric tube placement; one required reoperation. One additional early reoperation was performed for cecal ischemia. There were no mortalities. Functional results were available in 95.4% (21/22) of the patients receiving supercharged pedicled jejunum who survived at least 6 months after reconstruction. At the time of follow-up, 95% (20/21) of the patients were tolerating regular diet, and 76.2% (16/21) did not require any supplemental alimentation. Ninety-five percent (20/21) of the patients were free from reflux symptoms, and 80.9% (17/21) had no dumping symptoms. Only 1 patient required dilation of a midconduit stricture. One patient required late reoperation for conduit redundancy.

CONCLUSIONS

Supercharged pedicled jejunum is a suitable alternative conduit for total esophageal replacement in patients with cancer with otherwise limited reconstructive options. Functional outcomes are excellent, despite the severity of disease and technical challenges in this patient population.

Microsurgical reconstruction of the esophagus using supercharged pedicled jejunum flaps: special indications and pitfalls

This report outlines a microsurgical technique for total esophageal reconstruction in situations in which conventional methods using stomach or colon are not available. Eleven patients with corrosive injury and one patient following tumor resection underwent total esophageal reconstruction in a two-stage procedure. In the first stage, skin flaps or free jejunal transfers were used for the cervical reconstruction. In the second stage, supercharged pedicled jejunum flaps placed subcutaneously were used for thoracic esophageal replacement. The study included one male and 10 female patients, with a mean age of 38.4 years. The mean follow-up period was 78.9 months. All patients had one or more complications that required revisional surgery. Pedicled myocutaneous flaps were used to close fistulas or chronic wounds in four patients. The cervical skin tube in two patients and the jejunum in another two patients required shortening because of redundancy. Four patients had dysphagia caused by neck contractures, which were released. Two patients developed pharyngoesophageal strictures that required further free skin flaps for release. Two patients had reflux because of blind pouches arising from the original esophagus and required thoracotomy for removal. At long-term follow-up, all patients are fully rehabilitated and have resumed an oral diet with significant weight gain. Compared with lifelong jejunostomy feeding and its associated psychosocial disadvantages, the authors' experience demonstrates that the application of microsurgical techniques to fully reconstruct the esophagus is of considerable benefit to this difficult patient group.

Microsurgical reconstruction of the esophagus

The loss or stricture of the esophagus has a tremendous impact on daily life. Before the era of microsurgery, many patients had to rely on tube feeding from jejunostomy following failure of esophageal reconstruction with conventional methods. Since the application of microsurgery, almost all kinds of esophageal defects can be reconstructed successfully with microvascular transfer of jejunum, colon, and skin flaps. Microsurgery is also used to augment the blood supply for the pedicled colon and jejunum flaps. In 97.6% of cases, successful reconstruction has been achieved. The leakage rate and functional results are evaluated for each group. For the pharynx and cervical esophagus, jejunum is the best choice. For replacement of the thoracic esophagus, a pedicled colon flap is the first choice, but it can be supercharged with microvascular anastomoses to the neck vessels if necessary. We conclude that the microsurgical transfer of jejunum, colon, and skin flaps is a useful approach for reconstruction of the esophagus. With proper selection of the organ substitute and correct inset of the flap, it not only provides anatomical replacement, but also a superior functional result. Free jejunum flap transfer requires attention to flap length and duration of ischemia. Free colon flap transfer requires attention to arteriosclerotic changes and the vascular pattern. Free skin flaps require attention to leakage prevention. Semin. Surg. Oncol. 19:235-245, 2000.