Wadsworth JT, Futran N, Eubanks TR. Laparoscopic Harvest of the Jejunal Free Flap for Reconstruction of Hypopharyngeal and Cervical Esophageal Defects. Arch Otolaryngol Head Neck Surg. 2002;128(12):1384-1387. doi:10.1001/archotol.128.12.1384
Reconstruction of hypopharyngeal and cervical esophageal defects remains one of the greatest challenges to head and neck and reconstructive surgeons. Although the jejunal free flap is a well-known reconstructive choice, many authors prefer alternative methods because of the complication rates and donor site morbidity associated with traditional jejunal flap harvest. Laparoscopic resection of the small intestine is a well-documented surgical technique. However, laparoscopic harvest of a jejunal segment for use in free tissue transfer reconstruction of defects of the hypopharynx and cervical esophagus has primarily been described in animal models, with only a few clinical studies existent in the recent literature.
To evaluate the use of a laparoscopic technique for harvesting jejunal segments for use in free tissue transfer reconstruction of pharyngoesophageal defects.
Patients and Methods
The records of 12 patients who underwent laparoscopic jejunal flap harvest for reconstruction of large hypopharyngeal or cervical esophageal defects at the University of Washington, Seattle, from January 1998 through April 2001 were retrospectively reviewed. Time of harvest, need to convert to "open" technique, failure rate, complications, and length of hospital stay were evaluated.
All harvests were completed laparoscopically. The average operative time for the abdominal portion of the procedure was 2.4 hours. Warm ischemia time required for flap removal from the peritoneal cavity was less than 4 minutes. Each patient received a completely endoscopic jejunum harvest, bowel reanastomosis, and placement of a feeding jejunostomy tube. Enteral feedings began on the first postoperative day. No major complications were seen resulting from this technique, and no donor site morbidity was identified. All flaps were viable, with no revisions required. Activity in hospital and time to discharge were independent of the abdominal procedure.
Given the low complication rate and relative ease of harvest, we conclude that this new technique is currently the best way to harvest jejunal flaps for reconstructing these challenging defects and should renew enthusiasm for this versatile flap.
RECONSTRUCTION OF cervical esophageal and pharyngeal defects remains one of the greatest challenges facing head and neck and reconstructive surgeons today. During the 20th century, the jejunal free tissue transfer became a mainstay in the armamentarium of surgical techniques to address this challenge. Carrel1 first described this versatile flap in 1907. However, it was not until more than 50 years later that the jejunal flap became the first free flap to be well described clinically.2
Over the past decade, details of the flap and its use have been well described by many authors.3 It has become a reliable and reproducible flap, with an expected success rate of more than 95%. 4,5 It has inherent qualities that make it ideal for pharyngoesophageal reconstruction. The jejunum is self-lubricating, is well suited for circumferential defects of the esophagus, has some intrinsic peristalsis, is able to tolerate full-course external beam radiation therapy, and does not appreciably retract. Furthermore, only 2 suture lines are required for anastomosis in the neck. These qualities make it, at least intuitively, the most appropriate reconstructive option for pharyngoesophageal defects.
However, the technique is not without disadvantages. Conventional harvest of the jejunal flap involves a laparotomy and carries with it the risks and complications inherent to that procedure. Wound infection or dehiscence, increased pain, poor pulmonary toilet, deep venous thrombosis, prolonged ileus, and prolonged hospital stay are all significant factors that influence the decision to use this flap. These factors have led some authors to rely instead on the radial forearm flap because of its lower donor site morbidity and quicker recovery for reconstruction of these defects, particularly in elderly or high-risk patients, despite its lack of the jejunum's beneficial characteristics.6
With the further development of laparoscopic surgery, new techniques have allowed more abdominal surgery to be performed without a traditional laparotomy. Furthermore, these techniques have recently been applied to harvesting a variety of tissue for use in free tissue transfer.7 With these facts in mind, our goal with this study was to evaluate the use of a laparoscopic technique for harvesting jejunal segments for use in free tissue transfer reconstruction of pharyngoesophageal defects at the University of Washington Medical Center.
The charts of all patients who underwent laparoscopic harvest of jejunal interposition free flaps at the University of Washington Medical Center from January 1998 through April 2001 were reviewed retrospectively. Patient age and sex, tumor histology, and exposure to preoperative radiation therapy or chemotherapy were recorded.
Time of laparoscopic procedure, including harvest, placement of feeding jejunostomy tube, bowel reanastomosis, warm ischemia time, and closure, was recorded. Length of jejunal segment, hospital stay, and time it took before the patient could take liquids orally were also noted. Furthermore, complication and flap failure rates, as well as the need to convert to open procedure, were examined. Finally, follow-up data were analyzed when available.
The laparoscopic procedure itself is performed in a fashion similar to that described by Gherardini et al,8 with little modification. A surgeon and assistant are required. Two camera setups are used: one for visualization and one for transillumination of the mesentery. Four abdominal ports are used: two 5-mm ports and two 10/12-mm ports. After establishing the pneumoperitoneum, the surgeon can clearly identify the ligament of Treitz. The jejunum is then traced out approximately 10 to 30 cm, and an appropriate segment of jejunum is identified for harvest. The segment is then suspended to the anterior abdominal wall with percutaneous T fasteners. The mesentery is then transilluminated to identify the major vascular pedicle of the segment.
Cautery is used to create a mesenteric window through which the vascular arcade is controlled, thereby narrowing the pedicle to the dominant vessels. A Penrose drain is then placed around the pedicle for ease of retraction. The dominant artery and vein are then identified as they arise from the superior mesenteric artery and vein. Endoscopic gastrointestinal anastomosis staplers are used to section the jejunal segment. The segment is inspected for viability and harvested using vascular clips. The jejunal flap is then delivered from the abdomen through a bluntly widened 10/12-mm port to a diameter of approximately 3 cm and placed into the neck for insetting.
Closure of the bowel is performed endoscopically by aligning the antimesenteric borders of the jejunal segments. Enterotomies are created, and using the endoscopic gastrointestinal anastomosis stapler, a side-to-side jejunojejunostomy is performed. The enterotomies are closed with a final firing of the endoscopic gastrointestinal anastomosis stapler. Finally, the mesenteric window is then closed using an endoscopic suturing or stapling technique. A jejunostomy tube is positioned distal to the bowel anastomosis and a jejunostomy is created, securing the jejunum to the anterior abdominal wall with percutaneous T fasteners.
The results are summarized in Table 1. A total of 12 patients were identified. Patient age ranged from 45 to 78 years, with a mean age of 63.4 years. There were 2 women and 10 men. Ten (83%) of the 12 patients received preoperative radiotherapy, and five (42%) underwent preoperative combination chemoradiotherapy. One patient (8%) underwent induction chemotherapy and failed to respond and therefore did not undergo preoperative radiation therapy.
All 12 patients were treated by the same ablative, reconstructive, and harvest surgical teams. All patients were treated for squamous cell carcinoma of the hypopharynx with laryngopharyngectomy and cervical esophagectomy except patient 2, who underwent resection of a stomal recurrence. All patients received laparoscopic harvest of a jejunal segment, without the need to convert to an open procedure. The procedure time for flap harvest ranged from 1.5 to 3 hours, with a mean time of 2.4 hours. The length of jejunal segment harvested was 12 to 18 cm, with a mean of 14.8 cm. The warm ischemia time required for flap removal from the peritoneal cavity was less than 4 minutes and uniform for all patients. All patients received feeding jejunostomy tubes and began receiving enteral feedings on the first postoperative day. The total hospital stay ranged from 7 to 14 days, with a mean of 9.6 days. Activity in hospital and time to discharge for 10 of the 12 patients were independent of the abdominal procedure. Time to taking liquids orally varied from 7 to 12 days, with an average of 8.4 days.
There were no flap failures or revisions in this series. Furthermore, there were no major complications or donor site morbidity in any of the patients. One patient did have a prolonged ileus of 6 days, presumably due to a slow bleed from the bowel anastomosis, which was managed with transfusion of 2 U of packed red blood cells and observation. He was discharged on postoperative day 14, taking a liquid diet and with normal bowel function. The total minor complication rate was therefore 8.3%.
Follow-up data were available for 10 of the 12 patients (2 have been unavailable for follow-up). Follow-up thus far has ranged from 2 to 42 months. The average length of follow-up was 18.1 months. Seven of the 10 patients for whom follow-up data were available are currently alive and well without evidence of disease and without subjective dysphagia. Two patients are alive with recurrence of disease. One patient underwent resection of recurrent tumor and reconstruction with a tubed radial forearm free flap. Two patients have received subsequent tracheoesophageal punctures for speech rehabilitation. One patient died of his disease 10 months after surgery.
Laparoscopic harvest of the jejunum for use in free tissue transfer reconstruction was first described in the English-language literature by Staley et al9 in an animal pilot study using both pigs and dogs, followed by a single case report, thereby establishing the feasibility of the procedure. The technical feasibility of the procedure was further confirmed and described in an animal study by Rosenberg et al10 in 1995. The same year, Saltz11 described endoscopic harvesting of both omental and jejunal flaps and provided a single patient case report. Concurrently, Miller and Robb7 provided follow-up data from Staley and colleagues' original work, citing successful harvests in a total of 6 out of 7 cases.
Since that time, to our knowledge, the only study to report on a clinical series of patients who received endoscopically harvested jejunal segments in free tissue transfer is a follow-up study by Gherardini et al8 that expanded the original patient base of Staley et al9 and Miller and Robb.7 That study reported 10 of 11 cases in which laparoscopic harvest of a jejunal segment for use in free tissue transfer reconstruction of cervical esophageal defects was successfully completed; a mesenteric hematoma developed in 1 case, which was converted to a laparotomy. Similar to the present study, no major complications were discovered. All flaps were viable, and the patients were discharged between 9 and 11 days after surgery. Interestingly, unlike the patient population in Gherardini and coworkers' study, most of our patients underwent preoperative radiation therapy, and many had combination chemoradiotherapy. Despite this fact, we saw no complications at the recipient site.
All the above-mentioned studies used exteriorization techniques to reanastomose the bowel segments via a minilaparotomy. All 12 of our patients received completely intracorporeal endoscopic reanastomosis of the jejunal bowel segments. We were able to complete all laparoscopic harvests endoscopically. The average time of harvest is not particularly different from the time it takes our team to perform conventional laparotomy harvest. There is certainly a learning curve involved in this procedure, and a trend toward lower operative times was seen as the cases grew in number. We expect that continued use of this technique may further lessen the operative time somewhat. We also found that it is possible to perform the ablative surgery and the endoscopic harvest simultaneously, further lessening total operative time.
The laparoscopic method appears to have few disadvantages. Certainly, it remains a challenging technique to master and should be performed only by surgeons who are familiar with laparoscopic instrumentation and surgical technique. It is encouraging that 11 of our 12 patients' hospital stays were independent of the abdominal procedure. A worthy follow-up study is planned involving a direct comparison of the laparoscopic harvest technique with the traditional laparotomy harvest technique in terms of clinical outcome, complication and morbidity rates, operative costs, hospital fees, and total costs. It would be interesting to discover whether the technique provides a cost benefit in addition to its clinical benefits.
The potential limitations of this study are obvious. A retrospective review of 12 cases may be of limited statistical value. However, our results coupled with the one other similarly sized clinical study that has been reported in the literature are good indications of the procedure's safety and utility.
In this study, we have further proved that the endoscopic harvest of jejunal segments for free tissue transfer appears to be a safe technique, with good postoperative results, and does not possess the inherent risks and complications of a traditional laparotomy harvest. Therefore, it facilitates the use of jejunal free flaps in all patients requiring laryngopharyngectomy with cervical esophagectomy, including elderly, high-risk, or other patients in whom the complication rate of conventional laparotomy would have made them more likely to receive a radial forearm flap owing to its traditionally lower donor site morbidity. Laparoscopic harvest is now our preferred technique for jejunal free tissue transfers.
Accepted for publication June 17, 2002.
This study was presented at the Fifth International Conference on Head and Neck Cancer, San Francisco, Calif, July 31, 2000.
Corresponding author: J. Trad Wadsworth, MD, Department of Otolaryngology–Head and Neck Surgery, Eastern Virginia Medical School, 825 Fairfax Ave, Suite 510, Norfolk, VA 23507 (e-mail: email@example.com).