Microsurgery: Transplantation and Replantation by Harry J. Buncke, MD, et al.
  Table of Contents / Chapter 27:
Autogenous Jejunal Transplantation
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  In our department, we have performed more than 23 free jejunal transplants, with long-term follow-up available on 20 of these patients. Ten patients had reconstruction after radiation therapy, and 8 of the remaining 10 patients were irradiated postoperatively. Nine patients had undergone previous reconstructive procedures using local flaps, and two had undergone tumor ablation and diversion before undergoing elective reconstruction. Overall, 19 of 20 flaps survived, with one patient developing venous thrombosis leading to flap necrosis and infection. This patient went on to develop sepsis, which caused the only perioperative death. Early complications requiring reexploration occurred in two cases: one for leakage and one for a cervical hematoma. Two patients developed localized infections that required longer treatment with antibiotics; both survived. Late complications were seen more commonly in the patients radiated preoperatively, with four cervical fistuli and one late stricture. Overall, the average survival has been more than 13 months, and 15 patients have gained weight following reconstruction.

Summary

The free jejunal graft has seen increasing success in reconstruction of the cervical esophagus and hypopharynx. It remains a difficult microsurgical challenge, especially in patients who have undergone previous treatment or radiation. The one-stage procedure provides physiologic reconstruction of the upper GI tract and has a low morbidity rate as well as a short recuperation time. With free jejunal transfer, there is marked improvement in the quality of life and numerous advantages over the previous methods of reconstruction. In our opinion, jejunal transfer is the most efficient method of reconstruction of the cervical esophagus.

 

Clinical Cases

CASE 1

A 58-year-old man underwent immediate reconstruction following laryngopharyngectomy and partial esophagectomy with free jejunal transfer. The jejunal pedicle was anastomosed end-to-end to the superior thyroid vessels. Single anastomoses were performed between the jejunal segment and the hypopharynx with 3-0 vicral sutures and the esophageal stump was anastomosed to the distal jejunum in a similar manner. A contrast swallow on the tenth postoperative day showed no evidence of breakdown of the anastomoses or fistulae and the patient began a liquid diet. He was subsequently discharged from the hospital without complications.

FIG. 27-01. After resection of the proximal tumor, the divided larynx and cervical esophagus are reflected forward to allow access to the distal esophagus.


FIG. 27-02. The resected specimen shows the esophagus caught in a tumor behind the larynx.


FIG. 27-03. The surgical defect is shown graphically, with the recipient superior thyroid vessels isolated on sutures in the right neck.


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