A Revised Method for Pharyngoesophageal Reconstruction Using Free Jejunal Transfer

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.

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.

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.

Radiological analysis of swallowing and functional outcomes after hypopharyngo-laryngectomy with reconstruction using a jejunal autograft

CONCLUSION

We report a distinct pattern of tongue movement. This is interpreted as a compensatory mechanism after hypopharyngo-laryngectomy with reconstruction using a jejunal autograft. Passage through the oesophagus is mainly passive.

OBJECTIVE

Swallowing is normally initiated voluntarily, and afterwards presumed to be controlled by brainstem reflexes. Resection of the hypopharynx with reconstruction may affect this control. This study attempted to perform a biomechanical analysis of the motility in the small bowel graft and suggest possible implications for surgical management. We also analysed how oesophageal passage is affected by surgery.

METHODS

Five patients underwent a radiological examination of the neopharyngeal conduit and oesophagus and completed a simple questionnaire.

RESULTS

The radiological examinations revealed a distinct pattern of tongue movement in all patients, resulting in varying degrees of thrust. Passage through the jejunal graft was mainly passive, but observations of progressive reduction in diameter of the graft indicated muscular tone that may preserve pressure generated by the lingual thrust. The oesophageal transport appeared to be rather passive and largely depended upon the effect of gravity. Two of five patients were unable to eat normal food. Their impaired swallowing resulted in severely reduced quality of life.

Comparative study of hand sewn single layer anastomosis of dog's bowel

BACKGROUND: Two-layer intestinal anastomosis increases the inflammatory response while single-layer anastomosis results in a better wound healing. However the four main kinds of stitches which may be chosen in performing single layer intestinal sutures never before had been comparatively studied. AIM: To compare the four more commonly used types of single layer surgical anastomosis sutures of the digestive tract. METHODS: Six mongrel dogs were operated, each one receiving two anastomosis: one at 30 cm from de Treitz angle - sero-submucosal technique, and the other at 60 cm - total technique. This placement was alternatively inverted. The four more commonly used types of single layer surgical anastomosis sutures of the digestive tract, namely: sero-submucosal stitches tied in the lumen, over the submucosa; sero-submucosal stitches tied in the exterior of the organ, over the serosa; total stitches tied in the lumen, over the mucosa; and total sutures tied in the exterior, over the serosa (Gambee's stitches) were tested. After euthanasia (7th post-operative day) macro and microscopic features were evaluated. Friedman's test was applied for morphometry and for evaluation of the peritoneal adhesions. RESULTS: Statistical significance was demonstrated through major residual acute inflammation and proliferation in total sutures and more profuse adhesions with the sero-submucosal stitches tied in the lumen. The sero-submucosal stitches tied in the exterior over the serosa, had excellent realignment and regeneration of the layers. CONCLUSION: The sero-submucosal stitches tied in the exterior, over the serosa, were the best ones.

Functional and Radiological Evaluation of Free Jejunal Transplant Reconstructions After Radical Resection of Hypopharyngeal or Proximal Esophageal Cancer

Cancer of the pharyngoesophageal junction (PEJ) is associated with late onset of symptoms, high morbidity, and a dismal prognosis. Radical surgery with pharyngolaryngectomy and reconstruction with a free vascularized jejunal transplant has been increasingly practiced in the treatment of these patients. This strategy is not devoid of challenges, and the present study is aimed at evaluating the long-term functional outcome among patients who have undergone such surgical treatment. Ten patients (mean age 59 years) with a mean follow-up time of 54 months were included. Clinical assessment, health-related quality of life (HRQL) questionnaires, and a standardized radiography examination were used for evaluation. The Karnofsky index ranged from 60 to 90 (mean 82). Global QL scores (EORTC QLQ-C30) had a mean value of 74, and the mean scores for dysphagia-related items of the EORTC QLQ OES-18 questionnaire were within the lower range. Radiographic signs of disturbed bolus transport through the jejunal transplant were found in all patients examined despite the grading of dysphagia from 0 to 1. The Watson dysphagia score varied between 0.5 and 45.0 (mean 16.2). No correlations were found between radiographic findings and the clinical evaluations or the outcomes assessed by the HRQL questionnaires. HRQL was found to be generally good after cancer of the PEJ and jejunal transplant insertion. Most patients reported mild dysphagia. Radiologic signs of disturbed bolus passage were common, but their clinical impact seemed questionable.

Free jejunal transfer for patients with a history of esophagectomy and gastric pull-up

Some patients who undergo pharyngolaryngoesophagectomy with free jejunal transfer reconstruction have a history of esophagectomy and gastric pull-up. We retrospectively reviewed a series of 12 patients to examine the characteristic problems in free jejunal transfer for patients with a history of esophagectomy and gastric pull-up. There was no postoperative thrombosis. No anastomotic leakage or fistula was found. Five of 12 patients presented postoperatively with dysphagia. Two of the 5 patients showed stricture at the distal anastomosis. Three of the 5 patients showed no stricture. However, their reconstructed tracts were tortuous around the distal anastomosis, which could be a cause of dysphagia. Even in patients with a history of esophagectomy and gastric pull-up, free jejunal transfer can be performed safely, although the functional outcome of swallowing is not always satisfactory.