Jejunum Tissue Transfer Treatment & Management

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.

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

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 (see the images below). ^[10] 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 (see the image below).

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. See the images below.

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.

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.

A literature review by Bouhadana et al compared complications associated with the use of anterolateral thigh free flaps, jejunal free flaps, and radial forearm free flaps in the circumferential reconstruction of the pharynx and suggested that thigh flaps may be the best option. Meta-analysis indicated that with regard to the formation of strictures and fistulas, the difference between thigh and jejunal flaps is statistically insignificant. The investigators also reported that forearm flaps in the study had a significantly higher fistula rate than did jejunal flaps. Partial and complete flap failure, infection, donor site morbidity, and 30-day mortality rates were lowest for thigh flaps. ^[11]

A study by Onoda et al indicated that in patients who undergo jejunal free flap surgery for total pharyngo-laryngo-esophagectomy, the rate of postoperative complications and adverse events is not influenced by the extent of resection. ^[12]

The free jejunum flap has gained popularity as the success of the microvascular technique has increased. With flap survival and successful reconstruction rates as high as 97.6% and the patient mortality rate less than 5%, this technique has proven both effective and reliable.

Resumption of oral alimentation is observed in 60-90% of patients within 10-16 days postoperatively.

A retrospective study by Elaldi et al indicated that following total pharyngolaryngectomy, reconstruction with the jejunal free flap leads to better restoration of swallowing function than does surgery with other free flaps. In the first year post surgery, the jejunal free flap was associated with a higher Functional Oral Intake Scale (FOIS) score than were the other flaps, with this outcome remaining stable over the first 5 years. Moreover, chronic pharyngostoma and pharyngoesophageal stricture occurred more frequently in association with the other flaps. ^[13]

A literature review by Hung et al indicated that in gastric tube reconstruction following total esophagectomy, use of the jejunal free flap provides better results with regard to anastomosis leakage, length of hospital stay, and in-hospital mortality than does colon interposition (CI), while CI leads to less anastomotic stricture formation than does jejunal free flap surgery. However, the investigators suggested that the inferior results for CI may have been associated with out-of-date studies. ^[14]

Although the free jejunum effectively reconstructs the lost portion of the upper aerodigestive tract with a mucosal lined conduit, many problems still exist. Current techniques of tracheal puncture provide acceptable speech, but one of the most significant problems with jejunal reconstruction is the "wet" and relatively poor quality of voice. As experience with microsurgical technique increases, morbidity from the operation may decrease, and functional outcomes will naturally improve.