MESENTERIC FLAP IN FREE JEJUNAL TRANSFERS: A VERSATILE TECHNIQUE FOR HEAD AND NECK RECONSTRUCTION Yuhei Yamamoto, MD, Kunihiko Nohira, MD, Yoshihisa Shintomi, MD, Tetsunori Yoshida, MD, Hidehiko Minakawa, MD, Shunichi Okushiba, MD, Satoshi Fukuda, MD, Yukio Inuyama, MD, and Masao Hosokawa, MD

Background. The technique of free jejunal transfers has been widely used for pharyngoesophageal reconstruction. However, secondary infectious and fistulous complications may develop in extensive and preoperatively high-dose irra- diated cases.

Methods. A generous jejunomesenteric composite graft was harvested and the mesenterium was effectively applied for head and neck reconstruction.

Results. The mesenteric flap connected with the revascu- larized jejunum was used as means for obliterating dead space in the head and neck region, as a cover for the cervical vessels, as a vascularized bolstering for the vascular and en- teral anastomoses, or as a vascularized bed for skin grafting when the skin flaps are deficient. Only one small fistula oc- curred in 10 patients who underwent the mesenteric flap.

Conclusions. This versatile technique is expected to re- duce the incidence of postoperative complications in pharyngoesophageal reconstruction using free jejunal trans- fers. HEAD 81 NECK 1995;17:213-218 0 1995 John Wiley & Sons, Inc.

From the Department of Plastic and Reconstructive Surgery (Drs. Ya- mamoto, Yoshida, and Minakawa), the Second Department of Surgery (Dr. Okushiba), and the Department of Otolaryngology (Drs. Fukuda and Inuyama), Hokkaido University; the Clinic of Plastic and Reconstructive Surgery, (Drs. Nohira and Shintomi), Soshundo Hospital; and the Depart- ment of Surgery, (Dr. Hosokawa), Keiyukai Sapporo Hospital, Sapporo, Japan.

Address reprint requests to Dr. Yamamoto at the Department of Plastic and Reconstructive Surgery, Hokkaido University, Kita-14, Nishi-5, Kitaku, Sapporo 060, Japan.

Accepted for publication November 15, 1994

0 1995 John Wiley & Sons, Inc CCC 0148-6403/95/03021 S O 6

Since the initial successful reports of transfer of a segmental the procedure has be- come one of the reliable methods for pharyngo- esophageal reconstruction with development of microvascular surgical technique. From 1985 to 1994, more than 80 patients underwent total re- construction of hypopharynx and cervical esoph- agus by means of free jejunal transfer in our in- stitutes. The procedure is our method of choice for cervical esophageal reconstruction following re- section of certain invasive carcinomas in hy- popharynx, larynx, thyroid, or esophagus, and fol- lowing necrosis of a gastric pull-up. In the series, many of the patients had received preoperative high-dose radiotherapy. Among these patients, wound healing problems such as postoperative in- fectious and wound fistula leading to exposure or rupture of carotid artery and jugular vein have occurred. To obtain more secure reconstruction and reduce secondary complications, we have used the mesenteric flap connected with the re- vascularized jejunum in free jejunal transfer for oropharyngoesophageal reconstruction. This arti- cle describes the technique using the mesenteric flap and the indications for this reconstructive procedure in head and neck reconstruction using free jejunal transfer.

PATIENTS AND METHODS

From February 1992 to January 1994, a total of 10 patients underwent the mesenteric flap with

Mesenteric Flap in Free Jejunal Transfers HEAD 8, NECK May/June 1995 213

their free jejunal transfer. The ages of these pa- tients (8 men and 2 women) ranged from 42 years to 71 years. Six patients presented with hypopha- ryngeal carcinoma, two necrosis of a gastric pull- up, one esophageal carcinoma, and one thyroid carcinoma. Six of these patients had received be- tween 40 Gy and 80 Gy preoperative irradiation.

The procedure for harvesting a jejunal seg- ment suitable for transfer is started convention- ally. A generous jejunomesenteric composite graft, which is usually approximately 30 cm long, is isolated on the second or third jejunal vascular system. At first, the harvested jejunomesenteric segment is positioned in place for pharyngoesoph- ageal reconstruction, and microvascular anasto- mosis is performed between the jejunal vascular system and available cervical recipient vessels. After ensuring that these anastomosis are patent, restoration of pharyngoesophageal continuity is carried out. Following the proximal pharyngoje- junal and distal jejunoesophageal anastomoses are completed, either proximal or distal segment of the redundant intestine is sacrificed, preserv- ing the mesenterium carefully. The mesenteric flap connected with the revascularized jejunum is applied for obliterating the dead space in the head and neck region, covering the carotid artery and jugular vein, wrapping the vascular and intesti- nal anastomotic area, or providing a vascularized bed for skin grafting in which primary closure of the cervical wound is difficult (Figure 1).

RESULTS

The free jejunomesenteric transfers were success- ful in all patients. The length of the harvested jejunum was between 25 cm and 35 cm. Two pa- tients had a skin graft placed on the mesenteric flap to cover the skin defect. Secondary fistula formation occurred in one patient, which closed spontaneously, and no secondary operation was required. All the patients ate a normal diet fol- lowing the procedure and had an average follow- up of 9 months.

CASE REPORTS

Case I. A 64-year-old man presented with a squamous cell carcinoma of the hypopharynx. Following 40 Gy of radiotherapy, the patient un- derwent laryngopharyngoesophagectomy, right radical and left modified neck dissection. A 32 cm-long segment of jejunum on the second jejunal vascular system was harvested to reconstruct the hypopharynx and cervical esophagus. After microvascular anastomoses was performed,

FIGURE 1. (A) Schematic drawing of the jejunomesenteric composite graft. The size of the mesenteric flap is deter- mined by the amount of sacrificed jejunum. (6) Schematic drawing of the mesenteric flap. Following completion of the intestinal anastomoses, the mesenteric flap is effectively ap- plied for secure oropharyngoesophageal reconstruction.

dissection of the mesenteric flap was started with insetting the jejunal graft to the matched pharyn- goesophageal defect. The mesenteric flap was used to obliterate the dead space at right subman- dibular region and cover right carotid artery. The postoperative course was very smooth without any fistula formation (Figure 2).

Case 2. A 58-year-old man presented with a T4N2bMO squamous cell carcinoma in the poste- rior side of the hypopharynx. The patient under- went a total laryngectomy, total pharyngectomy, and upper cervical esophagectomy, as well as right radical neck dissection. A 27 cm-long seg- ment of jejunum was transferred for pharyngo- esophageal reconstruction. The second jejunal vascular system was anastomosed to right trans- verse cervical artery and external jugular vein. After the jejunal graft was sutured in place, the mesenteric flap was applied for obliteration of the

214 Mesenteric Flap in Free Jejunal Transfers HEAD & NECK MayiJune 1995

dead space at paratracheostoma region and cov- ering right carotid artery and the enteral anasto- moses between the grafted jejunum and the cut end of esophagus. The postoperative course was uneventful. The patient was able to eat a normal diet (Figure 3).

Case 3. A 62-year-old man had been treated with gastric pull-up for a esophageal carcinoma; however, the partial gastric necrosis and fistulous tract formation occurred. The end of pulled-up gastric tube was closed and esophagostoma was created temporally. To restore esophagogastric continuity, a free jejunal transfer was carried out. A 29 cm-long segment of jejunum was transferred and the second jejunal vascular system was anas- tomosed to the right transverse cervical artery and internal jugular vein. The mesenteric flap was used to protect the major vessels and to re- construct the cervical skin defect resulting from previous unsuccessful operation and repeated wound infection. A mesh skin graft was carried out on the mesenteric flap simultaneously. The

FIGURE 2. (A) lntraoperative view showing defect after re- section and neck dissections. (B) The jejunomesenteric com- posite graft was placed. The mesenteric flap was dissecting. (C) The mesenteric flap was positioned to obliterate the dead space at right submandibular region and cover right carotid artery.

postoperative course was complicated by fistulous formation at the jejunogastric suture line. After administration of antibiotics, the fistula healed spontaneously (Figure 4).

DISCUSSION

In the field of reconstructive surgery, microvas- cular transfer of autologous intraperitoneal tis- sues, such as jejunum, stomach, colon, omentum, mesenterium, and peritoneum, have been de- scribed. A segment of stomach:>8 and colong have been used as a conduit to bridge the gap between the oropharynx proximally and the cut end of the esophagus distally. At present, free jejunal transfer has become the preferred method for reconstruction of the cervical esophagus and hypopharynx. In the extreme case, free jejunal graft has also been used for reconstruction of the oropharynx.10-12 Recently, peritoneal free flap combined with rectus abdominis muscle was re- ported as an alternative reconstructive option for closure of intraoral defects.13 Omentum is well known to have a great ability to resist infection

Mesenteric Flap in Free Jejunal Transfers HEAD & NECK May/June 1995 215

FIGURE 3. (A) lntraoperative view showing defect after re- section and neck dissection. (B) The mesenteric flap was separating from the redundant jejunum. (C) The mesenteric flap was placed to obliterate the dead space at paratracheo- stoma region and cover right carotid artery and the jejuno- esophageal anastomoses.

and revascularize ischemic tissue through its rich blood supply and accompanying lymphatic ves- sels. It has been applied for a number of recon- structive cases such as treating lymphedema,14 covering major vessels or pro~thesis , '~ recon- struction of chronic ulcer,16'17 restoration of facial

etc., as either a predicled or free graft.8i20

To our knowledge, there have been only two reports using mesenterium in the reconstructive procedures. In 1984, Nahai and colleagues de- scribed one case report of the use of the jejunomes-

216 Mesenteric Flap in Free Jejunal Transfers HEAD & NECK MaylJune 1995

FIGURE 4. The mesenteric flap was used to protect right carotid artery and jugular vein and to reconstruct the cervical skin defect. Mesh skin grafts were carried out on the mesen- teric flap.

enteric flap to resurface the cervical wound.21 Benedetto and colleagues reported a new method for the closure of peritoneal wall defects using a free mesenterium transfer.22

Our article describes further applications of the mesenteric flap in pharyngoesophageal recon- struction using free jejunal transfer. Four major indications exist for this reconstructive proce- dure: (1) To obliterate dead space in the head and neck region. Postoperative dead space may occur at the submandibular or paratracheostoma re- gion following laryngopharyngoesophagectomy or radical neck dissection. The dead space may contribute to postoperative infectious and wound fistula. Moreover, in our institutes, most of the patients with carcinomas of the head and neck had been previously treated with high-dose radio- therapy before surgery. Primary wound healing of the neck flaps is poor under these circum- stances. Although the use of suction drains may obliterate dead space, an additional use of the mesenteric flap, which is well vascularized and very pliable, obliterates the dead space and may improve wound healing, thereby decreasing the incidence of infection and fistula. (2) To provide cover for the vital cervical vascular structures when previous high-dose radiation has resulted in decreased vascularity to the wall of carotid ar- tery or jugular vein. Coverage and protection of these vessels with well-vascularized mesenteric flap may reduce the risk of rupture, a serious and life-threatening complication. (3) To use as a vas- cularized bolster for the vascular anastomoses and enteral anastomotic region between the

Mesenteric Flap in Free Jejunal Transfers

grafted jejunum, the oropharynx proximally and the cut end of esophagus distally. The vascular anastomoses covered with the mesenteric flap will not be damaged even if postoperative infec- tions occur. In cases where there is a high possi- bility of fistula such as surgical salvage for radi- ation failures, wrapping the enteral anastomotic area with the mesenteric flap may decrease the risk of fistula formation. (4) To provide a good vascularized bed for skin grafting cases in which the skin flaps are deficient.

There are alternative methods to cover the vascular sheath, to cover microvascular anasto- moses or enteral anastomoses, and to cover the cervical skin defect in these type of cases. One of the common alternatives is to use a pectoralis myo- fascia1 or myocutaneous flap. However, addi- tional procedures such as dissection of the flap and closure of the donor site are required; these prolong the operating time. Furthermore, we have not encountered any additional morbidity related to resecting the additional length of jeju- num.

The overall fistulization rate was about 15% in a group of jejunal transfer patients who did not undergo the mesenteric flap technique. Because of the small number of patients, a direct compar- ison between those with and without the mesen- teric flap is not possible. However, further expe- rience with this procedure may result in fewer complications in pharyngoesophageal reconstruc- tion.

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218 Mesenteric Flap in Free Jejunal Transfers HEAD & NECK May/June 1995