Jejunum Tissue Transfer

Jejunal free flap reconstruction is used in the reconstruction of the oral cavity, the oropharynx, 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. ^{[1, 2]}

Neck surgical wound showing a circumferential pharyngeal defect from the base of tongue to the cervical esophagus.

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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%. ^[3] 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. ^[4]

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. ^[5]

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. ^[6] 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%. ^{[4, 7]}

As mentioned, jejunal free flap reconstruction is used in the reconstruction of the oral cavity, the oropharynx, and primarily circumferential defects of the upper aerodigestive tract. However, the most common indication is reconstruction of circumferential pharyngeal defects after extirpative surgery for hypopharyngeal carcinoma. ^{[1, 2]}

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.