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Extension of the jejunum in the reconstruction of cervical oesophagus with free jejunum transfer using the thoracoacrominal vessels as recipients
Journal of Plastic, Reconstructive & Aesthetic Surgery (2012) 65, 156e162
Extension of the jejunum in the reconstruction of cervical oesophagus with free jejunum transfer using the thoracoacrominal vessels as recipients Tomohisa Nagasao a,*, Yusuke Shimizu a, Shogo Kasai a, Asako Hatano a, Weijin Ding b, Hua Jiang b, Kazuo Kishi a, Nobuaki Imanishi c a
Department of Plastic and Reconstructive Surgery, Keio University Hospital, Shinjuku-Ward Shinanomachi 35, Tokyo, Japan b Department of Plastic Surgery, Shanghai Second Military College, Tokyo, Japan c Department of Anatomy, Keio University Medical Faculty, Tokyo, Japan Received 1 July 2011; accepted 21 August 2011
KEYWORDS Reconstrcution; Oesophagus; Microsurgery; Recipient vessels; Thoracoacrominal; Jejunum
Summary Backgrounds: The degree to which the jejunum can reach upward is a significant consideration in cervical oesophagus reconstruction with vascularised free jejunum transfer using the thoracoacrominal vessels as recipient vessels. The present study aims to elucidate this issue. Materials and methods: In 30 fresh cadavers, the thoracoacrominal vessels were dissected, and the jejunums were harvested, carrying the second branches of the superior mesenteric arteries and veins as their pedicles. After the mesenteric vessels were anastomosed to the thoracoacrominal vessels, the jejunums were advanced to their maximum upward degree, and the positions of the oral ends were evaluated referring to the hyoid bone. The evaluation was performed under three conditions. In the first condition, the jejunums were simply advanced. In the second condition, tension of the mesenteriums was reduced by incising their serosa. In the third condition, mesenterial incision was also performed, and the anastomosed pedicles were placed under the clavicles. Results: The jejunums can reach superior to the hyoid bone by 2.1 1.5 SD cm for males and by 1.9 1.5 SD for females. By incising the mesenteric serosa, these distances can be extended by about 2 cm for males and 1 cm for females. Further extension of 2 cm can be obtained for both sexes by placing the pedicle under the clavicle. Conclusion: With patients whose neck regions lack vessels available for vascular anastomosis, the thoracoacrominal vessels are used in free jejunum transfer for cervical oesophagus reconstruction. The findings of the present study are useful in planning this type of reconstruction. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ81 3 3353 1211; fax: þ81 3 3352 1054. E-mail address: [email protected] (T. Nagasao). 1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.044
Free jejunum transfer using thoracoacrominal vessels Defects of the cervical oesophagus remain after the removal of advanced cancers of the larynx or inferior pharynx. Free jejunum transfer is frequently used for the reconstruction of the cervical oesophagus.1e4 Because the jejunum is a tube, it is suitable for reconstructing wholecircular defects of the oesophagus. Recipient vessels are needed for free jejunum transfer. Vessels of the neck region e such as the facial, superior thyroid, and transverse coli vessels e are popular choices as recipient vessels.5 However, in cases where radical neck lymph node dissections or radiation therapy were performed as previous treatments, these vessels are often damaged and unavailable.6,7 One solution to this problem is to use the thoracoacrominal vessels as recipient vessels.8 The thoracoacrominal vessels are usually available even in cases with previous histories of radical neck lymph node dissection or radiation to the neck. Furthermore, their diameters are large enough for vascular anastomosis. Figure 1 presents a case of cervical oesophagus reconstruction where the thoracodorsal vessels were used as recipient vessels for free jejunum transfer. Because of previous radical neck lymph node dissection, no vessels were available for microvascular anastomosis in the neck region. Hence, the right thoracodorsal vessels were used as recipient vessels. Although the jejunum could be extended to the upper margin of the defect, considerable tension occurred at the junction between the jejunum and the upper margin of the defect, increasing the possibility of postoperative dehiscence of the junction. Fortunately, the junction did not develop dehiscence in the given case. However, this experience alerted the authors to the limitation of this reconstruction method. The thoracoacrominal vessels are located inferior to the neck region. Furthermore, the mesenterium of the jejunum has limitations in length. Hence, the rotation arc of the jejunum is limited (Figure 2), and there can be cases where the transferred jejunums cannot reach the upper border of defects. In performing free jejunum transfer using the thoracoacrominal vessels as the recipient vessels, it is
157 necessary to evaluate the degree to which the jejunum can be advanced. The present study aims to elucidate this issue.
Materials and methods Specimens and preparation As many as 30 fresh cadavers (17 males and 13 females) of Asian persons were included in the study. The average heights for the males and females were 169 4.0 SD cm and 158.5 2.8 SD cm, respectively. For each cadaver, skin incision was made on the right neck and thoracic regions and the right major pectoral muscle was exposed. The major pectoralis muscle was split along its muscle fibres at the groove between its clavicular and pectoral parts. When the whole thickness of the major pectoral muscle is split, the pectoral branches of the thoracoacrominal artery and vein are identified by surrounding fat tissue. The thoracoacrominal vessels are usually found along the clavicle about two-thirds of the distance from the sternum-clavicle joint. Once the thoracoacrominal vessels are found, the clavicular part of the major pectoral muscle is split along the vessels, in the direction crossing the muscle fibres. As the dissection proceeds to the subclavicular regions, the main trunks of the thoracoacrominal artery and vein are identified. Usually, three branches e the deltoid, clavicular, and pectoral branches e come out of the main trunk. The deltoid and clavicular branches are ligated and severed to give positional freedom to the pectoral branch, which is used as the recipient vessel. Then attention was moved to the abdominal region to harvest the jejunum. By choosing the second branches of the superior mesenteric artery and vein to be used as the pedicle of the jejunum, the mesenterium was severed at the branching points of these vessels. The harvested jejunum was transferred to the neck. The second branches of the mesenterium arteries and veins were anastomosed to the thoracoacrominal artery and
Figure 1 (A) A defect remained after the removal of cervical oesophagus cancer. (B) A vascularised free jejunum was transferred. The superior mesenterial arteries and veins are anastomosed to the thoracoacrominal artery and vein, respectively (arrow). (C) The transferred jejunum was sutured to reconstruct the cervical oesophagus.
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T. Nagasao et al. operations, the authors have found that sufficient blood supply can reach to the neighbouring two legs when the arcades of the mesenterium are opened. Taking this into consideration, the most distal point of the jejunum at which the jejunum is connected with the vessels directly streaming out of the second arcade leg was marked (point P in Figure 3). The jejunum located beyond this point was discarded.
Measurement
Figure 2 In performing vascularised free jejunum transfer for the reconstruction of the cervical oesophagus using the thoracoacrominal vessels as the recipient vessels, the jejunum might not reach the required position because of limitation in rotation arc.
vein, respectively. The vascular anastomosis was performed at the points where the diameter of the thoracoacrominal artery and vein was 1.5 mm, using 9-0 nylon threads with end-to-end fashion. Thereafter, vascular arcades ramifying out of the second branch were severed to mobilise the jejunum (Figure 3, left). To achieve maximum advancement in the superior direction, three to four arcade loops needed to be severed (Figure 3, right). In living humans, the end of the jejunum extended this way does not have enough blood supply to survive. Therefore, the peripheral part of the jejunum was discarded. The authors have experienced over 60 clinical cases of jejunum transfer for cervical oesophagus reconstruction in the past 5 years. Based on observation in these
After the parts with suspected insufficiency of blood supply were discarded, the jejunum was pulled in the superior direction to the maximum degree, taking care not to break the anastomosed vessels (Figure 4). In order to evaluate the reach of the transferred jejunum accurately, it is necessary to arrange the position of cadavers so that it matches the preferred patient body position in actual operations. When the authors perform cervical tumour removal operations, they extend patients’ necks by placing an 8 cm-thick cushion under the scapular region of the patients. To simulate the same condition, an 8 cm-thick piece of wood was placed under the scapular region of cadavers. Then the jejunum was released. After release, the jejunum shrinks spontaneously because of its plasticity and shifts downward. The location of the most distal point of the jejunum was evaluated under the condition of spontaneous shrinkage. Reference points of measurement The distal end of the transferred jejunum and the sternal notch were defined as Je and Sn, respectively; the central point of the upper margin of the hyoid bone was defined as Hy. The distance between Je and Hy, and the distance between Hy and Sn, were respectively defined as Je-Hy and Hy-Sn, and these values were measured (Figure 5). Conditions for measurement Je-Hy was measured in three conditions (Figure 6). Condition 1: The jejunum was advanced in its natural condition; the pedicle was placed above the clavicle. Condition 2: The jejunum was advanced after tensionreleasing incisions were made on the serosa of the mesenterium. Condition 3: The jejunum was advanced after tensionreleasing incisions were made on the serosa of the mesenterium, with the pedicle placed beneath the clavicle. The value of JeeHy measured in condition 1 was defined as JeeHy1. Similarly, the values measured in condition 2 and condition 3 were defined as JeeHy2 and JeeHy3, respectively.
Evaluation
Figure 3 (Left) Arcade loops were opened to mobilise the jejunum. (Right) Distant parts of the mobilized jejunum were discarded, because they are expected to lack blood supply in actual conditions. The parts more than two legs beyond the most proximal opened loop (MPOL) were discarded.
With each of HyeSn, JeeHy1, JeeHy2, and JeeHy3, average values and standard deviations were calculated for the male and female groups. These values were compared between the two groups. The non-paired t-test was used for the statistical calculation; p-values less than 0.05 were considered to be statistically significant.
Free jejunum transfer using thoracoacrominal vessels
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Figure 4 After the mesenterial vessels are anastomosed to the thoracoacrominal vessels (Left), the jejunum was advanced in the superior direction (Right) and the extent of the margin of the jejunum was evaluated. The arrows in the figures indicate the anastomosis site of vascular anastomosis.
Results
JeeHy2
Measured values are shown in Table 1.
JeeHy2 presented greater values for males than for females. JeeHy2 was greater than JeeHy1 by about 2 cm for males and by 1 cm for females. These differences indicate that additional extension is obtained by making tension-releasing incisions on the serosa of the mesenterium.
HyeSn SneHy presented greater values for males than for females.
JeeHy3 JeeHy1 JeeHy1 did not present statistically significant differences between males and females.
JeeHy3 presented greater values for males than for females. JeeHy3 was greater than JeeHy2 by 4 cm for males and by 3 cm for females. These differences indicate that further extension e in addition to the extension obtained by tension-releasing incision of the mesenterium serosa e is obtained by placing the vascular pedicle beneath the clavicle.
Discussion
Figure 5 JeeHy (the distance between the margin of the jejunum and the hyoid bone) and HyeSn (the distance between the hyoid bone and sterna notch) were measured.
When the thoracoacrominal vessels are used as recipient vessels for vascularised free jejunum transfer, the distance to which the jejunum can be extended is a significant issue. In the present study, the distance was measured referring to the anatomical position of the hyoid bone. This is because the hyoid bone is easily identifiable during operations and so can be used as a useful reference for evaluating the position of the upper margin of the defect left after the removal of the tumour. It was found that the jejunum can be extended superior to the hyoid bone by 2.1 1.5 SD cm for males and 1.9 1.4 SD cm for females. When the upper margin of the oesophageal defect is located below these levels, the
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Figure 6 JeeHy was measured in three conditions. In Condition 1, the jejunum was advanced in its natural condition; the pedicle was placed above the clavicle. In Condition 2, the jejunum was advanced after tension-releasing incisions were made on the serosa of the mesenterium. In condition 3, the jejunum was advanced after tension-releasing incisions were made on the serosa of the mesenterium, with the pedicle placed beneath the clavicle. CL, SCA, and SCV in the lower figures indicate the clavicle, subclavicular artery, and subclavicular vein, respectively.
jejunum can be sutured to the defect margin without tension. However, when the upper margin of the defect is located superior to these ranges, tension develops at the junction between the jejunum and the defect margin when sutured together, leading to dehiscence of the junction and subsequent leakage. To avoid these complications, additional surgical manoeuvres should be performed so that the jejunum can be extended further without tension. Although separation of the jejunum tube from the mesenterium increases mobility of the jejunum, it decreases blood supply to the jejunum and causes ischaemia at the margin. Hence, the jejunum should be advanced carrying the mesenterium. The mesenterium consists of the vessels, fat, nerves, and serosa. Among these components, the serosa has the least extensibility and provides the main resistance against advancing the jejunum. Hence, by making tension-releasing incisions on the mesenterium, the jejunum can obtain further advancement. The authors initially assumed that with all of JeeHy1, JeeHy2, and JeeHy3, the values would be greater for males than for females, because sizes of body parts are
Table 1
Measured data (cm). Male (n Z 17) Female (n Z 13) P-values
Height SneHy JeeHy1 JeeHy2 JeeHy3
169 8.5 2.1 4.1 6.1
4.0 0.9 1.5 1.6 1.8
SD SD SD SD SD
158.5 7.6 1.9 2.9 4.7
2.8 0.6 1.4 1.6 1.6
SD SD SD SD SD
p Z 0.001 P Z 0.003 NS (p Z 0.559) p Z 0.05 p Z 0.04
generally greater for males than for females. However, contrary to the initial expectation, JeeHy1 does not present statistically significant differences between sexes. JeeHy1 is defined by the balance between the sizes of the mesenterium, the width of the clavicle, and the length of the neck. Although the size of the mesenterium is greater for males than for females, the width of the clavicle and length of the neck also take greater values for males than for females. Therefore, these values offset one another, producing no statistically significant differences between sexes with JeeHy1. On the other hand, JeeHy2 presents greater values for males than for females. The authors attribute this finding to the structural differences of the mesenterium between sexes. Males’ mesenteriums are thicker than females’ because they include greater amounts of fat tissues than those of females. To keep the abundant fat inside, the serosa of the male mesenterium accordingly becomes thicker, producing greater surface tension than the female mesenterium. Hence, by incising the serosa and releasing the surface tension, greater additional extension can be achieved for males than females. The difference between JeeHy2 and JeeHy1 is about 2 cm for males and 1 cm for females, meaning that the jejunum can achieve further extension by these distances. When further extension is needed, in addition to the tension-releasing incision of the mesenterium, the pedicle is placed under the clavicle. The thoracoacrominal artery and vein proceed in the inferior direction after they branch out of the subclavicular artery and vein. When the thoracoacrominal arteries and veins are placed above the clavicle, they need to detour around it. The detour distance can be saved by placing the pedicle under the clavicle. The results for both male and female demonstrate
Free jejunum transfer using thoracoacrominal vessels
Figure 7 To bring point P to Point A in the figure to perform end-to-side jejunum anastomosis, the jejunum should be extended by at least X cm.
additional extension of the jejunum of about 2 cm by performing this manoeuvre. When the thoracoacrominal vessels are placed under the clavicle, anastomosing the thoracoacrominal vessels to the mesenterium vessels is tricky, because surgical approach to the vessels is hindered by the clavicle. To avoid this technical trickiness, the authors perform the anastomosis first. Thereafter, the jejunum is introduced to the supraclavicular space through the tunnel under the clavicle. The data obtained in the present study are useful in making preoperative plans for the reconstruction of the cervical oesophagus. As shown with the type 3 results, the jejunum can be extended to the maximum by 6.1 1.8 SD cm for males and by 4.7 1.6 SD cm for females superior to the hyoid bone e by combining serosa incision of the mesenterium and placement of the pedicle under the clavicle. In cases where the upper margin of the defect is located above these levels, extension of the pedicle by vein grafting9 or use of the cephalic vessels as Corlette loop,9e11 or use of the internal mammary vessels,6,12 or alternative reconstruction methods e such as reconstruction with local flaps or gastric transpositions13e17 e need to be considered. In planning the operation, the difference in the diameters of the upper margin of the defect and the transferred jejunum should also be taken into consideration. Although the diameter of the jejunum is usually 2e3 cm, the upper margin of the defect is often greater than this size. In these cases, end-to-side anastomosis needs to be performed to match the sizes. To perform end-to-side anastomosis, merely advancing the margin of the jejunum to the upper margin of the defect is insufficient. For instance, for cases where the diameter of the upper margin of the defect is X cm, the oral end of the jejunum needs to be advanced superior to the upper margin of the defect by at least X cm to enable end-to-side anastomosis (Figure 7). Thus, in the preoperative planning of cervical oesophagus reconstruction with vascularised free jejunum transfer, discrepancy of the diameters of the sides at the junction needs to be considered, as well.
Conclusion The present study elucidated the degree by which the jejunum can be extended when it is transferred for the reconstruction of the cervical oesophagus with the
161 thoracoacrominal artery and vein as recipient vessels. When transferred in its natural condition, the jejunum can be advanced superior to the hyoid bone by 2.1 1.5 SD cm for males and 1.9 1.4 SD cm for females. By making tension-releasing incisions on the serosa of the mesenterium, these distances can be increased by about 2 cm for males and 1 cm for females. When further advancement is needed, additional extension of about 2 cm can be achieved by placing the vascular pedicle beneath the clavicle for both males and females. The findings of the present study are useful in planning reconstruction of the cervical oesophagus for patients who lack neck vessels as recipient vessels for vascular anastomosis.
Disclosure The authors have no conflict of interest and received no funding for the present study.
References 1. Ikeguchi M, Miyake T, Matsunaga T, et al. Free jejunal graft reconstruction after resection of neck cancers: our surgical technique. Surg Today 2009;39:925e8. 2. Zhao D, Gao X, Guan L, et al. Free jejunal graft for reconstruction of defects in the hypopharynx and cervical esophagus following the cancer resections. J Gastrointest Surg 2009;13: 1368e72. 3. Daiko H, Hayashi R, Saikawa M, et al. Surgical management of carcinoma of the cervical esophagus. J Surg Oncol 2007;96: 166e72. 4. Saitua F, Madrid A, Capdeville F, Ferrada C, Herrera P. Pharyngo-esophageal reconstruction by free jejunal graft and microvascular anastomosis in a 10-year-old girl. J Pediatr Surg 2004;39:e10e2. 5. Nahabedian MY, Singh N, Deune EG, Silverman R, Tufaro AP. Recipient vessel analysis for microvascular reconstruction of the head and neck. Ann Plast Surg 2004;52:148e55. 6. Jacobson AS, Eloy JA, Park E, Roman B, Genden EM. Vesseldepleted neck: techniques for achieving microvascular reconstruction. Head Neck 2008;30:201e7. 7. Numajiri T, Fujiwara T, Nishino K, et al. Double vascular anastomosis for safer free jejunal transfer in unfavorable conditions. J Reconstr Microsurg 2008;24:531e6. 8. Numajiri T, Fujiwara T, Nishino K, et al. The thoracoacromial artery as the recipient artery for safer free jejunal transfer in patients with irradiated, extensively scarred necks. Br J Oral Maxillofac Surg 2009;47:73e4. 9. Reichenberger MA, Harenberg PS, Pelzer M, et al. Arteriovenous loops in microsurgical free tissue transfer in reconstruction of central sternal defects. J Thorac Cardiovasc Surg 2010; 140:1283e7. 10. Ethunandan M, Cole R, Flood TR. Corlett loop for microvascular reconstruction in a neck depleted of vessels. Br J Oral Maxillofac Surg 2007;45:493e5. 11. Engel H, Pelzer M, Sauerbier M, Germann G, Heitmann C. An innovative treatment concept for free flap reconstruction of complex central chest wall defectsethe cephalic-thoraco-acromial (CTA) loop. Microsurgery 2007; 27:481e6. 12. Urken ML, Higgins KM, Lee B, Vickery C. Internal mammary artery and vein: recipient vessels for free tissue transfer to the head and neck in the vessel-depleted neck. Head Neck 2006; 28:797e801.
162 13. Castillo MH, Peoples JB, Machicao CN, Singhal PK. The lateral island trapezius myocutaneous flap for circumferential reconstruction of hypopharynx and cervical esophagus. Dig Surg 2001;18:93e7. 14. Carlson GW, Schusterman MA, Guillamondegui OM. Total reconstruction of the hypopharynx and cervical esophagus: a 20-year experience. Ann Plast Surg 1992;29: 408e12.
T. Nagasao et al. 15. Cusumano RJ, Silver CE, Brauer RJ, Strauch B. Pectoralis myocutaneous flap for replacement of cervical esophagus. Head Neck 1989;11:450e6. 16. Fabian RL. Pectoralis major myocutaneous flap reconstruction of the laryngopharynx and cervical esophagus. Laryngoscope 1988;98:1227e31. 17. Schuller DE. Reconstructive Pharyngeal and/or cervical esophageal defects. Arch Otolaryngol 1985;111:193e7.
Extension of the jejunum in the reconstruction of cervical oesophagus with free jejunum transfer using the thoracoacrominal vessels as recipients Tomohisa Nagasao a,*, Yusuke Shimizu a, Shogo Kasai a, Asako Hatano a, Weijin Ding b, Hua Jiang b, Kazuo Kishi a, Nobuaki Imanishi c a
Department of Plastic and Reconstructive Surgery, Keio University Hospital, Shinjuku-Ward Shinanomachi 35, Tokyo, Japan b Department of Plastic Surgery, Shanghai Second Military College, Tokyo, Japan c Department of Anatomy, Keio University Medical Faculty, Tokyo, Japan Received 1 July 2011; accepted 21 August 2011
KEYWORDS Reconstrcution; Oesophagus; Microsurgery; Recipient vessels; Thoracoacrominal; Jejunum
Summary Backgrounds: The degree to which the jejunum can reach upward is a significant consideration in cervical oesophagus reconstruction with vascularised free jejunum transfer using the thoracoacrominal vessels as recipient vessels. The present study aims to elucidate this issue. Materials and methods: In 30 fresh cadavers, the thoracoacrominal vessels were dissected, and the jejunums were harvested, carrying the second branches of the superior mesenteric arteries and veins as their pedicles. After the mesenteric vessels were anastomosed to the thoracoacrominal vessels, the jejunums were advanced to their maximum upward degree, and the positions of the oral ends were evaluated referring to the hyoid bone. The evaluation was performed under three conditions. In the first condition, the jejunums were simply advanced. In the second condition, tension of the mesenteriums was reduced by incising their serosa. In the third condition, mesenterial incision was also performed, and the anastomosed pedicles were placed under the clavicles. Results: The jejunums can reach superior to the hyoid bone by 2.1 1.5 SD cm for males and by 1.9 1.5 SD for females. By incising the mesenteric serosa, these distances can be extended by about 2 cm for males and 1 cm for females. Further extension of 2 cm can be obtained for both sexes by placing the pedicle under the clavicle. Conclusion: With patients whose neck regions lack vessels available for vascular anastomosis, the thoracoacrominal vessels are used in free jejunum transfer for cervical oesophagus reconstruction. The findings of the present study are useful in planning this type of reconstruction. ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved.
* Corresponding author. Tel.: þ81 3 3353 1211; fax: þ81 3 3352 1054. E-mail address: [email protected] (T. Nagasao). 1748-6815/$ - see front matter ª 2011 British Association of Plastic, Reconstructive and Aesthetic Surgeons. Published by Elsevier Ltd. All rights reserved. doi:10.1016/j.bjps.2011.08.044
Free jejunum transfer using thoracoacrominal vessels Defects of the cervical oesophagus remain after the removal of advanced cancers of the larynx or inferior pharynx. Free jejunum transfer is frequently used for the reconstruction of the cervical oesophagus.1e4 Because the jejunum is a tube, it is suitable for reconstructing wholecircular defects of the oesophagus. Recipient vessels are needed for free jejunum transfer. Vessels of the neck region e such as the facial, superior thyroid, and transverse coli vessels e are popular choices as recipient vessels.5 However, in cases where radical neck lymph node dissections or radiation therapy were performed as previous treatments, these vessels are often damaged and unavailable.6,7 One solution to this problem is to use the thoracoacrominal vessels as recipient vessels.8 The thoracoacrominal vessels are usually available even in cases with previous histories of radical neck lymph node dissection or radiation to the neck. Furthermore, their diameters are large enough for vascular anastomosis. Figure 1 presents a case of cervical oesophagus reconstruction where the thoracodorsal vessels were used as recipient vessels for free jejunum transfer. Because of previous radical neck lymph node dissection, no vessels were available for microvascular anastomosis in the neck region. Hence, the right thoracodorsal vessels were used as recipient vessels. Although the jejunum could be extended to the upper margin of the defect, considerable tension occurred at the junction between the jejunum and the upper margin of the defect, increasing the possibility of postoperative dehiscence of the junction. Fortunately, the junction did not develop dehiscence in the given case. However, this experience alerted the authors to the limitation of this reconstruction method. The thoracoacrominal vessels are located inferior to the neck region. Furthermore, the mesenterium of the jejunum has limitations in length. Hence, the rotation arc of the jejunum is limited (Figure 2), and there can be cases where the transferred jejunums cannot reach the upper border of defects. In performing free jejunum transfer using the thoracoacrominal vessels as the recipient vessels, it is
157 necessary to evaluate the degree to which the jejunum can be advanced. The present study aims to elucidate this issue.
Materials and methods Specimens and preparation As many as 30 fresh cadavers (17 males and 13 females) of Asian persons were included in the study. The average heights for the males and females were 169 4.0 SD cm and 158.5 2.8 SD cm, respectively. For each cadaver, skin incision was made on the right neck and thoracic regions and the right major pectoral muscle was exposed. The major pectoralis muscle was split along its muscle fibres at the groove between its clavicular and pectoral parts. When the whole thickness of the major pectoral muscle is split, the pectoral branches of the thoracoacrominal artery and vein are identified by surrounding fat tissue. The thoracoacrominal vessels are usually found along the clavicle about two-thirds of the distance from the sternum-clavicle joint. Once the thoracoacrominal vessels are found, the clavicular part of the major pectoral muscle is split along the vessels, in the direction crossing the muscle fibres. As the dissection proceeds to the subclavicular regions, the main trunks of the thoracoacrominal artery and vein are identified. Usually, three branches e the deltoid, clavicular, and pectoral branches e come out of the main trunk. The deltoid and clavicular branches are ligated and severed to give positional freedom to the pectoral branch, which is used as the recipient vessel. Then attention was moved to the abdominal region to harvest the jejunum. By choosing the second branches of the superior mesenteric artery and vein to be used as the pedicle of the jejunum, the mesenterium was severed at the branching points of these vessels. The harvested jejunum was transferred to the neck. The second branches of the mesenterium arteries and veins were anastomosed to the thoracoacrominal artery and
Figure 1 (A) A defect remained after the removal of cervical oesophagus cancer. (B) A vascularised free jejunum was transferred. The superior mesenterial arteries and veins are anastomosed to the thoracoacrominal artery and vein, respectively (arrow). (C) The transferred jejunum was sutured to reconstruct the cervical oesophagus.
158
T. Nagasao et al. operations, the authors have found that sufficient blood supply can reach to the neighbouring two legs when the arcades of the mesenterium are opened. Taking this into consideration, the most distal point of the jejunum at which the jejunum is connected with the vessels directly streaming out of the second arcade leg was marked (point P in Figure 3). The jejunum located beyond this point was discarded.
Measurement
Figure 2 In performing vascularised free jejunum transfer for the reconstruction of the cervical oesophagus using the thoracoacrominal vessels as the recipient vessels, the jejunum might not reach the required position because of limitation in rotation arc.
vein, respectively. The vascular anastomosis was performed at the points where the diameter of the thoracoacrominal artery and vein was 1.5 mm, using 9-0 nylon threads with end-to-end fashion. Thereafter, vascular arcades ramifying out of the second branch were severed to mobilise the jejunum (Figure 3, left). To achieve maximum advancement in the superior direction, three to four arcade loops needed to be severed (Figure 3, right). In living humans, the end of the jejunum extended this way does not have enough blood supply to survive. Therefore, the peripheral part of the jejunum was discarded. The authors have experienced over 60 clinical cases of jejunum transfer for cervical oesophagus reconstruction in the past 5 years. Based on observation in these
After the parts with suspected insufficiency of blood supply were discarded, the jejunum was pulled in the superior direction to the maximum degree, taking care not to break the anastomosed vessels (Figure 4). In order to evaluate the reach of the transferred jejunum accurately, it is necessary to arrange the position of cadavers so that it matches the preferred patient body position in actual operations. When the authors perform cervical tumour removal operations, they extend patients’ necks by placing an 8 cm-thick cushion under the scapular region of the patients. To simulate the same condition, an 8 cm-thick piece of wood was placed under the scapular region of cadavers. Then the jejunum was released. After release, the jejunum shrinks spontaneously because of its plasticity and shifts downward. The location of the most distal point of the jejunum was evaluated under the condition of spontaneous shrinkage. Reference points of measurement The distal end of the transferred jejunum and the sternal notch were defined as Je and Sn, respectively; the central point of the upper margin of the hyoid bone was defined as Hy. The distance between Je and Hy, and the distance between Hy and Sn, were respectively defined as Je-Hy and Hy-Sn, and these values were measured (Figure 5). Conditions for measurement Je-Hy was measured in three conditions (Figure 6). Condition 1: The jejunum was advanced in its natural condition; the pedicle was placed above the clavicle. Condition 2: The jejunum was advanced after tensionreleasing incisions were made on the serosa of the mesenterium. Condition 3: The jejunum was advanced after tensionreleasing incisions were made on the serosa of the mesenterium, with the pedicle placed beneath the clavicle. The value of JeeHy measured in condition 1 was defined as JeeHy1. Similarly, the values measured in condition 2 and condition 3 were defined as JeeHy2 and JeeHy3, respectively.
Evaluation
Figure 3 (Left) Arcade loops were opened to mobilise the jejunum. (Right) Distant parts of the mobilized jejunum were discarded, because they are expected to lack blood supply in actual conditions. The parts more than two legs beyond the most proximal opened loop (MPOL) were discarded.
With each of HyeSn, JeeHy1, JeeHy2, and JeeHy3, average values and standard deviations were calculated for the male and female groups. These values were compared between the two groups. The non-paired t-test was used for the statistical calculation; p-values less than 0.05 were considered to be statistically significant.
Free jejunum transfer using thoracoacrominal vessels
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Figure 4 After the mesenterial vessels are anastomosed to the thoracoacrominal vessels (Left), the jejunum was advanced in the superior direction (Right) and the extent of the margin of the jejunum was evaluated. The arrows in the figures indicate the anastomosis site of vascular anastomosis.
Results
JeeHy2
Measured values are shown in Table 1.
JeeHy2 presented greater values for males than for females. JeeHy2 was greater than JeeHy1 by about 2 cm for males and by 1 cm for females. These differences indicate that additional extension is obtained by making tension-releasing incisions on the serosa of the mesenterium.
HyeSn SneHy presented greater values for males than for females.
JeeHy3 JeeHy1 JeeHy1 did not present statistically significant differences between males and females.
JeeHy3 presented greater values for males than for females. JeeHy3 was greater than JeeHy2 by 4 cm for males and by 3 cm for females. These differences indicate that further extension e in addition to the extension obtained by tension-releasing incision of the mesenterium serosa e is obtained by placing the vascular pedicle beneath the clavicle.
Discussion
Figure 5 JeeHy (the distance between the margin of the jejunum and the hyoid bone) and HyeSn (the distance between the hyoid bone and sterna notch) were measured.
When the thoracoacrominal vessels are used as recipient vessels for vascularised free jejunum transfer, the distance to which the jejunum can be extended is a significant issue. In the present study, the distance was measured referring to the anatomical position of the hyoid bone. This is because the hyoid bone is easily identifiable during operations and so can be used as a useful reference for evaluating the position of the upper margin of the defect left after the removal of the tumour. It was found that the jejunum can be extended superior to the hyoid bone by 2.1 1.5 SD cm for males and 1.9 1.4 SD cm for females. When the upper margin of the oesophageal defect is located below these levels, the
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Figure 6 JeeHy was measured in three conditions. In Condition 1, the jejunum was advanced in its natural condition; the pedicle was placed above the clavicle. In Condition 2, the jejunum was advanced after tension-releasing incisions were made on the serosa of the mesenterium. In condition 3, the jejunum was advanced after tension-releasing incisions were made on the serosa of the mesenterium, with the pedicle placed beneath the clavicle. CL, SCA, and SCV in the lower figures indicate the clavicle, subclavicular artery, and subclavicular vein, respectively.
jejunum can be sutured to the defect margin without tension. However, when the upper margin of the defect is located superior to these ranges, tension develops at the junction between the jejunum and the defect margin when sutured together, leading to dehiscence of the junction and subsequent leakage. To avoid these complications, additional surgical manoeuvres should be performed so that the jejunum can be extended further without tension. Although separation of the jejunum tube from the mesenterium increases mobility of the jejunum, it decreases blood supply to the jejunum and causes ischaemia at the margin. Hence, the jejunum should be advanced carrying the mesenterium. The mesenterium consists of the vessels, fat, nerves, and serosa. Among these components, the serosa has the least extensibility and provides the main resistance against advancing the jejunum. Hence, by making tension-releasing incisions on the mesenterium, the jejunum can obtain further advancement. The authors initially assumed that with all of JeeHy1, JeeHy2, and JeeHy3, the values would be greater for males than for females, because sizes of body parts are
Table 1
Measured data (cm). Male (n Z 17) Female (n Z 13) P-values
Height SneHy JeeHy1 JeeHy2 JeeHy3
169 8.5 2.1 4.1 6.1
4.0 0.9 1.5 1.6 1.8
SD SD SD SD SD
158.5 7.6 1.9 2.9 4.7
2.8 0.6 1.4 1.6 1.6
SD SD SD SD SD
p Z 0.001 P Z 0.003 NS (p Z 0.559) p Z 0.05 p Z 0.04
generally greater for males than for females. However, contrary to the initial expectation, JeeHy1 does not present statistically significant differences between sexes. JeeHy1 is defined by the balance between the sizes of the mesenterium, the width of the clavicle, and the length of the neck. Although the size of the mesenterium is greater for males than for females, the width of the clavicle and length of the neck also take greater values for males than for females. Therefore, these values offset one another, producing no statistically significant differences between sexes with JeeHy1. On the other hand, JeeHy2 presents greater values for males than for females. The authors attribute this finding to the structural differences of the mesenterium between sexes. Males’ mesenteriums are thicker than females’ because they include greater amounts of fat tissues than those of females. To keep the abundant fat inside, the serosa of the male mesenterium accordingly becomes thicker, producing greater surface tension than the female mesenterium. Hence, by incising the serosa and releasing the surface tension, greater additional extension can be achieved for males than females. The difference between JeeHy2 and JeeHy1 is about 2 cm for males and 1 cm for females, meaning that the jejunum can achieve further extension by these distances. When further extension is needed, in addition to the tension-releasing incision of the mesenterium, the pedicle is placed under the clavicle. The thoracoacrominal artery and vein proceed in the inferior direction after they branch out of the subclavicular artery and vein. When the thoracoacrominal arteries and veins are placed above the clavicle, they need to detour around it. The detour distance can be saved by placing the pedicle under the clavicle. The results for both male and female demonstrate
Free jejunum transfer using thoracoacrominal vessels
Figure 7 To bring point P to Point A in the figure to perform end-to-side jejunum anastomosis, the jejunum should be extended by at least X cm.
additional extension of the jejunum of about 2 cm by performing this manoeuvre. When the thoracoacrominal vessels are placed under the clavicle, anastomosing the thoracoacrominal vessels to the mesenterium vessels is tricky, because surgical approach to the vessels is hindered by the clavicle. To avoid this technical trickiness, the authors perform the anastomosis first. Thereafter, the jejunum is introduced to the supraclavicular space through the tunnel under the clavicle. The data obtained in the present study are useful in making preoperative plans for the reconstruction of the cervical oesophagus. As shown with the type 3 results, the jejunum can be extended to the maximum by 6.1 1.8 SD cm for males and by 4.7 1.6 SD cm for females superior to the hyoid bone e by combining serosa incision of the mesenterium and placement of the pedicle under the clavicle. In cases where the upper margin of the defect is located above these levels, extension of the pedicle by vein grafting9 or use of the cephalic vessels as Corlette loop,9e11 or use of the internal mammary vessels,6,12 or alternative reconstruction methods e such as reconstruction with local flaps or gastric transpositions13e17 e need to be considered. In planning the operation, the difference in the diameters of the upper margin of the defect and the transferred jejunum should also be taken into consideration. Although the diameter of the jejunum is usually 2e3 cm, the upper margin of the defect is often greater than this size. In these cases, end-to-side anastomosis needs to be performed to match the sizes. To perform end-to-side anastomosis, merely advancing the margin of the jejunum to the upper margin of the defect is insufficient. For instance, for cases where the diameter of the upper margin of the defect is X cm, the oral end of the jejunum needs to be advanced superior to the upper margin of the defect by at least X cm to enable end-to-side anastomosis (Figure 7). Thus, in the preoperative planning of cervical oesophagus reconstruction with vascularised free jejunum transfer, discrepancy of the diameters of the sides at the junction needs to be considered, as well.
Conclusion The present study elucidated the degree by which the jejunum can be extended when it is transferred for the reconstruction of the cervical oesophagus with the
161 thoracoacrominal artery and vein as recipient vessels. When transferred in its natural condition, the jejunum can be advanced superior to the hyoid bone by 2.1 1.5 SD cm for males and 1.9 1.4 SD cm for females. By making tension-releasing incisions on the serosa of the mesenterium, these distances can be increased by about 2 cm for males and 1 cm for females. When further advancement is needed, additional extension of about 2 cm can be achieved by placing the vascular pedicle beneath the clavicle for both males and females. The findings of the present study are useful in planning reconstruction of the cervical oesophagus for patients who lack neck vessels as recipient vessels for vascular anastomosis.
Disclosure The authors have no conflict of interest and received no funding for the present study.
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