|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
| The patient is again positioned supine, with the neck extended, and a two-team approach is carried out. In patients who have had previous neck surgery, it is often important to have a member of the microsurgical team take part in the neck dissection to evaluate the quality and availability of recipient vessels. The jejunal segment is harvested again through a midline abdominal incision and adhesions from previous surgeries are lysed to isolate an adequate jejunal segment. The arcade vessels are again identified by transillumination and an adequate segment of small bowel is isolated on its perfusing mesenteric vessels.
The neck dissection remains the greatest challenge for jejunal transplantation in patients with multiple previous surgical procedures. Distortion of the operative anatomy and fibrosis around the vessels require careful dissection to avoid carotid or jugular vein injury. If possible, the initial skin incisions are made through previous surgical incisions. A method for reconstruction of the overlying soft tissue should be included in the preoperative planning. Frequently, the superior thyroidal vessels are not accessible or are too badly scarred to act as recipients, and end-to-side anastomosis to the internal jugular vein and carotid artery are frequently required. The transverse cervical vessels can be used, but the vein is frequently too small. Venous drainage may also be provided by transposition of the distal cephalic vein into the neck by passing it below the clavicle and anastomosing it to the jejunal vessels. Vein grafts may be required to complete the venous anastomoses. Once the surgical anastomosis has been performed and the bowel appears healthy, the bowel is anastomosed to the recipient structures as before. A size mismatch between the hypopharynx and the jejunal segment may require an antimesenteric incision on the jejunal segment to create a fishmouth widening of the proximal jejunum. When the diameter of the jejunum is less than half the size required to anastomose to the hypopharynx, the proximal intestinal stump is closed and anastomosis is subsequently performed end-to-side. This anastomosis may be somewhat difficult because the hypopharynx stump is near the base of the tongue, leaving a small field to work in. After the proximal anastomosis to the hypopharynx, the distal jejunum is anastomosed to the cervical esophageal stump, which is frequently deep in the neck near the trachea. Fibrosis surrounding these two structures often requires surgical release. After the distal anastomosis, the neck is closed, using local skin flaps if possible. In irradiated patients or those who have undergone previous multiple reconstructive procedures, a deltopectoral flap may be needed to close any remaining defect.
The patient is instructed in the postoperative period not to turn his head, and no food is allowed (NPO) until the fifth postoperative day. We do not use systemic heparin or low molecular weight dextran in these patients. Antibiotics are continued for 5 days and then discontinued if the patient is otherwise asymptomatic. Tube feedings are begun on the fifth day and the patient is kept NPO until the tenth postoperative day. At that time, a contrast swallow is performed to determine if there is any anastomotic leak. A liquid diet is begun if no leaks are detected.
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