| The transplantation of the jejunal segment is performed by the microsurgical team, who will additionally close the neck wound. The recipient vessels are usually the superior thyroidal, with end-to-end anastomosis to the mesenteric vessels of the jejunal segment. The facial vessels, however, are easy to locate and have appropriate diameter to permit revascularization. End-to-side anastomosis of the mesenteric vessels to the common carotid artery and internal jugular vein may be necessary when other satisfactory recipient vessels cannot be found. Before the microsurgical anastomosis, the jejunal segment is tacked in place with several 4-0 nylon sutures to prevent it from falling from the field or placing undue stretch on the microsurgical anastomosis. The bowel must be placed in an isoperistaltic position.22 Using 16-power magnification, the recipient and donor vessels are irrigated with heparin solution and standard end-to-end, or end-to-side microsurgical anastomosis is made with 9-0 or 10-0 interrupted nylon suture. Following anastomosis, the clamps are removed to check the patency of the vessels and pulsation within the mesentery as well as bleeding from the cut edges of the bowel. Visible disordered peristalsis should be present within the flap, and the color of the mucosa should rapidly become pink. 23
Following the microsurgical anastomosis, the intestinal segment is tailored to prevent redundancy. We prefer to perform the proximal pharyngeal-jejunal anastomosis in a one-layer technique using interrupted vicral sutures followed by a similar jejunal anastomosis to the stump of the esophagus. The EEA stapler has also been used.23 Before completion of the proximal and distal anastomoses, a small feeding nasal gastric tube is passed under direct vision through the segment to prevent injury to any of the anastomoses. The neck wound is subsequently irrigated with normal saline and a Penrose drain placed near the microsurgical anastomoses along the jejunal segment. A suction drain may be placed on the contralateral side of the neck but should not be used near the vascular repairs. The local skin is subsequently closed with 4-0 nylon and sterile tapes and a minimal amount of occlusive dressing is applied.
In patients who have had previous neck and abdominal surgery, it is necessary to obtain a more complete preoperative history and physical examination. The timing and extent of previous procedures must be determined, including abdominal surgery and any history of radiation therapy. All previous operative reports and film must be reviewed. The patient should be warned that, under these circumstances, the free jejunal graft is more difficult and has a higher failure rate. In addition, the patient must be aware that free jejunal transfer may not be possible if recipient vessels cannot be localized, and that alternative methods of reconstruction may have to be performed. Again, a small bowel preparation is done routinely in the preoperative period. Cultures of any current neck fistulae are completed and specific perioperative antibiotics are begun.