Refinement and Modification of Free Jejunal Graft for Pharyngeal Reconstruction after Total Laryngopharengectomy for Post Cricoid Carcinoma
Adel Denewer, Ashraf Khater, Osama Hussein, Fayez Shahhto, Sameh Roshdy, Mohammed Hafez, Khaled Abdel Wahab, Adel Fathi, Fathy Denewer and Emad Hamed
Abstract: Hypo pharyngeal carcinoma is relatively uncommon. No single surgical technique is superior in achieving the best oncologic and functional results.Reconstruction of the digestive tract to restore postpharyngectomy continuity is challenging. Free jejunum transfer remains the most reliable option. Micro vascular techniques minimize partial flap necrosis and the subsequent salivary fistula and are superior to pedicled flaps. Improving the results of free jejunum pharyngeal substitute is thus of utmost importance to the success of treatment of patients with hypo pharyngeal carcinoma.
Methods:
Refinement plan: Considerations for organ preservation determine the choice of therapy in the majority of cases. Most patients present with stage III or resectable stage IV tumors. Combined surgery and chemo-irradiation is essential for these patients. A few of our patients present as early cancers (stage I, II).
Surgical ablative phase: the majority of patients need formal total laryngectomy, pharyngectomy, thyroidectomy and bilateral modified block dissection (i.e. neck emptying).
Reconstructive phase
The jejunal loop is harvested through an abdominal midline incision. Careful dissection of the mesentery exposes the primary branches of the superior mesenteric artery (SMA). The free flap is based on the second and third branches of SMA. Refinement in the technique includes
The distal jujeno-esophageal anastomosis is performed with a circular (EEA) stapler.
Double vascular pedicle is used in the irradiated neck.
A jejunal window is always used in the irradiated neck.
Results: In total, mortality rate was 8.3% (4 patients). The most common causes of operative death were pulmonary embolism and sepsis syndrome. Hospital stay ranged from 10-22 days. Three flaps were lost out of 28 traditional flaps and the remaining 25 flaps were evaluated for technique-related morbidity. One flap was lost after 20 modified procedures and 19 patients were evaluated for technique-related morbidity.
Conclusion: Free jejunal transfer remains the most effective method of reconstruction of the hypopharynx. Several modifications have been recently introduced to refine the technique and maximize the chance of rapid recovery and improved function of these debilitated patients.
Adel Denewer, Ashraf Khater, Osama Hussein, Fayez Shahhto, Sameh Roshdy, Mohammed Hafez, Khaled Abdel Wahab, Adel Fathi, Fathy Denewer and Emad Hamed
Abstract: Hypo pharyngeal carcinoma is relatively uncommon. No single surgical technique is superior in achieving the best oncologic and functional results.Reconstruction of the digestive tract to restore postpharyngectomy continuity is challenging. Free jejunum transfer remains the most reliable option. Micro vascular techniques minimize partial flap necrosis and the subsequent salivary fistula and are superior to pedicled flaps. Improving the results of free jejunum pharyngeal substitute is thus of utmost importance to the success of treatment of patients with hypo pharyngeal carcinoma.
Methods:
Refinement plan: Considerations for organ preservation determine the choice of therapy in the majority of cases. Most patients present with stage III or resectable stage IV tumors. Combined surgery and chemo-irradiation is essential for these patients. A few of our patients present as early cancers (stage I, II).
Surgical ablative phase: the majority of patients need formal total laryngectomy, pharyngectomy, thyroidectomy and bilateral modified block dissection (i.e. neck emptying).
Reconstructive phase
The jejunal loop is harvested through an abdominal midline incision. Careful dissection of the mesentery exposes the primary branches of the superior mesenteric artery (SMA). The free flap is based on the second and third branches of SMA. Refinement in the technique includes
The distal jujeno-esophageal anastomosis is performed with a circular (EEA) stapler.
Double vascular pedicle is used in the irradiated neck.
A jejunal window is always used in the irradiated neck.
Results: In total, mortality rate was 8.3% (4 patients). The most common causes of operative death were pulmonary embolism and sepsis syndrome. Hospital stay ranged from 10-22 days. Three flaps were lost out of 28 traditional flaps and the remaining 25 flaps were evaluated for technique-related morbidity. One flap was lost after 20 modified procedures and 19 patients were evaluated for technique-related morbidity.
Conclusion: Free jejunal transfer remains the most effective method of reconstruction of the hypopharynx. Several modifications have been recently introduced to refine the technique and maximize the chance of rapid recovery and improved function of these debilitated patients.
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