Hypopharyngeal reconstruction with free microvascular jejunal transfer after total laryngopharyngectomy

Laryngopharyngectomy with reconstruction

A wide range of reconstructive options allows the ablative surgeon to resect tumors completely with wide margins. Wide resection is especially important because of the rich lymphatic drainage and submucosal spread seen with carcinomas in the hypopharyngeal area. Postoperative stenosis can be a difficult, recurring problem if the neopharynx does not have enough tissue incorporated into the closure. Therefore, most laryngopharyngectomy procedures benefit from the addition of transposed tissue, either pedicled or using free tissue transfer microvascular techniques. Often the location of the tumor is a major factor in determining which reconstruction is best for the patient. Minimizing the donor-site morbidity must be carefully considered, also.

The free radical forearm flap: a reliable method for reconstruction of the laryngohypopharynx after in-continuity resection

Between 1992 and 1996 14 patients with a squamous cell carcinoma of the laryngohypopharynx underwent tumour resection and primary reconstruction with the free volar forearm flap. Tumour resection was performed by a head and neck surgeon and reconstruction by a plastic surgeon. Preoperative radiotherapy was given to 13 patients and postoperative radiation to one patient. Thirteen patients were male and one patient was female, with a mean age of 66 years (range 53-79 years). The flap was harvested from the left forearm in 12 cases and from the right in two. The mean operation time was 12 h (range 11-20 h), and the mean intraoperative bleeding volume was 700 ml (range 400-1,000 ml). Twelve of 14 flaps survived. One flap was totally lost 3 weeks postoperatively and another was partially lost 2 weeks after surgery. Overall revisional surgery was carried out in six patients. Infections and fistulae at the neck occurred in six of the 14 patients. Six of the 14 patients were alive at follow-up. One patient died of an acute haemorrhage from an oesophageal ulcer 2 months after surgery, one patient died of a second primary oesophageal cancer and six patients developed recurrences. The mean survival time was 26 months (range 2-43 months).

Contrast-enhanced computed tomography of freely transplanted jejunal patches after surgery in the oral cavity and oropharynx

Thirty-two patients with jejunal patches in the oral cavity and oropharynx were examined with contrast-enhanced computed tomography (CT). The morphology of the intestinal wall, the mesenteric fatty tissue, mesenteric lymph nodes and the region of the anastomosis were evaluated and correlated with clinical findings. The size and number of mesenterial lymph nodes, which were found in 16 cases, did not correlate with tumour recurrence. The benign alterations of the intestinal wall ranged from flat surfaces with no enhancement to significant enhancement with persisting folds. In cases with persisting intestinal folds, separation of tumour recurrence was achieved by identification of a typical double-layer configuration of the enhancing mucosa, and the restriction of alterations to the intestinal wall compartment. Tumour recurrences occurred at patch margins and were reliably distinguished from normal patches. For differentiation of findings, an exact localization of jejunum-patch compartments and margins with contrast-enhanced CT was, therefore, necessary.

Safety of radiating jejunal interposition grafts in head and neck cancer

The safety of high-dose postoperative radiation therapy to a jejunal graft has not been established in the literature. The purpose of the present study is to review the effect of postoperative radiation on swallow function in patients who have received a jejunal interposition graft as part of their reconstruction after cancer resection. Charts of patients undergoing hypopharyngeal resections for cancers with placement of jejunal interposition grafts who received postoperative radiation therapy were reviewed. Swallow function was determined from records of patients' subjective characterization of their swallow function, records of weights at each visit, use of gastrostomy tube, need for jejunal dilatation and review of barium swallows. Seventeen patients were identified who had undergone resection of cancers with jejunal interpositions and postoperative radiation therapy. Four patients never regained adequate swallow function postoperatively to allow G-tube removal. The remaining thirteen patients had their G-tubes removed, generally several months after resection, and were able to obtain adequate nutrition orally to maintain or increase their weights. The present series suggests that a segment of jejunum transferred into the neck after laryngopharyngoesophagectomy can be irradiated to high dose with generally acceptable morbidity.