Jejunum Tissue Transfer

No Results

No Results

processing….

Patients with cancer of the hypopharynx and cervical esophagus are faced with several daunting issues. First, they must face the fact that their disease carries an overall 5-year survival rate for stage II-IV disease of 24-39%. ^[1] Second, and perhaps equally important, they must become reconciled with the fact that they will lose their ability to swallow or speak normally. The hypopharynx is the most inferior portion of the pharynx. Its superior border begins at the tip of the epiglottis, and the inferior border incudes the lower level of the cricoid cartilage.

For most patients dealing with such a dire prognosis, the one thing that allows them to consider pharyngoesophageal resection is the knowledge that a reconstructive procedure can help to restore speech and swallowing functions. Depending on surgeon preference and postoperative hospital course, patients can be introduced to liquids and solids within 1 week of surgery. ^[2]

Because of the low survival rate and the likelihood of recurrence in advanced cases of pharyngoesophageal cancer, the method of reconstruction chosen should provide restoration of swallowing in one stage with minimal morbidity. Given that a significant amount of hyopharyngeal cancer resections result in circumferential defects, it is important for the reconstruction to provide adequate coverage with limited complications. Microvascular free flaps are increasingly being used for reconstruction of these complex defects. The jejunal flap, the tubed radial forearm flap, and the anterolateral thigh flap work well in these situations. ^[3]

Other methods commonly used for pharyngoesophageal reconstruction include colon interposition, gastric pull-up, or tubed pectoralis major myocutaneous flaps. Although all these techniques can provide a good pharyngoesophageal reconstruction, they are associated with higher rates of operative mortality (11-20%) and fistula formation (35-40%) than jejunum free tissue transfer.

The free jejunal flap is unique because it was the first free flap described in the literature. Seidenberg first published his case in 1959, and the technique was further refined by Serafin and Buncke in 1979. ^[4] Microvascular free jejunal reconstruction of the pharyngoesophagus has become increasingly reproducible and reliable. Currently, overall success of free jejunal flap for reconstruction ranges from 95-97%. ^{[2, 5]}

Jejunal free flap reconstruction is used in the reconstruction of the oral cavity, oropharyngeal, and primarily circumferential defects (see the image below) of the upper aerodigestive tract. However, the most common indication is reconstruction of circumferential pharyngeal defects after extirpative surgery for hypopharyngeal carcinoma. ^{[6, 7]}

Reconstruction using the jejunum provides a way to reestablish the mucosal conduit, thereby preserving the patient’s ability to swallow. Speech, if lost as a result of resection of the larynx, is not as effectively restored. Patients commonly project a “wet voice.” Tube lengths of up to 30 cm can replace lost segments of the cervical esophagus from the nasopharynx to the thoracic inlet. ^[8]

The ablative procedure dictates the most appropriate reconstructive technique. Defects that extend into the chest are best reconstructed using techniques that do not place a suture line in the chest, which potentially results in mediastinitis should a leak occur. Typically, a gastric pull-up or colonic interposition is performed in these cases.

The large amount of normal secretions formed by the jejunum make its use in patients with an intact larynx suboptimal. These secretions lead to persistent aspiration if the jejunal free flap is not below a functioning cricopharyngeus. Other options such as the tubed radial forearm flap, scapular or parascapular flap, a combination of a pectoralis flap and a free flap, or anterolateral thigh flap can be used for the reconstruction without the problems associated with excess secretions.

The small bowel is composed of 3 distinct anatomic and physiologic segments: the duodenum, jejunum, and ileum. The jejunum begins at the ligament of Treitz and extends distally 6-8 feet. Its vascular supply is based off the superior mesenteric artery and vein; these vessels pass over the middle portion of the duodenum and enter the mesentery of the jejunum. Several jejunal arterial segmental branch off the superior mesenteric artery, and each communicates with an arcade that in turn communicates with the vasa recta. The vasa recta supply specific segments of the jejunum. This allows the surgeon to pick a segment of jejunum (usually 10-20 cm) and to trace the blood supply back to the jejunal segment feeding this jejunal segment.

As one moves distally in the small bowel, the number of vascular arcades increases in the ileum, and, therefore, indistinct perfusion patterns arise off of single arterial pedicles. Typically, the second jejunal branch is the pedicle of choice. When the dissection is carried right down to the superior mesenteric artery, arterial pedicles up to 3-4 mm in diameter and up to 20 cm in length can be obtained.

Previous small-bowel surgery (jejunal), uncontrolled ascites, chronic diseases of the jejunum, and documented mesenteric vascular disease specifically preclude the use of the jejunum.Patients who require upper aerodigestive tract reconstruction secondary to ablative cancer surgery often have much comorbidity. Most of the associated medical factors are not absolute contraindications to a lengthy surgery or, specifically, using a jejunal free flap. Medical risk factors that may complicate intra-abdominal and free flap surgery should be optimized preoperatively.

National Cancer Data Base based on patients diagnosed in 1998-1999. AJCC Cancer Staging Manual. 7th ed. 2010.

Numajiri T, Sowa Y, Nishino K, Fujiwara H, Nakano H, Shimada T. Does a vascular supercharge improve the clinical outcome for free jejunal transfer?. Microsurgery. 2013 Mar. 33(3):169-72. [Medline].

Anthony JP, Singer MI, Mathes SJ. Pharyngoesophageal reconstruction using the tubed free radial forearm flap. Clin Plast Surg. 1994 Jan. 21(1):137-47. [Medline].

Seidenberg MD, Rosenak SS, Hurwitt ES, Som ML. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg. 1959 Feb. 149(2):162-71. [Medline].

Walker RJ, Parmar S, Praveen P, Martin T, Pracy P, Jennings C. Jejunal free flap for reconstruction of pharyngeal defects in patients with head and neck cancer-the Birmingham experience. Br J Oral Maxillofac Surg. 2014 Feb. 52(2):106-10. [Medline].

Xu W, Lyu ZH, Zou JD, Ma JK, Sa N, Cao HY. [Reconstruction with free jejuna flap for the defect after removal of hypopharyngeal and cervical esophageal caneer: clinical analyses of 103 cases]. Zhonghua Er Bi Yan Hou Tou Jing Wai Ke Za Zhi. 2016 Dec 7. 51 (12):914-917. [Medline].

Hsieh MH, Yang YT, Tsai YJ, Kuo YR, Lin PY. Comparison of the outcomes of free jejunal flap reconstructions of pharyngoesophageal defects in hypopharyngeal cancer and corrosive injury patients. Microsurgery. 2017 Sep. 37 (6):552-557. [Medline].

Nagasao T, Shimizu Y, Kasai S, Hatano A, Ding W, Jiang H, et al. Extension of the jejunum in the reconstruction of cervical oesophagus with free jejunum transfer using the thoracoacrominal vessels as recipients. J Plast Reconstr Aesthet Surg. 2012 Feb. 65(2):156-62. [Medline].

Cordeiro PG, Shah K, Santamaria E, Gollub MJ, Singh B, Shah JP. Barium swallows after free jejunal transfer: should they be performed routinely?. Plast Reconstr Surg. 1999 Apr. 103(4):1167-75. [Medline].

Dionyssopoulos A, Odobescu A, Foroughi Y, Harris P, Karagergou E, Guertin L, et al. Monitoring buried jejunum free flaps with a sentinel: a retrospective study of 20 cases. Laryngoscope. 2012 Mar. 122(3):519-22. [Medline].

Chen HC, Tang YB. Microsurgical reconstruction of the esophagus. Semin Surg Oncol. 2000 Oct-Nov. 19(3):235-45. [Medline].

Clark JR, Gilbert R, Irish J, Brown D, Neligan P, Gullane PJ. Morbidity after flap reconstruction of hypopharyngeal defects. Laryngoscope. 2006 Feb. 116(2):173-81. [Medline].

Coleman JJ 3rd, Tan KC, Searles JM. Jejunal free autograft: analysis of complications and their resolution. Plast Reconstr Surg. 1989 Oct. 84(4):589-95; discussion 596-8. [Medline].

Haller JR. Concepts in pharyngoesophageal reconstruction. Otolaryngol Clin North Am. 1997 Aug. 30(4):655-61. [Medline].

Huang JL, Duan ZQ, Li-Yang, Guo ZW, Sun Q, Li AF, et al. Esophageal reconstruction by jejunal transfer. Ann Plast Surg. 1999 Jun. 42(6):658-61. [Medline].

Kimata Y, Uchiyama K, Sakuraba M, Ebihara S, Nakatsuka T, Harii K. Simple reconstruction of large pharyngeal defects with free jejunal transfer. Laryngoscope. 2000 Jul. 110(7):1230-3. [Medline].

Lorentz RR, Alam DS. The increasing use of enteral flaps in reconstruction for the upper aerodigestive tract. Current Opinon in Otolaryngology Head and Neck Surgery. 2003. 11:230-235.

Reece GP, Bengtson BP, Schusterman MA. Reconstruction of the pharynx and cervical esophagus using free jejunal transfer. Clin Plast Surg. 1994 Jan. 21(1):125-36. [Medline].

Shangold LM, Urken ML, Lawson W. Jejunal transplantation for pharyngoesophageal reconstruction. Otolaryngol Clin North Am. 1991 Dec. 24(6):1321-42. [Medline].

Smith DF, Ott DJ, McGuirt WF, Albertson DA, Chen MY, Gelfand DW. Free jejunal grafts of the pharynx: surgical methods, complications, and radiographic evaluation. Dysphagia. 1999 Summer. 14(3):176-82. [Medline].

Theile DR, Robinson DW, Theile DE, Coman WB. Free jejunal interposition reconstruction after pharyngolaryngectomy: 201 consecutive cases. Head Neck. 1995 Mar-Apr. 17(2):83-8. [Medline].

Tamer A Ghanem, MD, PhD Senior Staff, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health System

Tamer A Ghanem, MD, PhD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Triological Society

Disclosure: Nothing to disclose.

Hamad Chaudhary, MD, MS Resident Physician, Department of Otolaryngology-Head and Neck Surgery, Henry Ford Health Systems

Hamad Chaudhary, MD, MS is a member of the following medical societies: American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society, Michigan State Medical Society, Michigan Otolaryngological Society

Disclosure: Nothing to disclose.

Stephen M Weber, MD, PhD, FACS Facial Plastic and Reconstructive Surgeon, Weber Facial Plastic Surgery, PC

Stephen M Weber, MD, PhD, FACS is a member of the following medical societies: Alpha Omega Alpha, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, Phi Beta Kappa

Disclosure: Nothing to disclose.

Mark K Wax, MD Professor and Program Director, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University; Service Chief, Department of Surgery, Section of Otolaryngology, Veterans Affairs Medical Center

Mark K Wax, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Head and Neck Society, Canadian Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Rhinologic Society, American Society for Laser Medicine and Surgery, North American Skull Base Society, Royal College of Physicians and Surgeons of Canada

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Received salary from Medscape for employment. for: Medscape.

David W Stepnick, MD Associate Professor, Departments of Otolaryngology-Head & Neck Surgery and Plastic Surgery, Case Western Reserve University School of Medicine, MetroHealth Medical Center

David W Stepnick, MD is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Medical Association, Society of University Otolaryngologists-Head and Neck Surgeons, American College of Surgeons

Disclosure: Nothing to disclose.

Arlen D Meyers, MD, MBA Professor of Otolaryngology, Dentistry, and Engineering, University of Colorado School of Medicine

Arlen D Meyers, MD, MBA is a member of the following medical societies: American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American Head and Neck Society

Disclosure: Serve(d) as a director, officer, partner, employee, advisor, consultant or trustee for: Cerescan;RxRevu;Cliexa;Preacute Population Health Management;The Physicians Edge<br/>Received income in an amount equal to or greater than $250 from: The Physicians Edge, Cliexa<br/> Received stock from RxRevu; Received ownership interest from Cerescan for consulting; for: Rxblockchain;Bridge Health.

Terance (Terry) Ted Tsue, MD Vice-Chairman for Administrative Affairs, Professor, Residency Program Director, Department of Otolaryngology-Head and Neck Surgery, University of Kasnas School of Medicine

Terance (Terry) Ted Tsue, MD is a member of the following medical societies: Alpha Omega Alpha, Association for Research in Otolaryngology, American Head and Neck Society, Johns Hopkins Medical and Surgical Association, American Academy of Facial Plastic and Reconstructive Surgery, American Academy of Otolaryngology-Head and Neck Surgery, American College of Surgeons, American Medical Association, Missouri State Medical Association, Phi Beta Kappa, Society of University Otolaryngologists-Head and Neck Surgeons

Disclosure: Nothing to disclose.

Jejunum Tissue Transfer

Research & References of Jejunum Tissue Transfer|A&C Accounting And Tax Services
Source

Share on Facebook

Tweet

Follow us