Reconstruction of pharyngolaryngectomy defects using the jejunal free flap: A 10-year

experience from a single reconstructive team

Moradi P, Glass GE, Atherton DD, Eccles S, Coffey

M, Majithia A, Speirs A, Clarke P M, Wood S H

Introduction• Reconstruction following

pharyngolaryngectomy presents a complex reconstructive challenge.

• Goals of reconstruction:– a single stage, reliable reconstruction – prompt discharge from hospital – return of swallowing and speech function

Introduction

• We present our 10-year experience of 43 jejunal free flaps for pharyngolaryngectomy reconstruction by a single team and outline our operative algorithm to minimise post-operative morbidity.

Method

• Retrospective chart review of all patients who underwent jejunal free flap reconstruction of circumferential pharyngoesophageal defects

• March 2000 and September 2009

Patient Study Group

• 43 patients– 31 male and 12 female

• Mean age of 62 (+/- 9 years, 1SD)

Patient Study Group

• 23 patients (53%) were reconstructed for primary disease

• 20 patients (47%) for recurrence or a second primary.

• 21 cases (49%) were undertaken for recurrence having had previous radiotherapy.

Method All flaps were performed by the two senior

authors (PC and SW) at Charing Cross Hospital

Surgical protocols were based on the standard principles of free jejunal transfer with 2 major modifications:

1. Gastrointestinal bowel stapler was favoured for both the proximal and distal anastomosis where possible

2. All patients who had been exposed to previous radiotherapy received a prophylactic pedicled pectoralis major muscle flap to cover both bowel anastomoses unless both anastomoses were performed using the stapler.

Results

• 43/43 (100%) acute flap survival

Radiotherapy and the incidence and location of fistula formation in patients having undergone hypopharygeal reconstruction with

a free jejunal flap

Fistula

• Overall benign fistula rate– 2/43 (4.7%)

Radiotherapy

• Chang et al reported that those patients who received preoperative radiation therapy had a higher incidence of fistula formation than patients who had not, but this did not reach significance (16.3 percent versus 11.4 percent p=0.36).

Fistula• 14/21 cases (67%) who underwent

radiotherapy had a prophylactic pedicled pectoralis major muscle flap to cover the anastomosis.

• Of these 14 patients:– 0 had a pharyngocutaneous fistula.

D.W. Chang, et al Plast Reconstr Surg 109 (2002), pp. 1522–1527) Reported a leak rate of 43.5% in the distal anastomosis sutured with a double layer

closure

Proximal anastomosis

34 of 43 cases (79%) double layer sutures. 2 of 34 (6%) developed a leak.

The remaining 9 were closed with the gastrointestinal stapler. There were no leaks among the 9 stapled proximal

anastomoses (P=NS).

Distal anastomosis

• 39 of 43 (91%) were performed with the stapler. – There were no leaks identified from the distal

anastomosis

• The remaining 4 cases were sutured.

Anastomosis

• 48/86 (56%) of the anastomosis were performed with the stapler– 0/48 developed a fistula

• 2/38 hand sutured anastomosis developed a fistula

Literature Review• Nelligan (J Plast Reconstr Aesthet Surg. 2008)

reported a fistula rate of:– 13% for all fasciocutaneous flaps

• ALT flap 16.4% • radial forearm free flap 14.4%.

– Jejunum 9.4%

Murray D, Novak C, Neligan P. Fasciocutaneous free flaps in pharyngolarngo-oesophageal reconstruction: A critical review of literature. J Plast Reconstr

Aesthet Surg. 2008

Overall benign stricture rate was 6/43 (14%).

Voice Restoration• 22 of 42 received a

primary (TEP)• 14 of 42 received a

secondary TEP

• 36/42 (85%) received either a primary or secondary TEP

• Speech was analysed in 39 patients. • Voice was reported as:

– Good in 17 of 39– Fair in 11 of 39.

– 28 of 39 (72%) used their tracheoesophageal puncture as their primary mode of communication

•

Yu P, et al. Plast Reconstr Surg. 2006

8/26 (31%) of the ALT groupand 2/31 (6%) Jej group used the TEP prosthesis as the

primary mode of communication.

Swallowing• Swallowing was analysed in 41 patients,

– 27/41 (66%) had a “good” swallow, • regular diet.

– 9/41 (22%) had a “moderate” swallow• pureed diet

– 5/12 (12%) had a “poor” swallow, • partially or totally dependent on tube feeding

Conclusion