Jejunal Esophageal Replacemento

The free jejunal autograft is the most popular transplant for reconstruction of phar-yngoesophageal defects. A segment of the second jejunal loop along with its superior @

Figure 22 Revascularized jejunal segment in place provides a conduit between the oropharynx and esophagus.

mesenteric arcade of vessels is transplanted into the neck and revascularized using microvascular techniques (Fig. 22). A general surgical team can harvest the flap in less than 1 h. A feeding jejunostomy is performed at the same setting. The flap is carefully placed in an isoperistaltic orientation and both enteric anastomoses are completed prior to revascularization. The marker segment is brought out through the lower medial neck incision (Fig. 23). The distal anastomosis (esophagojejunal) is prone to stricture because of the continuous circumferential suture line. It is best to break up the continuous line of suture by creating a V-plasty. Postoperative radiation is well tolerated with minimal morbidity. Although distal anastomotic stricture is relatively rare, it is obviously more common to this technique than to gastric pull-up. Significant intra-abdominal complications occur infrequently. Voice rehab- |

ilitation is on par with gastric pull-up. ยง

Regional Flap Esophageal Replacement

Regional flaps have a limited role in the reconstruction of circumferential pharyngeal .3

defects. However, prior to the common use of microvascular flaps, regional flaps were briefly the flap of choice. The deltopectoral flap (1965) was heralded as a major o advance in reliable pharyngoesophageal replacement. The deltopectoral flap was also a significant advance in the understanding of axial flap physiology. This flap

was well vascularized and outside the usual neck irradiation portals and it could be transferred easily to the pharynx. However, as with the Wookie procedure, reconstruction required multiple stages. A controlled fistula is created after the initial surgical transfer of the flap. After at least 3 weeks, the pedicle is divided and the esophageal anastomosis is completed, closing the fistula. In practice, multiple procedures are usually required finally to close the fistula and postoperative stricture at the distal anastomosis is common. Time to a successful swallow averages 10 weeks and several months of hospitalization are typical.

The other most commonly used regional flap is the pectoralis major. This flap became the workhorse of head and neck reconstruction including the pharynx shortly after it was introduced in the late 1970s. Early reports of its use | by Baek and Withers for circumferential defects included a recommendation to create of a temporary controlled fistula because of the high rate of uncontrolled fistula formation after primary reconstruction. The main problem using the pec-toralis flap for circumferential pharyngeal defects is its excessive bulk. Forming a tube with this flap has been likened to trying to form the New York City Yellow Pages into a tube. The suture line is under some tension as a result of this phe- o nomenon, making postoperative fistulization more likely. In addition, the interior of the neopharynx becomes quite tight causing significant dysphagia postopera-

Figure 24 The tubed radial forearm flap is depicted as harvested from the arm with a proximal marker segment. After the flap is inset, the marker segment is incorporated into the cervical flap incision for monitoring purposes.

tively. Today, the pectoralis flap is relegated to repair of only partial pharyngeal defects. Of course, it remains a workhorse for other types of head and neck defects.

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