Expansion of the oral end of free revascularised jejunum with a jejunal patch flap rotated like a folding fan

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1 British Journal of Plastic Surgery (1998), 51, The British Association of Plastic Surgeons BRITISH JOURNAL OF ~ PLASTIC SURGERY Expansion of the oral end of free revascularised jejunum with a jejunal patch flap rotated like a folding fan T. Yoshida, S. Shimizu, N. Sakai, I. Mochimatsu, H. Enomoto and A. Nakano Departments of Plastic and Reconstructive Surgery, Otolaryngology and Second Department of Surgery Yokohama City University Hospital Yokohama, Japan SUMMARY. We have devised a new expansion process for the reconstruction of the cervical oesophagus with free revascularised jejunum in cases of hypopharyngeal cancer. The jejunal island flap is divided into three subislands and the major island of the caudal end is split partially at its oral end. The middle island is split, trimmed triangularly, and inserted into opened major island to expand the diameter of the oral end of the conduit for the cervical oesophagus and to make it funnel-shaped. The smallest island on the oral side is used as a circulation monitor for the transferred jejunum. Because the jejunal island patch is rotated around the root of mesentery like a folding fan and joined to the major island, there is neither shortening of the pedicle nor distortion. This method allows expansion of the oral end by up to 180% to facilitate end to end anastomosis in proximal pharyngeal defects. When reconstructing the hypopharynx and cervical oesophagus with free vascularised jejunum, there is often the need for some ingenuity in anastomosis, especially at the oral end, because of the discrepancy in size. L3 When the height of the excision reaches both tonsils, end to end anastomosis becomes impossible. This problem has been solved by means of end to side anastomosis with reverse L-shaped or 9- shaped donor jejunum as has been reported and is being used by many head and neck surgeons including the present authors (Figs 1, 2). 4~ This may be complicated by the formation of a pouch at the oral end of the conduit causing disturbance of the passage of food (Fig. 3). It would seem better to make the donor jejunum straight and funnel-shaped when there is a discrepancy in the anastomosis. We present here our experience with a new jejunal expansion method. Patients and methods In the period from April 1995 to May 1997, 11 patients with hypopharyngeal cancer were treated at our hospital. As 7 of them had relatively advanced piriform sinus type tumours, it was necessary to excise up to the moesopharyngeal area including both tonsils (Table). The patients were all male, aged (average 63.9) years. All underwent preoperative chemotherapy and 2 patients underwent preoperative radiotherapy of a total of 70Gy. The others 4 patients without one received postoperative radiotherapy. They were followed up for 1 month to 2 years and 1 month (average 1 year, 2.3 months) and their swallowing ability evaluated by interview and by pharyngo-oesophagography. Surgical technique About 30 cm length of jejunum supplied by the 2nd or 3rd jejunal artery is prepared and cut off at both ends. This jejunal island is further cut into 3 subislands (Fig. 4A). The first island from the oral side is 3 cm in length and is used as a circulation monitor outside the body. The second island is 7 cm in length, and the third one should be 15 cm or more according to the length requirement for the reconstruction. When the cervical recipient blood vessels are on the left these islands form a "C" shape, and when the vessels are on the right the islands form reverse "C". The middle island is prepared for expansion of the oral side of the reconstructed jejunal tube by splitting the anterior wall and trimming it into a triangular patch. 7 The patch is then inserted into a corresponding triangular space formed by partially splitting and spreading the posterior wall of the third island (Figs 4B, 5). This permits the formation of a funnel-shaped tube without shortening or twisting the vascular pedicle (Figs 4C, 6). The 2nd jejunal artery and vein are freed for as great a length as possible, clamped and cut, and the prefabricated funnel-shaped conduit is transported to the cervical region and aligned with the recipient vessels. Anastomoses are performed using the internal jugular vein and the recipient artery which is usually the superior thyroid artery. After confirming the restoration of circulation and peristalsis in the jejunal tube, the edges of the wedge-shaped lateral defect in the excised moesopharyngeal wall are approximated as much as possible and sutured. This narrows the pharyngeal space which in turn facilitates the first stage of swallowing. Anastomosis of the conduit is begun at the oral end and the distal 103

2 104 British Journal of Plastic Surgery 3 1 Fig. 1 Figure 1--Reported types of expansion of the jejunal oral end: (1) Reverse L side-to-end anastomosis; (2)p-shaped side-to-end anastomosis; (3) Double folding: Harashina's expansion method; (4) Double lumen: J-Pouch. end is then trimmed short so that a slight longitudinal tension is produced when the anastomosis is sutured. This is important to ensure the smooth passage of food. The smallest jejunal island for blood circulation monitor is tacked to the neck skin with a few external sutures before final wound closure. Results Figure 2 p-type reconstruction. Fig. 2 Two weeks after operation, all patients had pharyngo-oesophagography, and after ascertaining that there was no fistula or food passage disturbance, oral feeding was started. Radiotherapy was started 4 weeks after surgery in the cases who had not had preoperative radiotherapy (Table). There was one patient who had a small fistula at the anterior pharyngeal anastomosis (Case 6). This closed spontaneously without further surgery in 2 weeks and he could eat foods smoothly. All other patients have had no problem in swallowing and can eat a normal meal taking between 30 min and 45 min, over their courses (Fig. 9).

3 Jejunal expansion with patch flap 105 A B Fig. 3 Figure 3~Pharyngo-oesophagography: p-type. (A) Frontal view. Kinking at bilateral pharyngeal angles and pooling are seen (B) Lateral view. Divertiulum with pooling at the loop is seen. Table List of Cases: Reconstruction of cervical oesophagus with free revascularized jejunum with its oral end expanded in the period from April 1995 to May The excision was at the level of both tonsils in all cases Case Age (years) Sex Location TNM Operation Other therapy Complications Follow-up Status 1 62 Male PS* T3N2aM0 EL.E** Chemo, DXT~ No 2 years, 3 months Metastasis 1 year, 7 months alive 2 71 Male PS T3N2bM0 EL.E** Chemo, DXT t No 2 years, 2 months DF**** 3 77 Male PS T3N1M0 RL.E.** Chemo, DXT~ No 1 year, 5 months DF 4 61 Male PS T3NOM0 RL.E.** Chemo No 1 year, 2 months DF 5 66 Male PS T3N2bM0 RL.E.** Chemo, DXT' No 9 months~ Metastasis 6 45 Male PS T3N2cM0 RL.E.** Chemo, DXT 2 Fistula 3 months DF spontaneous cure 7 65 Male PS T3N2cM0 EL.E** Chemo, DXT 2 No 2 months DF * PS : piriform sinus; ** P.L.E. : pharyngo-laryngo-oesophagectomy with bilateral tonsils; *** bil. RND:bilateral radical neck dissection; **** DF : disease free. *Death Chemo: Chemotherapy given preoperatively. DXT~: Radiotherapy given postoperatively. DXT2: Radiotherapy given preoperatively Discussion The free jejunal flap is the most popular method for the reconstruction of the hypopharynx and cervical oesophagus today with specific advantages in relation to colonic transposition. 8 ~0 One common technical problem is that the jejunum is usually too narrow to anastomose with the pharyngeal stump. To solve this problem the jejunum conduit can be given the form of a reverse L or a P and a side-to-end anastomosis created at the upper end. Each of these methods tends to make a diverticulum-like pouch and stricture that disturbs the passage of food over a period of time. The alternative method for expanding the oral opening of the gut into a funnel shape has been developed and used in seven cases of reconstruction which had a discrepancy in anastomotic size on the hypothesis that an end-to-end repair is the best for smooth passage of

4 106 British Journal of Plastic Surgery Fig. 4 Fig. 5 Fig. 7 Fig. 6 Figure 4--Schematic illustration of the process of expanding the jejunum. (A) Dividing into three jejunal islands. (B) Cutting open and making the middle island into a triangular patch, and cutting and expanding the anal island. (C) Circulation monitoring island and completed funnel shape conduit. Figure 5--Operating on the jejunum: procedure corresponding to Figure 4B. Figure ~-Procedure corresponding to Figure 4C. Figure 7--Resection complete: the pharynx has been excised above the level of both tonsils.

5 Jejunal expansion with patch flap 107 Fig. 8 //,' / IIII A Fig. 10 B Figure ~Vascular anastomoses completed and end-to-end anastomoses of the conduit achieved at both ends without size mismatch. The small jejunal island on the left side of the neck is for circulation monitoring. Figure 9--Pharyngo-oesophagography. (A) Frontal view. (B) Lateral view. There is smooth passage of barium with no kinking or pooling. Figure 10--Splitting folding fan at about 1/3 of its width and rotating the small piece behind the large one. Fig. 9 food. The expansion is achieved by splitting open longitudinally the anterior wall or posterior wall of each gut island as described above, rotating blood vessels and conjoining the 2 islands without distortion or shortening of the vascular pedicle. Although the gut should ideally be cut along the antimesenteric border to preserve circulation, this would cause distortion and shortening of the vessels. We did not experience any circulatory impairment. We believe that this is easier to perform than the double-folded graft suggested by Harashina. The concept is simple and may be likened to splitting a folding fan at about one third of its width, and rotating the small piece behind the large one (Fig. 10) preserving the distance to the centre of rotation and thereby avoiding distortion. Acknowledgements The author would like to thank Professor K. Fujita, Department of Oral and Maxillofacial Surgery for his sympathy with my procedure and encouragement. References 1. Inoue Y, Tai Y, Fujita H, Tanaka S, Migita H, Kiyokawa K, Hurano M, Kakegawa T. A retrospective study of 66 oesophageal reconstructions using microvascular anastomoses: problems and our methods for atypical cases. Plast Reconstr Surg 1994; 94: Katsaros J, Tan E. Free bowel transfer for pharyngooesophageal reconstruction: an experimental and clinical study. Br J Plast Surg 1982; 35: Reuther JF, Steinau, HU, Wagner R. Reconstruction of large defects in the oropharynx with a revascularised intestinal

6 108 British Journal of Plastic Surgery graft: an experimental and clinical report. Plast Reconstr Surg 1984; 73: Jones NF, Eadie PA, Meyers EN. Double lumen free jejunal transfer for reconstruction of the entire floor of mouth, pharynx and cervical oesophagus. Br J Plast Surg 1991; 44: Longmire WR Construction of a substitute gastric reservoir following total gastrectomy. Ann Surg 1952; 135: Nozaki M, Huang, TT, Hayashi M, Endo M, Hirayama T. Reconstruction of the pharyngoesophagus following pharyngoesophagectomy and irradiation therapy. Plast Reconstr Surg 1985; 76: Sheen R, Mitchell GM, MacLeod AM, O'Brien BMoC. Intraoral mucosal reconstruction with microvascular free jejunal autografts:an experimental study. Br J Plast Surg 1988; 41: Boyd JB, Hynes B, Manktelow RT, Cooper JD, Rotstein LE. Extensive pharyngo-oesophageal reconstruction using multiple jejunal loops. Br J Plast Surg 1987; 40: Robinson DW, MacLeod A. Microvascular free jejunum transfer. Br J Plast Surg 1982; 35: Smith RW, Garvey CJ, Dawson PM, Davies DM. Jejunum versus colon for free oesophageal reconstruction:an experimental radiological assessment. Br J Plast Surg 1987; 40: Harashina T, Inoue T, Andoh T, Sugumoto C, Fujino T. Reconstruction of cervical oesophagus with free doublefolded intestinal graft. Br J Plast Surg 1985; 38: The Authors Toyokazu Yoshida MD, Chief, Department of Plastic and Reconstructive Surgery S. Shimizu N. Sakai Izumi Mochimatsu H. Enomoto Department of Otolaryngology A. Nakano Second Department of Surgery Yokohama City University Hospital, 3-9 Fukuura Kanazawa-Ku, Yokohama 236, Japan. Correspondence to Dr T. Yoshida. Presented in part at the 39th Japanese Congress of Plastic and Reconstructive Surgery in Osaka, Japan, on April Paper received 25 July Accepted 10 December 1997.