eMedicine Specialties > Otolaryngology and Facial Plastic Surgery > Reconstructive Surgery

Tissue Transfer, Jejunum: Treatment

Author: Tamer A Ghanem, MD, PhD, Microvascular/Reconstructive Fellow, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University
Coauthor(s): Stephen M Weber, MD, PhD, Fellow in Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Division of Plastic and Reconstructive Surgery, University of Michigan; Mark K Wax, MD, Professor and Program Director, Department of Otolaryngology-Head and Neck Surgery, Oregon Health Sciences University; Service Chief, Department of Surgery, Section of Otolaryngology, Veterans Affairs Medical Center
Contributor Information and Disclosures

Updated: May 27, 2008

Treatment

Surgical Therapy

Patients undergoing free jejunal reconstruction are not usually given a bowel preparation before surgery. A bowel preparation is given the night before surgery only if concern exists over extensive adhesions and the possibility of an enterotomy.

Preoperative Details

Perioperative antibiotics as well as 81 mg of aspirin are routinely administered before surgery.

Intraoperative Details

One of the advantages of this flap is the ablative and reconstructive team are able to work simultaneously. Jejunal harvesting is performed by a general surgeon in conjunction with the microvascular reconstructive surgeon. Depending on the general surgeon's preference and expertise, harvesting can be via an open laparotomy approach or laparoscopically.

The following discussion focuses on the open laparotomy approach.  An upper midline laparotomy is followed by identification of the ligament of Treitz. Transillumination of the mesentery helps the surgeon to select the segment of the jejunum that is to be harvested. A longer segment than is needed to reconstruct the defect is usually harvested. If a sentinel loop of jejunum is to be used for monitoring, this is factored into the length to be harvested. The distal end of the jejunum is marked so that the jejunum can be placed in an isoperistaltic orientation in the neck.

The artery supplying the segment of the jejunum to be harvested is located, and the mesentery is marked in a triangle. The vessels are dissected back to their branching point off the superior mesenteric artery. Care at this point in the dissection prevents troublesome bleeding at the root of the small bowel mesentery. The bowel is then divided using a GIA stapler (US Surgical Corp; Norwalk, CT). Small-bowel continuity is reestablished with a stapled jejunojejunostomy. The mesentery is closed, and a distal feeding jejunostomy tube is placed. The artery and vein supplying the divided segment are not separated until the neck vessels have been prepared for microvascular anastomosis.

Neck vessel preparation is simultaneously completed by a second surgical team. Because the jejunum tolerates ischemia poorly, preparation of the neck vessels is vital prior to separating the jejunum from its vascular supply. Typically, ischemic times should be less than 90 minutes; longer intervals can lead to permanent damage or loss of the jejunum.

In general, the enteric anastomoses are performed first. High proximal enteric anastomoses tend to be the most difficult. As such, they are carried out first in a 2-layered fashion with absorbable sutures. The serosa is attached to the prevertebral fascia so as to take tension off this proximal enteric anastomosis. An end-to-end distal enteric anastomosis is performed, placing the jejunal autograft in an isoperistaltic position and under a small amount of stretch. This prevents kinking of the jejunal segment in the neck, which can cause regurgitation of food and dysphagia. The microvascular anastomoses are then completed. If a sentinel loop of bowel has been designed, it is left free to be brought out through the skin incision as a postoperative monitor. This monitor loop is removed one week postoperatively.

Modifications of the enteric anastomoses are performed to allow the jejunum to fit the defect in the upper aerodigestive tract. Spatulation proximally allows the small-caliber jejunum to fit larger defects. Triangular interdigitation distally into the esophagus decreases the incidence of stricture formation. Excess mesentery may be used to reinforce the enteric anastomosis. In addition to hand-sewn anastomosis, a GI end-to-end anastomotic device maybe utilized to anastomose the jejunum to the upper esophagus.

Postoperative Details

Postoperatively, the patient is monitored overnight on the floor or in an intensive care step-down unit, depending on the institutional preference. No anticoagulation other than the preoperative aspirin is routinely administered. The sentinel loop is monitored for arterial and venous insufficiency and mucus production. This segment may be placed in a bowel bag to collect the secretion and prevent desiccation. Enteral feeding via the jejunostomy tube is begun immediately. Internal Doppler probes may also be used in conjunction to the bowel monitoring segment to monitor the arterial or veinous anastomosis.

A barium swallow is performed approximately 10 days to 2 weeks postoperatively. Normal findings on barium swallow do not guarantee sealed enteric anastomoses. Similarly, the presence of a leak observed radiologically does not always carry clinical significance. Clinical judgment must always be used prior to beginning oral feeding.

Complications

The goal of reconstruction is to restore functional status in the shortest period of time with the least morbidity. With the jejunal free flap, complications specific to the operation can occur in the donor area, the microvascular anastomosis, or at the enteric anastomoses. Each can compromise reconstructive efforts or the patient's life.

Abdominal complications, while infrequent, include bleeding and hematoma from the root of the mesentery of the jejunum. Care in dissection of the vascular pedicle to the segment of jejunum to be used is of prime importance. Individual identification and ligation of the vessels usually eliminates problems.

Internal hernia and small-bowel leaks are rare and can be kept to a minimum by closure of the mesentery and careful reestablishment of bowel continuity. Abdominal tenderness postoperatively can cause difficulties with patient mobility and pulmonary toilet.

Microvascular complications have significantly improved over the past 20 years. Overall failure rates have been reported to be 3-20%. A large review has reported an overall free flap success rate of 91% in 672 patients. Ischemia tolerance is notoriously poor with this flap, necessitating rapid vascular reanastomosis and detection of flap compromise when it occurs.

Fistula formation and stricture formation can occur with any reconstructive technique. The rate of fistula formation is reported at 18%. Of these, over two thirds close spontaneously. Use of the free jejunum has the advantage of a relatively low rate (ie, 10%) of stricture formation.

More on Tissue Transfer, Jejunum

Overview: Tissue Transfer, Jejunum
Workup: Tissue Transfer, Jejunum
Treatment: Tissue Transfer, Jejunum
Follow-up: Tissue Transfer, Jejunum
Multimedia: Tissue Transfer, Jejunum
References
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References

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

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

  3. 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. Apr 1999;103(4):1167-75. [Medline].

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

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

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

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

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

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

  10. 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.

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

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

  13. 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. Summer 1999;14(3):176-82. [Medline].

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

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Further Reading

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Keywords

free intestinal transfer, free jejunum transfer, jejunum free tissue transfer, jejunal free autograft, cancer of the hypopharynx, cancer of the cervical esophagus, pharyngoesophageal resection, pharyngoesophageal cancer, jejunal free flap reconstruction, speech function, swallowing function

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Contributor Information and Disclosures

Author

Tamer A Ghanem, MD, PhD, Microvascular/Reconstructive Fellow, Department of Otolaryngology-Head and Neck Surgery, Oregon Health and Science University
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, and Triological Society
Disclosure: Nothing to disclose.

Coauthor(s)

Stephen M Weber, MD, PhD, Fellow in Facial Plastic and Reconstructive Surgery, Department of Otolaryngology, Division of Plastic and Reconstructive Surgery, University of Michigan
Stephen M Weber, MD, PhD 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, and Triological Society
Disclosure: Nothing to disclose.

Mark K Wax, MD, Professor and Program Director, Department of Otolaryngology-Head and Neck Surgery, Oregon Health Sciences 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 Academy of Otolaryngology-Head and Neck Surgery, American Bronchoesophagological Association, American College of Surgeons, American Rhinologic Society, American Society for Head and Neck Surgery, American Society for Laser Medicine and Surgery, Canadian Academy of Facial Plastic and Reconstructive Surgery, North American Skull Base Society, and Royal College of Physicians and Surgeons of Canada
Disclosure: Nothing to disclose.

Medical Editor

Terance (Terry) Ted Tsue, MD, Vice-Chairman for Administrative Affairs, Professor, Residency Program Director, Department of Otolaryngology-Head and Neck Surgery, University of Kansas School of Medicine
Terance (Terry) Ted Tsue, MD 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, American College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, Association for Research in Otolaryngology, Johns Hopkins Medical and Surgical Association, Missouri State Medical Association, Phi Beta Kappa, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

David W Stepnick, MD, Associate Professor, Departments of Plastic Surgery and Otolaryngology-Head and Neck Surgery, Case Western Reserve University School of Medicine, University Hospitals of Cleveland Case 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 College of Surgeons, American Medical Association, American Society for Head and Neck Surgery, and Society of University Otolaryngologists-Head and Neck Surgeons
Disclosure: Nothing to disclose.

CME Editor

Christopher L Slack, MD, Otolaryngology-Facial Plastic Surgery, Private Practice, Associated Coastal ENT; Medical Director, Treasure Coast Sleep Disorders
Christopher L Slack, MD 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, and American Medical Association
Disclosure: Nothing to disclose.

Chief Editor

Arlen D Meyers, MD, MBA, Professor, Department of Otolaryngology-Head and Neck Surgery, 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, and American Head and Neck Society
Disclosure: Advanced Headache Intervention Consulting fee Consulting; Covidien Corp Consulting fee Consulting

 
 
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