| Although the technique of free jejunal autograft transfer is the same in nearly all patients, those who have had previous radiation therapy or multiple previous reconstructive procedures using local or thoracic flaps remain a challenge. The most difficult patients for reconstruction of the cervical esophagus are those who have undergone previous surgery, particularly of the chest wall and abdomen, including tumor resection; those with reconstructive failure; and those who are postoperative from gastric or biliary surgery. 42,43
The preoperative planning of reconstruction in patients who have not had previous surgical treatment requires a careful examination of the neck and abdomen by both the microsurgical and the head and neck teams. Any evidence of abdominal or neck pathology in these regions must be carefully evaluated to rule out metastatic disease. A completely informed consent, taking into consideration all the risks and alternate methods of reconstruction, is usually not feasible in the preoperative period until the extent of local disease can be determined. Mechanical small bowel preparation is performed in the 12 hours before surgery, and broad spectrum antibiotics are begun preoperatively. At surgery, the patient is usually prepped and draped for an elective tracheostomy, after which he or she is positioned supine with the neck extended. The sterile prep is extended from the superior border of the pubis to above the angle of the mandible, usually with one arm and one leg free, for rapid dissection of vein or skin grafts if needed. The head and neck team begins the laryngopharyngectomy and partial esophagectomy while the abdominal incision, extending from the xiphoid to below the umbilicus, is made by the microsurgical team. A careful intra-abdominal inventory is performed to rule out the evidence of metastatic disease to the liver or other organs. The spleen, colon, small bowel, large bowel, and mesentery must all be inspected. If a suspicious lesion is present, an incisional biopsy with immediate frozen section is performed and the procedure terminated if the biopsy is positive for metastatic disease. The jejunal segment is harvested by first reflecting the transverse colon and stomach superiorly and localizing the ligament of Treitz in the left upper quadrant. The small bowel is followed to approximately 40 cm below the ligament of Treitz, where the vascular arcades are evaluated by transillumination. Using Loupe dissection, an incision is made into the mesentery approximately 6 to 7 cm from the base to dissect free the arcade of vessels that will form the pedicle of the jejunal segment. Small side branches are divided with bipolar cautery or tied with fine sutures. Special care must be taken in patients with extensive mesenteric fat to avoid damage to branches of the mesenteric vessels. Vessel loops are not recommended because they produce spasm and trauma to the pedicle vessels. Once the mesenteric vessels have been isolated to form the pedicle, the mesentery is divided in a V shape wide enough to provide an appropriate length for reconstruction of the resected cervical esophagus. The bowel is transected and intestinal continuity restored by an end-to-end closure of the small bowel with a single layer of interrupted 3-0 silk sutures or an appropriate stapling device.
The jejunal segment, isolated on its mesenteric pedicle, is transferred to the neck when the recipient vessels have been isolated by the team performing the tumor resection. The abdomen is subsequently closed.