Reconstruction Following Total Laryngopharyngoesophagectomy and Extensive Resection of the Superior Mediastinum

Abstract

Our experience with four patients who underwent immediate reconstruction following total laryngopharyngoesophagectomy and extensive resection of the superior mediastinum is presented. The reconstructive procedures included free jejunal graft or microvascularly augmented gastric pedicle for esophageal reconstruction, pectoral fasciocutaneous or myocutaneous flap for tracheal reconstruction, and mesenteric flap connected with jejunal graft omental flap, or pectoral flap for protection of the great vessels and obliteration of the dead space in the cervical and superior mediastinal region. The reconstructive procedures were successful, and no pharyngocutaneous fistula, mediastinitis, or great vessel rupture was noted in any patient. There was one patient who developed lung edema and liver dysfunction postoperatively. Combinations of reconstructive procedures using well-vascularized soft tissues can be expected to provide well-tolerated reconstruction following extensive cervical and superior mediastinal resection.

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

“…These findings suggest that jejunal flap transfer with multiple vascular pedicles is a safe and reliable procedure. Yamamoto et al () used the mesenteric part of a jejunal flap to protect the innominate artery in combination with omental and pectoralis major flaps in 3 cases. Our method differs largely in that we harvested a long (80‐120 cm) segment of jejunum containing multiple vascular pedicles with a redundant mesentery, as compared to a 30 cm segment with 1 vascular pedicle in the previously reported cases.…”

Second Free Jejunal Transfer in Complicated Pharyngoesophageal Reconstructions

“…Free jejunal transfer provides an excellent reconstruction for pharyngolaryngectomy defects, with a high success rate of graft survival. [1][2][3][4][5][6][7][8] In the rare cases in which total or partial loss of the free jejunal graft occurs, despite successful microvascular anastomoses, the reasons for failure should be carefully explored. In our case 1, severe longitudinal tension at the pharyngo-jejunal anastomotic site was strongly suspected to compromise the blood supply from the mesenterium to the jejunum, according to intraoperative findings and secondary examinations.…”

“…Part of the harvested jejunum was used for replacement of the jejuno-esophageal junc- tion, and the remaining mesenterium was used to wrap the tracheostoma for separation from the adjacent brachiocephalic trunk. 6,8 The left subclavicular artery and vein were prepared as recipient vessels. Both arterial and venous anastomoses were carried out in an end-to-side fashion.…”

“…In pharyngoesophageal reconstruction, the free jejunal transfer has been frequently utilized for restoring continuity of the alimentary tract. [1][2][3][4][5][6][7][8] It offers a reliable, fast, and safe single-stage reconstruction with acceptable morbidity, early restoration of swallowing, and low stricture rates. However, once fistula formation occurs after free jejunal transfer for pharyngoesophageal reconstruction, it produces a serious complication with potentially critical consequences.…”

Reconstruction after total pharyngolaryngoesophagectomy

“…Complications for reconstruction of the trachea is also one of the most serious problems [11]. We must be cautious not to impair the bronchial arteries and keep the tracheostoma separated from the major vessels, using a mesenterium flap, e.g., a greater omentum flap and a pectoralis major myocutaneous flap [11,12,13]. When the resection of trachea extends over three rings, a tracheostoma in the upper chest must be created.…”