Two shapes of a transferred jejunal graft according to the side of the recipient vessels. In the upper diagram, diagonal shading indicates a large defect of the lateral wall of the mesopharynx. A, The mesenteric vessels of a jejunal graft with an antimesenteric incision are anastomosed ipsilateral to the highest point of the defect. B, The mesenteric vessels of a jejunal graft with an antimesenteric incision are anastomosed contralateral to the highest point of the defect.
Microangiographs of vessels in the jejunum. A, The segment of jejunum was opened with a paramesenteric incision. Barium sulfate was then administered through the mesenteric vessels. The arrow indicates the antimesenteric area of the jejunum. B, The segment of jejunum without incision. C, The antimesenteric area is shown magnified (original magnification×5).
Illustrations of the operative procedures. A, The pharyngojejunal anastomosis is started from the highest point of the pharyngeal defect. B, Anastomosis is performed toward the opposite side of the highest point of the defect. C, The jejunal graft is incised longitudinally with scissors. D, The distal jejunoesophageal anastomosis is performed followed by microvascular anastomosis.
A, The diagonal shading indicates a large defect of the right lateral wall of the mesopharynx. B, Free jejunal graft was transferred to the defect. The arrow indicates the design of the paramesenteric incision. C, After reconstruction. Postoperative (15 days) esophagograms: front (D) and lateral (E) view.
Kimata Y, Uchiyama K, Ebihara S, Asai M, Saikawa M, Hayashi R, Ohyama W, Haneda T, Nakatsuka T, Harii K. A New Concept and Technique for Reconstruction of the Lower Pharyngeal Space Using the Free Jejunal Graft. Arch Otolaryngol Head Neck Surg. 1998;124(7):745-749. doi:10.1001/archotol.124.7.745
To report on a new concept and simple operative procedure to conform the diameter of the oral end of free jejunal grafts to that of pharyngeal defects for reconstruction of the lower pharyngeal space.
Design and Methods
A preliminary study showed that the jejunum is supplied by a highly vascular network and that longitudinal paramesenteric incisions can be made without disturbing the blood supply of the jejunum. We then developed the following operative procedure. The position of the highest point of the pharyngeal defect and the site of the recipient vessels are determined. The free jejunal graft is positioned with its mesentery in correspondence with the location of the recipient vessels. The position of a longitudinal incision 180° to the highest point of the defect is then determined. After the oral border of the jejunum is opened with scissors, a pharyngojejunal end-to-end anastomosis is performed.
Eighteen patients with defects of the lower pharyngeal space after cancer treatment.
We transferred jejunal grafts in 18 patients using this operative procedure. In 7 of these patients, paramesenteric incisions were made. The lengths of the incisions ranged from 2 to 8 cm. Transfer was successful in all 18 patients. Postoperative leakage occurred in 1 patient in whom an antimesenteric incision had been made; however, a fistula did not develop.
Our method allows defects of the lower pharyngeal space to be reconstructed with end-to-end anastomosis of free jejunal grafts regardless of the location of the defect or of recipient vessels. This method is simple and appropriate for correcting large pharyngeal defects.
VASCULARIZED FREE jejunal grafts are often used to reconstruct defects of the lower pharyngeal space after cancer has been resected.1,2 In patients in whom cancer has spread to the mesopharynx, however, the pharyngeal defect lies in an oblique plane and has a diameter greater than that of a free jejunal graft. To resolve this problem, end-to-end anastomoses of the oral side of jejunal grafts with antimesenteric incisions have been used.3,4 In this type of reconstruction, vessels ipsilateral to the highest point of the pharyngeal defect are the most appropriate recipients for the reconstruction of a straight pharyngeal space. In patients whose ipsilateral recipient vessels are unavailable after the resection of cancer, microsurgical anastomosis must be performed with existing contralateral recipient vessels. In such patients, the reconstructed pharyngeal space may become L-shaped or the oral end of the grafted jejunum may become dilated and thus make oral feeding impossible (Figure 1).4,5 These problems are a result of the misconception that only the antimesenteric side of the jejunal graft can be incised without disturbing the blood supply of the graft. If a longitudinal incision can be made at any site on the jejunal graft, a conventional end-to-end anastomosis can be performed.
In this report, we first examine the feasibility of paramesenteric incisions by performing a vascular anatomical study of the jejunal graft. We next describe a new concept and a simple procedure that we have developed for reconstruction of the lower pharyngeal space using free jejunal grafts with longitudinal incisions.
We obtained a small segment of a human jejunal graft that remained after reconstruction of the lower pharyngeal space. The segment of jejunum, with its own short mesenteric pedicle, was 10 cm long. To prepare the segment for vascular injection, the jejunal lumen was rinsed with warm water to remove all ingesta. The jejunal segment was incised longitudinally 5 mm anteriorly to the site of mesenteric attachment (paramesenteric incision) and opened. The mesenteric artery was cannulated with a blunt 20-gauge needle, and the blood was removed by administering isotonic sodium chloride solution at 37°C through a 60-mL syringe. Modified barium sulfate, as described by Snyder et al,6 was administered to the arteries, after which radiographs were obtained to visualize the vascularity of the jejunum.
Microangiographs of the jejunal vessels were similar to those previously reported.7- 9 The jejunum was supplied by numerous vascular loops within its mesentery that anastomose with cranial and caudal loops. The arteries branch at right angles from these arcades, penetrate the serosa, and enter the primary penetrating vessels of the circumferential submucosal network. The primary penetrating vessels anastomose with vessels from oral and aboral sections and with their contralateral counterparts at the antimesenteric border. Through this vascular network, the vascularity of the entire jejunum is visualized with barium sulfate (Figure 2). The high vascularity of the jejunal network allows paramesenteric incisions to be made without disturbing the graft's blood supply. Therefore, a longitudinal incision can be made at any location at the oral end of the jejunal graft.
Thus, we have developed a simple operative concept that takes advantage of this extensive vascularity to conform free jejunal grafts to large pharyngeal defects. A longitudinal incision is made at the corner of the free jejunal graft opposite the highest point of the defect. With this concept, defects of the lower pharyngeal space can be reconstructed with an end-to-end anastomosis of a free jejunal graft regardless of the location of the most extensive point of the defect and the recipient vessels.
The surgical procedures involved in the end-to-end pharyngojejunal anastomosis are simple and are performed by a team of plastic and reconstructive surgeons. During primary reconstruction, suitable recipient vessels for microvascular anastomosis are identified and the position of the highest point of the defect of the pharyngeal space is confirmed. The segment of jejunum is harvested in the usual manner.
The harvested jejunal graft is prepared for positioning with the mesenteric vessels in correspondence with the locations of recipient vessels. The proximal pharyngojejunal anastomosis is performed before the distal jejunoesophageal anastomosis. The anastomosis is first established at the highest point of the pharyngeal defect (Figure 3). Then, the posterior and anterior sides of the pharyngojejunal anastomosis are performed in 2 layers toward the side opposite the highest point of the defect. At the corner of the side opposite the highest point, the difference between the diameters of the pharynx and jejunum is measured to determine the length of the longitudinal incision of the jejunal graft. The oral border of the jejunum is then opened longitudinally with scissors opposite the highest point of the defect. If the determined position of the incision is precisely where the mesentery and the nutrient vessels are attached, the incision is made 5 mm anteriorly or posteriorly to the site of mesenteric attachment (paramesenteric incision).
When the pharyngeal defect is in the horizontal plane and its diameter is greater than that of the jejunal graft, we first establish the anastomosis at the center of the posterior side of the defect, and a longitudinal incision is made at the center of the anterior side of the free jejunal graft.
The distal jejunoesophageal anastomosis is also performed in 2 layers. After both visceral anastomosis sites are completed, microvascular anastomosis is performed.
From January 1, 1996, through December 31, 1996, 18 patients underwent esophagopharyngeal reconstruction at the National Cancer Center Hospital, Tokyo, Japan, and the National Cancer Center Hospital East, Chiba, Japan, with free jejunal grafts and the operative procedure we have described. Of the 18 patients, 7 underwent reconstruction with free jejunal grafts and paramesenteric incisions. In these 7 patients, appropriate recipient vessels were not present ipsilateral to the highest point of the defect. In 2 patients, the defect of the unilateral mesopharyngeal wall extended to the top of the tonsil. The lengths of paramesenteric incisions ranged from 2.5 to 6.0 cm (Table). The other 11 patients underwent reconstruction with nonparamesenteric jejunal incisions. In each patient, the diameters of the pharynx and the oral side of the jejunum differed. The lengths of the incisions ranged from 2 to 8 cm.
Transfer was successful in all 18 patients. In patients in whom a paramesenteric incision was made, no leakage or fistulas were found on barium swallow radiographs 10 days after surgical reconstruction. A proximal anastomotic leak was discovered on radiographs in 1 patient in whom an antimesenteric incision had been made, but a fistula did not develop. No serious postoperative complications occurred, and postoperative deglutition was satisfactory in all patients.
A 61-year-old woman was referred to our hospital for the treatment of hypopharyngeal cancer. Bilateral neck resection and pharyngolaryngectomy involving dissection of the mesopharynx were performed. The defect of the mesopharynx extended to the upper part of the right tonsil, and appropriate recipient vessels were not present ipsilateral to the highest point of the defect. The difference in diameter between the pharynx and the oral side of the jejunal graft was 10 cm. A 5-cm paramesenteric incision was made in the transferred free jejunal graft, and the mesenteric vessels were anastomosed to recipient vessels at the left side of the neck.
The graft survived well, and the patient was able to resume oral intake 15 days after the operation without symptoms of regurgitation or stenosis (Figure 4).
To conform the diameter of the oral end of the free jejunal graft to that of the pharyngeal defect for end-to-end anastomosis, an incision can be made on the antimesenteric side of the graft.3,4 The L-shaped end-to-side anastomosis is also acceptable and is used by many surgeons.4,5,10 In patients whose pharyngeal defect is in the horizontal plane or recipient vessels are ipsilateral to the highest point of the pharyngeal defect, the 2 methods described here allow free movement of a normal diet through the reconstructed area. We have often encountered cases, however, in which the vessels ipsilateral to the highest point of the defect were inappropriate for microsurgical anastomosis following surgical ablation of an invasive cancer. In such patients, the reconstructed esophagus is occasionally bent, and postoperative deglutition is impaired.
Another technique used in such patients is tucking of the pharyngeal mucosa. Excessive tucking often creates high tension, disturbs the circulation of the jejunal graft between the sutures, and may result in postoperative leakage.
Modified procedures that use a double-folded intestine graft,11 a patch of the jejunal graft,12,13 or an ρ-shaped anastomosis14 have been used to correct the differences in diameter. These complicated procedures have the disadvantages of long operative times and many long suture lines. Colon grafts15 are effective, but a coloesophageal anastomosis is difficult to establish and is associated with a high risk of postoperative leakage at the donor site.
Compared with other methods, the procedure described here is simple and effective, does not require long operative times, and is associated with a low rate of postoperative leakage. No tension is placed on the jejunal mucosa between sutures because the diameter of the oral end of the jejunal graft is corrected with a longitudinal incision. Therefore, we suggest that longitudinal incisions at any location do not affect the blood supply of the jejunal graft. Our concept and method can be applied when free jejunum is used for a patch graft because the appropriate position and pathway for mesenteric vessels can be achieved at several recipient locations.
For patients in whom the pharyngeal defect is in the horizontal plane, our method is appropriate when all defects are below the tonsils. For patients in whom the pharyngeal defect is in an oblique plane, our method can be used when the highest point of the pharyngeal defect is below the top of the unilateral tonsil, as in the case described here. In patients in whom tumors have invaded extensive areas of the mesopharynx (eg, the lateral and posterior walls of the mesopharynx), reconstruction with our method is difficult. In addition, when our method is used to repair an extremely wide horizontal pharyngeal defect, the reconstructed esophagus may be bent and inclined toward the incision site of the grafted jejunum. In patients in whom the pharyngeal defect extends to the nasopharynx, the mesenteric vessels might be too short for our method to be used.
We investigated the high vascularity of the jejunal graft after making a longitudinal paramesenteric incision and developed a new concept for pharyngoesophageal reconstruction. Our simple method is appropriate for correcting large pharyngeal defects by free jejunal grafts.
Accepted for publication October 8, 1997.
Presented in part at the 20th annual meeting of the Japan Society for Head and Neck Cancer, Fukui, Japan, July 12, 1996.
This work was supported by Grant-in-Aid for Cancer Research, grants 7-25 and 7-26 from the Ministry of Health and Welfare of Japan, Tokyo.
Reprints: Yoshihiro Kimata, MD, Division of Plastic and Reconstructive Surgery, National Cancer Center Hospital East, 6-5-1 Kashiwanoha, Kashiwa, Chiba 277, Japan.