FREE JEJUNAL FLAP TRANSFER FOR PHARYNGOESOPHAGEALRECONSTRUCTION IN PATIENTS WITH INTESTINALMALROTATION: TWO CASE REPORTS

TAKAHIDE MIZUKAMI, M.D.,1* IKUO HYODO, M.D.,2 and HIDEKAZU FUKAMIZU, M.D., Ph.D.1

Intestinal malrotation results from failure of intestinal rotation and fixation during fetal life. We report two cases of esophageal reconstruc-tion with free jejunal flaps following total laryngopharyngectomy of hypopharyngeal and cervical esophageal carcinoma in which intestinalmalrotation was detected during the jejunal flap harvesting. In both cases, the ligament of Treitz was absent, and the laparotomy incisionwas thus extended to identify the jejunum. In case 1, harvesting an adequate length of the vascular pedicle of the flap was impossiblebecause of the abnormal position of the pancreas; thus, a jejunal flap of maximal length was harvested for optimal pedicle positioning inthe recipient site. In case 2, Ladd’s ligament prohibited the release of the jejunum from the ascending colon and required its dissection.Both patients underwent successful reconstruction. When the ligament of Treitz is absent during jejunal flap harvesting, investing thewhole bowel by extended laparotomy incision is recommended. When anatomical abnormality caused by intestinal malrotation is detected,releasing an adhesion of the jejunum from circumferential organs and identifying the adequate vascular pedicle of a jejunal flap are neces-sary. If harvesting the long vascular pedicle is impossible, a jejunal flap of maximal length should be harvested for optimal positioning forvascular anastomosis at the shortest distance in the recipient site. VC 2014 Wiley Periodicals, Inc. Microsurgery 34:582–585, 2014.

Reconstruction of total laryngopharyngectomy defects is

often challenging for the reconstructive microsurgeon.

The aim of pharyngoesophageal reconstruction is to cre-

ate a conduit from the oropharynx to the cervical esopha-

gus that facilitates swallowing and phonation with

protection of the vital head and neck structures.1

Although various reconstruction techniques have been

described, those currently performed are mainly of two

types: the free jejunal flap and the tubed fasciocutaneous

free flap.1–4 There have been a number of reports com-

paring these reconstruction tequniques.1,3–5 The advan-

tages of free jejunal flap reconstruction are good

swallowing function, a low pharyngocutaneous fistula

rate, and a low anastomotic stricture rate, while the dis-

advantage is the relatively poor suitability for voice reha-

bilitation.5,6 Despite this disadvantage, the free jejunal

flap currently remains the method of choice in pharyng-

oesophageal reconstruction.1,2,5,6

Intestinal malrotation results from failure of normal

intestinal rotation and fixation. Most intestinal malrota-

tions are diagnosed with intestinal obstruction within the

first year of life; this condition is very rarely diagnosed

in adults.7

We herein report two cases of esophageal reconstruc-

tion with free jejunal flaps following total laryngophar-

yngectomy of hypopharyngeal and cervical esophageal

carcinoma in which intestinal malrotation was detected

during jejunal flap harvesting and describe the technical

details of such harvesting.

CASE 1

A 71-year-old man with hypopharyngeal carcinoma

was admitted to Aichi Cancer Center. He had no history

of abdominal surgery. He denied any history of acute or

chronic abdominal symptoms suggestive of intestinal

malrotation.

The patient underwent total laryngopharyngectomy

followed by free jejunal flap reconstruction. During the

small epigastric laparotomy for free jejunal flap harvest-

ing, we were unable to identify the ligament of Treitz,

an important landmark of the duodenojejunal junction.

We extended the laparotomy incision and invested the

whole bowel. The duodenum ran caudally from its first

portion onward, and the ligament of Treitz was not pres-

ent. The small intestine was present in the right abdo-

men, the colon was on the left side, and the pancreas

was in the mesentery of the jejunum (Figs. 1 and 2). We

diagnosed the patient with intestinal malrotation.

To harvest the free jejunal flap, we searched for reli-

able jejunal vessels. The first and second jejunal vessels

were present, but no other reliable vessels were found.

The pancreas was present in the mesentery of the jeju-

num at the base of the first and second jejunal vessels,

and harvesting of a long vascular pedicle of the jejunal

flap was impossible. Therefore, a jejunal flap of maximal

length based on the second jejunal vessels was harvested

so that the flap could be placed in the optimal position

1Department of Plastic and Reconstructive Surgery, Hamamatsu UniversitySchool of Medicine, Shizuoka, Japan2Department of Plastic and Reconstructive Surgery, Aichi Cancer Center,Aichi, Japan

*Correspondence to: Takahide Mizukami, MD, Department of Plastic andReconstructive Surgery, Hamamatsu University School of Medicine, Han-dayama 1-20-1, Higashi-ku, Hamamatsu, Shizuoka 431-3192, Japan.E-mail: takahide1210@gmail.com

Received 31 August 2013; Revision accepted 18 February 2014; Accepted28 February 2014

Published online 24 March 2014 in Wiley Online Library(wileyonlinelibrary.com). DOI: 10.1002/micr.22248

� 2014 Wiley Periodicals, Inc.

for vascular anastomosis at the shortest distance (Fig. 2).

The length of the defect was 12 cm, and the length of

the jejunal flap was 26 cm when stretched. The jejunal

flap was placed in the optimal position of the recipient

site, and the remnant portion of the flap was cut and dis-

carded. The second jejunal artery and accompanying vein

were anastomosed to the superior thyroid artery and com-

mon facial vein, respectively. We did not perform surgi-

cal correction of intestinal malrotation or prophylactic

appendectomy.

The postoperative course was uneventful. The patient

has been followed up for 1 year and has remained free

of abdominal symptoms.

CASE 2

A 79-year-old woman with cervical esophageal carcinoma

was admitted to Aichi Cancer Center. She had no significant

medical history and no history of abdominal surgery.

She underwent total laryngopharyngectomy followed

by free jejunal flap reconstruction. During the small epi-

gastric laparotomy for free jejunal flap harvesting, we

were unable to identify the ligament of Treitz. We

extended the laparotomy incision and invested the whole

bowel. The duodenum ran caudally from its first portionFigure 1. Schematic drawing of intestine of the patient in case 1.

Figure 2. The pancreas was present in the mesentery of the jejunum at the base of the first and second jejunal vessels (above, left). Long

jejunal flap based on the short pedicle of the second jejunal vessels (below, left). The jejunal flap was placed in the optimal position for vas-

cular anastomosis at the shortest distance (right). [Color figure can be viewed in the online issue, which is available at wileyonlinelibrary.

com.]

Free Jejunal Flap in Intestinal Malrotation 583

Microsurgery DOI 10.1002/micr

and continued into the jejunum without the ligament of

Treitz. The ileocecum was present in the upper part of

the abdomen, and an adhesion between the jejunum and

ascending colon suggestive of Ladd’s ligament was pres-

ent (Figs. 3 and 4). We diagnosed the patient with intes-

tinal malrotation.

In this case, dissection of Ladd’s ligament between the

jejunum and the ascending colon was needed to release

the jejunum. The pancreas was normally positioned, and

variation of jejunal vessels was not present. Therefore, a

jejunal flap based on the third jejunal vessels was har-

vested (Fig. 4). The length of the defect was 14 cm, and

the length of the jejunal flap was 25 cm when stretched.

The jejunal flap was placed in the recipient site, and the

remnant portion of the flap was cut and discarded. The

third jejunal artery was anastomosed to the transverse cer-

vical artery, and its two accompanying veins were anasto-

mosed to the internal jugular vein and external jugular

vein. We did not perform surgical correction of intestinal

malrotation or prophylactic appendectomy.

The postoperative course was uneventful. The patient

has been followed up for 1 year and has been free of

abdominal symptoms.

DISCUSSION

The midgut rotates 270� counterclockwise and is

fixed in the normal position from weeks 5 to 13 ofFigure 3. Schematic drawing of intestine of the patient in case 2.

Ladd’s ligament (arrow).

Figure 4. Adhesion between the jejunum and ascending colon suggestive of Ladd’s ligament (above, left). Jejunal flap based on the third

jejunal vessels (below, left). The jejunal flap was placed in the recipient site (right). [Color figure can be viewed in the online issue, which

is available at wileyonlinelibrary.com.]

584 Mizukami et al.

Microsurgery DOI 10.1002/micr

embryonic life. Any derangement during the process of

intestinal rotation will give rise to a wide variety of

anomalies that may be classified with respect to the stage

of rotation.8

Approximately 90% of patients with malrotation are

diagnosed with intestinal obstruction complicated by volvu-

lus and intestinal necrosis within the first year of life, and

80% are diagnosed within the first month of life.7 On the

other hand, malrotation is very rarely diagnosed in adults.

It may present acutely as a bowel obstruction, chronically

as vague intermittent abdominal pain, or incidentally owing

to an unrelated abdominal pathology such as acute appendi-

citis.9 Autopsy studies suggest that some form of malrota-

tion may exist in 0.5%–1% of the population.10,11

Therefore, the vast majority of individuals with intestinal

rotational anomalies are clinically asymptomatic.11 It is

assumed that adults with malrotation who remain mostly

asymptomatic throughout their lifetime are not so rare.12

In this report, patients with intestinal malrotation

underwent successful reconstruction with no complications.

A potential problem of free jejunal flap reconstruction in

patients with intestinal malrotation is the difficulty in iden-

tifying the jejunum. In our hospital, the computed tomog-

raphy (CT) scan range for preoperative evaluation of

hypopharyngeal cancer is from the head and neck region

to the chest, not to the pelvic region. Therefore, preopera-

tive diagnosis of intestinal malrotation was impossible in

these patients. It may be possible to diagnose malrotation

preoperatively if the CT scan range is enlarged to the pel-

vis or other diagnostic tools are used, such as ultrasonog-

raphy or upper gastrointestinal contrast study. However,

we do not believe that it is appropriate to add these preop-

erative examinations for all patients who will undergo free

jejunal flap reconstruction considering the relatively low

incidence and low diagnostic accuracy of this disease.13

When it is difficult to identify the jejunum during jejunal

flap harvest, extending the laparotomy incision and inves-

ting the whole bowel is recommended considering the

presence of intestinal malrotation.

The other problem is the possibility of an abnormal

anatomical relationship between the jejunum and circum-

ferential organs, such as the pancreas. There have been

no reports on anatomical displacement of the pancreas in

patients with intestinal malrotation. The pancreas of the

patient in case 1 was present in the mesentery of the

jejunum at the base of the first and second jejunal ves-

sels, and harvesting of the long vascular pedicle of the

jejunal flap was impossible. In such cases, identification

of other jejunal vessels suitable for vascular anastomosis

is necessary. If harvesting the long vascular pedicle is

difficult, a jejunal flap of maximal length based on its

vascular pedicle should be harvested so that the flap can

be placed in the optimal position for vascular anastomo-

sis at the shortest distance. In case 2, an adhesion

between the jejunum and the ascending colon suggestive

of Ladd’s ligament prohibited the release of the jejunum.

In such cases, dissection of Ladd’s ligament is needed to

release the jejunum.

We herein reported two cases of hypopharyngeal and

cervical esophagus carcinoma in which intestinal malrota-

tion was detected during free jejunal flap harvesting for

reconstruction following total laryngopharyngectomy.

When intestinal malrotation is incidentally detected dur-

ing free jejunal flap harvesting, investigation of the

whole bowel and the anatomical relationship between the

jejunum and circumferential organs is recommended. If

harvesting the long vascular pedicle of the jejunal flap is

impossible because of an anatomical abnormality, har-

vesting a jejunal flap of maximal length is recommended.

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