• Archives of Plastic Surgery
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• v.34 no.4
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• pp.432-435
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• 2007

Purpose: The jejunal free flap has the shorter ischemic time than other flap and requires a laparotomy to harvest it. As the evaluation of the perfusion the buried flap is very important, the perfusion of the buried jejunal free flap requires monitoring for its salvage. We tried to improve the monitoring flap method in the jejunal free flap and examined its usefulness. Methods: From March 2002 to March 2006, the monitoring flap method was applied to 4 cases in 8 jejunal free flaps for the pharyngeal and cervical esophageal reconstructions. The distal part of the jejunal flap was exposed without suture fixation through cervical wound for monitoring its perfusion. The status of perfusion was judged by the color change of jejunal mucosa and mesentery. If necessary, pin prick test was performed. Doppler sonography was applied to mesenteric pedicle of the monitoring flap in case of suspicious abnormal circulation. Results: The monitoring flap shows no change in 3 cases, but the congestion happened in one case at the 12 hours after the operation. This congestion was caused by the twisting or kinking of the mesenteric pedicle of the monitoring flap. So, we fixed up the monitoring flap close to adjacent cervical skin for prevention of rotation. Finally, the main part of transferred jejunal flap was intact. Conclusion: The success of a jejunal free flap depends on close postoperative monitoring and early detection of vascular compromise. So, various monitoring methods have been tried, for instance, direct visualization using a fiberoptic pharyngoscope, through a Silastic window placed in the neck flap, or external surface monitoring with an Doppler sonography, use of a buried monitoring probe. But, all of the above have their own shortcomings of simplicity, non-invasiveness, reliability and etc. In our experience, monitoring flap can be a accurate and reliable method.

• Archives of Craniofacial Surgery
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• v.9 no.2
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• pp.110-113
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• 2008

Purpose: The jejunal free flap is the most standard and reliable procedure of reconstruction of the circumferential pharyngoesophageal defect because it provides pliable, elastic, secreting mucosa and posses reliable vascular anatomy. In this report, the authors introduce the modification of jejunal free flap for decreasing the complications in fatty complicated patients. Method: After harvesting the jejunum with mesentery and mesenteric vessels, both ends of jejunum were excised remaining the mesenteric portion. The jejunal portion of this composite flap was placed to reconstruct esophagopharyngeal defect area and the mesenteric portion was used to obliterate the dead space at paratracheal region and to cover the vital structure and the vascular anastomotic region. Result: A 72 year-old man with recurrent hypopharyngeal cancer who had about 15 cm sized circumferential pharyngoesophageal defect after total pharyngectomy was reconstructed with jejunomesenteric composite free flap without any complications. Conclusion: The mesenteric flaps at both side of jejunomesenteric composite free flap provide the advantages that could obliterate dead space, that could provide cover for the vital cervical vascular structure in case of vascularity was compromised due to previous radiation therapy, and that could preserve as much vascularity at both ends of jejunal flap as possible.

• Archives of Craniofacial Surgery
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• v.16 no.3
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• pp.105-113
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• 2015

The main challenge in pharyngoesophageal reconstruction is the restoration of swallow and speech functions. The aim of this paper is to review the reconstructive options and associated complications for patients with head and neck cancer. A literature review was performed for pharynoesophagus reconstruction after ablative surgery of head and neck cancer for studies published between January 1980 to July 2015 and listed in the PubMed database. Search queries were made using a combination of 'esophagus' and 'free flap', 'microsurgical', or 'free tissue transfer'. The search query resulted in 123 studies, of which 33 studies were full text publications that met inclusion criteria. Further review into the reference of these 33 studies resulted in 15 additional studies to be included. The pharyngoesophagus reconstruction should be individualized for each patient and clinical context. Fasciocutaneous free flap and pedicled flap are effective for partial phayngoesophageal defect. Fasciocutaneous free flap and jejunal free flap are effective for circumferential defect. Pedicled flaps remain a safe option in the context of high surgical risk patients, presence of fistula. Among free flaps, anterolateral thigh free flap and jejunal free flap were associated with superior outcomes, when compared with radial forearm free flap. Speech function is reported to be better for the fasciocutaneous free flap than for the jejunal free flap.

• Archives of Plastic Surgery
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• v.33 no.2
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• pp.245-248
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• 2006

Besides gastric pull-up or colonic interposition, microvascular technique in esophageal reconstruction has been approved reliable methods. When free intestinal transfer is considered, jejunal free flap is commonly used. We treated the patient who had undergone reconstruction with a right colon interposition and suffered from inability of swallowing because of stricture and necrosis of the interposed flap. Although we have planned jejunal free transfer, we couldn't use jejunum due to adhesion by previous gastrojejunostomy and colon interposition. Salvage procedure with microvascualr free left colon flap was executed successfully. After 9 month follow-up, the patient was able to consume a normal diet.

• Korean Journal of Head & Neck Oncology
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• v.24 no.1
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• pp.43-46
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• 2008

Hypophayngeal cancers are usually diagnosed in advanced stages and in many cases, they need total pharyngocervical esophagectomy and surgical reconstruction. Among many surgical reconstructive methods, jejunal free flap has anatomical and functional advantages such as tubed nature, peristaltic activity, excellent blood supply. In this study we analysed the surgical procedure and complications of jejunal free flap after total pharyngo-cervical esophagectomy. 20 cases performed jejunal free flap from 1995 to 2007 at Severance Hospital were reviewed. According to time of onset, early and late complications were reviewed. Surgical procedure was reviewed with operation record. Oral diet tolerance was reviewed on the basis of pharyngogram and subjective symptoms. The most common complication was stricture, and it occurred in 40% of cases and 63% of them were managed with conservative care. As early complication, fistula formation was all managed with conservative care. Oral feeding tolerance after jejunal free flap was 65% and 7 patients were tolerable to general diet. In our study, stricture was the most common complication and its management is important in post op oral diet tolerance.

• Korean Journal of Head & Neck Oncology
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• v.16 no.1
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• pp.26-32
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• 2000

Background and Objectives: Various flaps are using for reconstruction of hypopharyngeal and esophageal defect. However, complication and indication of each flap are not fully analyzed. Patient and Methods: Records of 52 hypopharyngeal cancer patients who had surgical treatment and 13 other head and neck cancer patients who underwent hypopharyngeal and/or esophageal reconstruction with flap were retrospectively analyzed. Eighty three percent(54 cases) of patients needed reconstruction other than primary pharyngeal closure. Five split thickness skin graft, 1 pectoralis major myocutaneous flap, 20 forearm free flap, 13 jejunal free flap, 15 gastric pull up were used. Result: Flap failure was noted in 2 cases who had subsequent gastric transposition. Wound dehiscence and fistula were most common problem of forearm free flap. Most fistulas were developed in patients with conduit type reconstruction of forearm flap while there wasn't any fistula in patient with patch type reconstruction. Stenosis of lower anastomosis was the frequent problem of jejunal transfer. Gastric pull-up has frequent com-plication of stomal stenosis. All but three patients had reached oral feeding postoperatively. Conclusion: Based on this study, forearm flap is effective in partial hypopharyngeal defect while jejunum is the choice for circumferential defect. Gastric pull-up is for combined esophageal defect.

• Archives of Plastic Surgery
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• v.44 no.6
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• pp.550-553
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• 2017

Esophageal perforation is a rare but potentially fatal complication of robot-assisted thyroidectomy (RAT). Herein, we report the long-term outcome of an esophageal reconstruction with a jejunal free flap for esophageal rupture after RAT. A 33-year-old woman developed subcutaneous emphysema and hoarseness on postoperative day1 following RAT. Esophageal rupture was diagnosed by computed tomography and endoscopy, and immediate surgical exploration confirmed esophageal rupture, as well as recurrent laryngeal nerve injury. We performed a jejunal free flap repair of the 8-cm defect in the esophagus. End-to-side microvascular anastomoses were created between the right external carotid artery and the jejunal branches of the superior mesenteric artery, and end-to-end anastomosis was performed between the external jugular vein and the jejunal vein. The right recurrent laryngeal nerve injury was repaired with a 4-cm nerve graft from the right ansa cervicalis. Esophagography at 1 year after surgery confirmed that there were no leaks or structures, endoscopy at 1 year confirmed the resolution of vocal cord paralysis, and there were no residual problems with swallowing or speech at a 5-year follow-up examination. RAT requires experienced surgeons with a thorough knowledge of anatomy, as well as adequate resources to quickly and competently address potentially severe complications such as esophageal rupture.

• Archives of Reconstructive Microsurgery
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• v.8 no.2
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• pp.154-162
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• 1999

The laryngopharyngectomy for tumor ablation is the most common indication for pharyngoesophageal reconstruction in our country. Most of these cases are advanced laryngeal cancer that has spread beyond the larynx, pharynx and cervical esophagus. Such patients are obviously unable to breathe, swallow, or speak in the normal manner. The ideal reconstruction would restore normal anatomy, permitting patients to breathe and swallow without aspiration, and would not require a permanent tracheostomy. Reconstruction of the pharyngoesophageal defect traditionally been carried out with tubed local random flap, deltopectoral or musculocutaneous flap. Another approach is the pedicled enteric flap. But microsurgical reconstruction of the pharyngoesophagus, using either the free jejunal or the tubed radial forearm flap, have now become the preferred technique. Among them, we used jejunal free flap in 39 cases, tubed radial forearm free flap in 5 cases, patched radial forearm free flap in 2 cases and pectoralis major myocutaneous island flap in 2 cases from December 1990 to Febrary 1999. In this paper we illustrated that both forearm and jejunal free flap is a usful alternative in reconstruction of hypopharynx and cervical esophagus.

• Archives of Reconstructive Microsurgery
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• v.7 no.1
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• pp.47-53
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• 1998

Despite of technical advances in surgery & other therapeutic modalities five-year survival rates in patients with carcinoma of hypopharynx have remained low. Many techniques have been used to create a structure capable of allowing the passage of food and fluids in an attempt to maintain the anatomy and physiology of the upper digestive system. The development of microsurgical techniques and the concept of mucocutaneous unit has brought about important changes in the reconstruction of cervical esophagus following tumor resection. The one-stage procedure using microvascular anastomosis of free jejunal graft provides physiologic reconstruction of cervical esophagus and has a low morbidity rate as well as a short recuperation time. With free jejunal graft, there is marked improvement in the quality of life and numerous advantages over the previous methods of reconstruction. Reconstruction of esophageal defect after resection of carcinomas of the hypopharynx, and cervical esophagus has traditionally been carried out with deltopectoral, or musculocutaneous skin-lined flaps. A second approach is to reconstruct the defect with the colon or stomach. A more ideal mettled is to repair these defects with mucosa-lined flaps. The authors experienced 35 cases of reconstruction of cervical esophagus after resection of carcinoma of the hypopharynx with free jejunal autograft and one case of secondary repair with radial forearm free flap after failure of initial free Jejunal autograft. Postoperative results were satisfactory in most patients and two patients expired in 8 days postoperatively because of carotid blow out by chronic inflammation.

• Archives of Plastic Surgery
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• v.33 no.4
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• pp.407-412
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• 2006

Purpose: Various attempts of reconstruction for pharyngoesophageal defects after ablative surgery have been made to restore the function of the pharyngoesophagus. A fabricated tubed radial forearm free flap or free jejunal free flap was used when the width of remnant pharyngeal wall was less than 50% of the normal width. However there are many disadvantages such as stricture, saliva leakage and fistula formation on tubed radial forearm free flap. The jejunal free flap has the problem such as short pedicle, poor tolerance of ischemic time, wet voice and delayed transit of swallowed food due to the uncoordinated contraction. The authors studied the utility of patch-type radial forearm free flap using the remnant posterior pharyngeal wall of the hypopharynx. Methods: Retrospective reviews in Severance Hospital were made on 25 patients who underwent reconstruction surgery with patched radial forearm free flap because of the hypopharyngeal cancer between 1996 and 2005. The patients of Group I had the narrow posterior pharyngeal wall and its width was less than 3centimeters after the tumor was resected. Those of Group II had the partial pharyngectomy and the width of the remnant pharynx was larger than 3 centimeters. Results: Seven patients belonged to the group I and the flap of this group had 100% survival rate. One case of fistula and no swallowing discomfort due to stricture was reported. The Group II including 18 patients also had the 100% flap survival rate. Neither fistula nor stricture was seen but the lower diet grade was checked. Conclusion: The patch type radial forearm free flap using the remnant pharyngeal wall have the advantage of the radial forearm free flap, and furthermore this flap is the safe reconstructive method even if the width of the remnant pharyngeal wall is less than 30% of that of normal pharynx.