|Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
| We are aware that the postoperative monitoring of free flaps in head and neck reconstruction is more difficult than with similar reconstruction in the extremities.44 The jejunal free flap is a buried flap and monitoring in the postoperative period is therefore difficult. Vascular compromise of this flap may be caused by either intraluminal thrombosis secondary to problems with the microsurgical technique or thrombosis secondary to external compression from edema, hematoma, or a tight skin closure. Kinking of the vascular pedicle or a surrounding neck infection may contribute to loss of the jejunal transfer. In our opinion, fiberoptic endoscopy remains the best method for evaluation of the jejunal segment. Several authors have used a window between the neck sutures to permit a direct view of the flap.45,46
Complications associated with free jejunal transplant involve those resulting from harvesting of the graft as well as placement of the graft and the microanastomoses. Complications following jejunal harvest, similar to those in all other abdominal surgical procedures, include abdominal wound dehiscence, peritonitis, intestinal obstruction, and small bowel fistulae. Those associated with placement of the graft may develop early or late. Early complications include venous thrombosis of the vascular pedicle, which requires immediate action to save the jejunal transplant. Hematoma and seroma, as well as carotid rupture and rupture of the internal jugular vein, have been described,5 and require immediate treatment to avoid injury to the jejunal segment or the microsurgical pedicle. Pharyngeal cutaneous fistulae are usually observed at the proximal anastomotic site and result from a difference in the diameter of the two segments.41 If they occur on the side ipsilateral to the microvascular pedicle, they should be diverted to minimize damage to the vessels. Most fistulae close spontaneously within 15 to 20 days and can be managed conservatively.
Dysphagia is a common delayed complication that may be caused by continued edema of the jejunal segment or an altered functional ability to swallow.47 Late stenosis of the jejunal anastomosis may occur, particularly in patients who have had radiation therapy, and again is found most frequently at the proximal anastomosis. These patients may require dilatation of the proximal cervical anastomosis to limit dysphasia. In patients with intractable obstructive symptoms, recurrence of tumor must be considered and local biopsies are required.
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