Comparative Study of Free Flap Reconstruction after Total Laryngopharyngectomy for Hypopharyngeal Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Recently, both jejunal and fasciocutaneous free flap reconstruction are widely used after total laryngopharyngetomy for the treatment of hypopharyngeal cancer. The aim of this study is to evaluate and compare the functional outcomes between jejunal and fasciocutaneous free flap in the reconstruction of hypopharynx after total laryngopharyngectomy. SUBJECTS AND METHOD: The medical records of 27 patients with hypopharyngeal cancer who underwent total laryngopharyngectomy and free flap reconstruction were reviewed retrospectively. Of 27 patients, 18 (66.7%) were reconstructed with jejunal free flap and 9 (33.3%) with fasciocutaneous free flap. We compared complications, flap success rates, functional outcomes such as swallowing, respiration and quality of life (QOL) between two reconstruction groups. The swallowing function was evaluated by Functional Outcome of Swallowing Scale (FOSS), and QOL was evaluated by EORTC QOL-C30, HN35. RESULTS: Twenty-seven patients consisted of 26 males and 1 female. The mean age of 69+/-9.1. There were 4, 13, and 10 cases for T2, T3, and T4, respectively. Also, there were 8, 5, 7, and 7 for N0, N1, N2 and N3 cases. The success rate of free flap was 96.3%. The complication rate, operative time, the period of hospital stay did not differ between the two groups. The average score of FOSS was 0.92 in the jejunal group and 1.00 in the fasciocutaneous group. Quality of life was satisfactory in both groups. CONCLUSION: Both jejunal and fasciocutaneous free flap are very effective reconstructive methods after total laryngopharyngectomy for hypopharyngeal cancer. The choice of free flap can be determined based on the individual status of patient and preference of surgeon.

Pharyngoesophageal Reconstruction Using Modified Jejunomesenteric Composite Free Flap

PURPOSE: The jejunal free flap is the most standard and reliable procedure of reconstruction of the circumferential pharyngoesophageal defect because it provides pliable, elastic, secreting mucosa and posses reliable vascular anatomy. In this report, the authors introduce the modification of jejunal free flap for decreasing the complications in fatty complicated patients. METHOD: After harvesting the jejunum with mesentery and mesenteric vessels, both ends of jejunum were excised remaining the mesenteric portion. The jejunal portion of this composite flap was placed to reconstruct esophagopharyngeal defect area and the mesenteric portion was used to obliterate the dead space at paratracheal region and to cover the vital structure and the vascular anastomotic region. RESULT: A 72 year-old man with recurrent hypopharyngeal cancer who had about 15cm sized circumferential pharyngoesophageal defect after total pharyngectomy was reconstructed with jejunomesenteric composite free flap without any complications. CONCLUSION: The mesenteric flaps at both side of jejunomesenteric composite free flap provide the advantages that could obliterate dead space, that could provide cover for the vital cervical vascular structure in case of vascularity was compromised due to previous radiation therapy, and that could preserve as much vascularity at both ends of jejunal flap as possible.

Usefulness of External Monitoring Flap in the Buried Jejunal Free Flap

PURPOSE: The jejunal free flap has the shorter ischemic time than other flap and requires a laparotomy to harvest it. As the evaluation of the perfusion the buried flap is very important, the perfusion of the buried jejunal free flap requires monitoring for its salvage. We tried to improve the monitoring flap method in the jejunal free flap and examined its usefulness. METHODS: From March 2002 to March 2006, the monitoring flap method was applied to 4 cases in 8 jejunal free flaps for the pharyngeal and cervical esophageal reconstructions. The distal part of the jejunal flap was exposed without suture fixation through cervical wound for monitoring its perfusion. The status of perfusion was judged by the color change of jejunal mucosa and mesentery. If necessary, pin prick test was performed. Doppler sonography was applied to mesenteric pedicle of the monitoring flap in case of suspicious abnormal circulation. RESULTS: The monitoring flap shows no change in 3 cases, but the congestion happened in one case at the 12 hours after the operation. This congestion was caused by the twisting or kinking of the mesenteric pedicle of the monitoring flap. So, we fixed up the monitoring flap close to adjacent cervical skin for prevention of rotation. Finally, the main part of transferred jejunal flap was intact. CONCLUSION: The success of a jejunal free flap depends on close postoperative monitoring and early detection of vascular compromise. So, various monitoring methods have been tried, for instance, direct visualization using a fiberoptic pharyngoscope, through a Silastic window placed in the neck flap, or external surface monitoring with an Doppler sonography, use of a buried monitoring probe. But, all of the above have their own shortcomings of simplicity, non-invasiveness, reliability and etc. In our experience, monitoring flap can be a accurate and reliable method.

Reconstrução faringoesofágica com retalho livre de jejuno após faringolaringoesofagectomia cervical / Pharyngoesophageal reconstruction using free jejunal flap following neck pharyngolaryngoesophagectomy

OBJETIVO: Os autores apresentam os resultados de reconstruções esofágicas com retalho microcirúrgico de jejuno obtidos no Instituto Nacional de Câncer entre dezembro de 1998 e março de 2001, ressaltando suas vantagens, desvantagens e suas complicações. MÉTODO: Foram estudados sete pacientes portadores de neoplasias avançadas de laringe, faringe ou da tireóide que foram submetidos no Instituto Nacional de Câncer (Rio de Janeiro-Brasil) à reconstrução esofágica cervical com interposição de retalho livre de jejuno após faringolaringectomia associada à esofagectomia cervical. Foram cinco homens e duas mulheres com uma média de idade de 54 anos (39-66). Três pacientes foram submetidos à reconstrução esofágica imediata e em quatro casos a reconstrução foi tardia, em média após 10,5 meses. RESULTADOS: Não existiram perdas do retalho ou mortes no período pós-operatório avaliado. Das complicações, a mais freqüente foi infecção de ferida operatória (57,1 por cento). Fístulas salivares acometeram dois casos (28,5 por cento) e necessitaram de tratamento cirúrgico. Outras complicações incluíram estenose (14,1 por cento) e hipopafatireoidismo (28,5 por cento). Não houve complicações abdominais. Quatro dos sete casos apresentaram recidiva da doença em um período médio de 16,6 meses. Cinco pacientes reconquistaram uma satisfatória capacidade de deglutição após o procedimento. CONCLUSÃO: A experiência apresentada sugere que o retalho livre de jejuno consiste em um procedimento seguro, com elevados índices de sucesso para reabilitação da via digestiva e com baixos índices de complicações se comparado a outros métodos.

OBJECTIVE: The present study describes the results at the Instituto Nacional de Câncer (Rio de Janeiro-BRAZIL) in reconstruction of cervical esophagus using jejunal interpositional flap. Advantages, disadvantages and possible complications are discussed. METHOD: Seven patients with Iocally advanced carcinoma of the Iarynx and thyroid underwent pharyngoesophageal reconstruction using free jejunal interpositional flap after pharyngolaryngectomy-esophagectomy from december/1 998 through march/2001 at Instituto Nacional de Cancer. There were five men and two women with mean age of 54,1 years old (39-66 years). Three patients underwent immediate esophageal reconstruction. In four cases, the reconstructions were performed under delayed basis (in mean, after 10,5 months). RESULTS: There were no flap failures or perioperative deaths. The most frequent complication was wound infection (57,1 percent). Salivary fistula occured in two cases (28,5 percent) and required secundary revision. Other complications were stenosis (14,1 percent) and hypoparathyroidism (28,5 percent).There were no abdominal complications. Four out of seven patients presented recurrent disease in a mean time of 8,5 months (3-13 months). Five patients (71 percent) acquired a satisfactory swallow function after surgery. CONCLUSION: The cases here presented, suggest that free jejunal flap is a safe procedure with high success rates for high digestive tract reabilitation, with few complications.