One-Segment Double Vascular Pedicled Free Jejunum Transfer for the Reconstruction of Pharyngoesophageal Defects

Abstract

The reported success rates of free jejunal transfer are over 95%, but in cases of postoperative vascular thrombosis, the salvage of jejunal flap is often difficult because of poor ischemic tolerance of the jejunum. To reduce the incidence of jejunal necrosis due to vascular thrombosis to nearly zero, we employed one-segment double vascular pedicled free jejunal transfer. Different from conventional double pedicled free jejunal transfer (transfer of the two jejunal segments by anastomosing two pairs of jejunal root vessels), the arcade vessels are used as an additional feeder after the routine anastomosis of jejunal root vessels in our method. Between December 2004 and January 2006, 20 patients with laryngeal, pharyngeal, or cervical esophageal cancer underwent free jejunal transfer using this method. In all patients, the jejunal flap survived completely without any complication associated with vascular anastomosis or blood circulation of the flap. The disadvantage of this procedure is the approximately 1-hour prolonged operative time. Although we have experienced only 20 cases and not obtained statistically significant validity of this method compared with conventional one, we believe that the concept of our method is one of the help for safer pharyngoesophageal reconstruction, especially in patients with higher risk of vascular thrombosis.

Free jejunal flap transfer with multiple vascular pedicles for safe and reliable pharyngoesophageal reconstruction

“…2,3 On the other hand, jejunal flaps are vulnerable to ischemic and congestive states, 9 and, therefore, it is extremely difficult to salvage jejunal flaps by removal of thrombi, unlike other types of flaps. 2,3 On the other hand, jejunal flaps are vulnerable to ischemic and congestive states, 9 and, therefore, it is extremely difficult to salvage jejunal flaps by removal of thrombi, unlike other types of flaps.…”

“…2,3 On the other hand, jejunal flaps are vulnerable to ischemic and congestive states, 9 and, therefore, it is extremely difficult to salvage jejunal flaps by removal of thrombi, unlike other types of flaps. 3,[10][11][12][13] However, as these studies were limited in sample size, we retrospectively examined a large case series of vascularized free jejunal flap transfer with multiple vascular anastomoses. 14 Furthermore, occlusion of anastomosed vessels cannot always be avoided even for skilled microsurgeons, and, therefore, surgeons must be prepared for vascular thrombosis and carefully avert flap loss when performing reconstruction with jejunal flap transfer.…”

“…1,2 Free jejunal flap transfer has been considered a reliable procedure for pharyngoesophageal reconstruction due to its low complication rate and low donor site morbidity, 2,3 with low overall failure rates of 3%-8%. 3,[10][11][12][13] However, the number of cases reported to date remains low. Moreover, total flap loss can lead to life-threatening complications, such as severe surgical site infections, sepsis, and carotid blowout.…”

“…The primary goal of pharyngoesophageal reconstruction is to restore continuity of the aerodigestive tract, using free fasciocutaneous or visceral flaps, and to improve the quality of life by maximizing speech and swallow function. 1,2 Free jejunal flap transfer has been considered a reliable procedure for pharyngoesophageal reconstruction due to its low complication rate and low donor site morbidity, 2,3 with low overall failure rates of 3%-8%. 1,[3][4][5][6][7][8] However, total flap loss due to vascular occlusion (ie, the most devastating outcome in free tissue transfer), cannot always be avoided.…”

Free jejunal flap transfer containing multiple vascular pedicles for pharyngoesophageal reconstruction in conjunction with anterior mediastinal tracheostomy

“…Following pharyngoesophagectomy, alimentary tract reconstruction is performed using visceral (e.g., stomach, jejunum, and colon), musculocutaneous, or fasciocutaneous flaps in order to restore the continuity of the digestive tract (Hsieh, Yang, Tsai, Kuo, & Lin, 2017;Orringer, 1992). In particular, the use of free jejunal flaps has been considered reliable due to low complication rates and low donor site morbidity (Okazaki, Asato, Okochi, & Suga, 2007;Razdan, Albornoz, Matros, Paty, & Cordeiro, 2015) with high overall success rates of 92%-97% (Chan, Ng, Liu, Chung, & Wei, 2011;Hsieh et al, 2017;Nakatsuka et al, 1998;Nakatsuka et al, 2003;Okazaki et al, 2007;Sugiyama, Takao, Suzuki, & Kimata, 2016;Yu, Lewin, Reece, & Robb, 2006). We aimed to achieve restoration of digestive tract continuity in conjunction with anterior mediastinal tracheostomy using a novel 1-stage technique to reconstruct both the trachea and alimentary tract, although 2-stage reconstruction is sometimes used given the complexity of combined tracheal and esophageal reconstruction (Ghali et al, 2015).…”