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Reconstruction of cervical oesophagus with free double-folded intestinal graft
Brirish hurnul of Phic Surgery (1985) 38.4X3-487 I’ 19X5 The Trustees of British Association of Plastic Surgeons
Reconstruction of cervical oesophagus with free double-folded intestinal graft T. HARASHINA, Departments Tokyo
T. INOUE, T. ANDOH,
of Plastic and Reconstructive
C. SUGIMOTO
and T. FUJINO
Surgery and General Surgery, Keio University School of Medicine,
Summary-Reconstruction of cervical oesophagus with free revascularised small intestine is a reliable and effective technique but a common complication is dysphagia. This paper presents a method of splitting the wall of the intestine longitudinally, folding it and suturing it to double the size of the lumen of the reconstructed conduit and to abolish effective peristalsis. The method has proved to be useful in three clinical cases,
Developments in microvascular surgery have renewed interest in reconstructing the cervical oesophagus with free revascularised intestinal grafts and the procedure has proved to be reliable and effective (Harashina et al., 1981). However, the worst shortcoming of the technique is the resulting dysphagia which may be due to persistent peristalsis in the transplanted intestine. We have developed a new technique to avoid this complication. Operative method In primary reconstruction appropriate recipient vessels are identified and tagged after the pharyngolaryngo-oesophagectomy. In secondary reconstruction both stumps of the remaining oesophagus are exposed and freshened, and recipient vessels selected and prepared. The length of the defect in the cervical oesophagus is measured. Through an upper midline abdominal incision the jejunum is exposed and a segment is harvested which is nourished by one pair of jejunal vessels and is twice as long as the defect. The graft is placed on the table and the entire jejunal wall is split longitudinally along a line about halfway between the mesentery and antimesenteric border and the jejunal lumen is opened (Figs 1 and 2). The mucosal surface is cleaned with a mild antiseptic and the whole graft is washed with normal saline solution. The jejunal wall and mesentery are then folded upon themselves so that the mucosal surfaces face each other (Fig. 3). The cut edge of the jejunum which is closer to the mesentery is sutured in two layers. The transplant
is fixed in the neck wound
temporary sutures and the microvascular anastomoses are performed. After completion of the anastomoses and release of vascular clamps profuse bleeding occurs from the cut edges of the jejunal wall and all these bleeders are coagulated with the bipolar diathermy or underrun with sutures. The sutured jejunal edge is also carefully checked for bleeding. After haemostasis is complete the superior and inferior visceral anastomoses are performed. The inferior anastomosis between the transplanted jejunum and retained oesophageal stump can be performed with an EEA stapler. After both visceral anastomoses are completed a nasogastric tube is inserted and the still unsutured side wall is closed in two layers. When the skin wounds are closed it is advisable to leave a small window through which the colour of the transplanted intestine can be observed or the probe of a Doppler flowmeter can be applied directly to the serosal surface. If primary skin closure cannot be obtained due to skin flap shortage in secondary reconstruction. a split skin graft can be used directly on the serosa. Case reports Case 1. A 60-year-old male patient who had previously had reconstruction of his cervical oesophagus with a retrosternal colon interposition was diagnosed as having recurrence of cancer and had received 4000 rads of Co 60 therapy. After radiotherapy had proved ineffective he was scheduled for reconstruction of the cervical oesophagus with free revascularised intestinal transfer. He had already had four laparotomies and a segment of jejunum was harvested for free transfer with considerable difficulty. Reconstruction was performed as described except
with 483
BRITISH JQURNAI. OF PLASTIC SURGERY
Fig. 1
Figure i-The
harvested jejunum and mesentery with a single nutrient artery and
vein.A
dotted line shows the fine af *spiiti.ing.
Excess jejnnal wall and mesentery will be discarded.
that both side walls of the new oesophagus were sutured before the vascular anastomoses. His postoperative course was stormy due to septicaemia, transient lymphorroea from the neck wound and haematemesis 10 days after the surgery. Endoscupy showed that a baematoma had formed along the suture line in the newly reconstructed oesaphagus. It is now 7 months after the reconstruction and he can enjoy a normal diet freely. Curse2. A 70”year-old male patient who had already had a gastrectomy for gastric ulcer and a right upper lobectomy for lung cancer was diagnosed as having cancer of the hypopharynx and the remaining stomach. Caryngopharyngo-oesophagectomy combined with bilateral neck dissections and total gastrectumy were performed. Continuity of the abdominal digestive tract was restored with the Roux-en-Y method and the cervical oesophagus was reconstructed with a double-folded intestinal graft. He had an uneventfut recovery and was able to enjoy a normal diet 6 weeks after the reconstruction. Case 3. A 67”year-old male patient had previously undergone reconstruction of the cervical oesophagus with a
presternal colon swing procedure. Due to poor circulation the distal tip of the transferred colon necrosed, leaving a 10 cm oesophageal defect on the anterior chest. The deficient oesophagus was reconstructed with a daublefolded intestinal graft which measured I.5 cm long. A split skin graft was applied directly over the serosa to compensate for skin flap shortage. The transfer itself was successful but the patient cannot eat freely due to poor run-off of food through the raised colon and is being scheduled for further surgery.
Discussion Methods of reconstruction of the cervical oesophagus have been analyscd by Surkin ct al. (1984). The use of free, revascularised small intestine has a number of advantages over other methods; in particular it is a one stage procedure with a low incidence of anastomotic leak, fistula formation or stricture and involves minimal sacrifice of normally functioning tissue.
RECONSTRUCTION
OF CERVICAL
OESOPHAGUS
WITH
FREE DOUBLE-FOLDED
INTESTINAL
GRAFT
485
Fig. 2 Figure Z-The
entire length of the jejunal wali is split longitudinally
and the lumen is opened.
Fig. 3 Figure 3.-Opened jejunum and mesentery are folded upon themselves and the cut edge of the jejunal wall which is closer to the mesentery is sutured transversely in two layers. The other edge is sutured at the end of the operation after revascularisation and complete haemostasis has been achieved.
BRITISH JOURNAL OF PLASTIC SURGERY
486
Fig. 4
Figure b-Reconstructed
cervical oesophagus. Tips of forceps indicate vascular anastomoses.
There are also several disadvantages such as dysphagia in some patients possibly due to persistent peristalsis, the need for special skills for a laparotomy, and a long operating time. Of these the first is the real problem. So far we have performed seven cases of reconstruction of the cervical oesophagus with aconventional free intestinal graft; all of them showed some degree of dysphagia and some of them required almost 1 hour to finish a meal of average size. The cause of this dysphagia has not yet been clarified (Meyers et al., 1980) but for a number of reasons we consider that peristalsis may play a significant role. First, dysphagia may exist even when a barium swallow shows smooth passage of contrast material through the reconstructed oesophagus, without stricture or diverticulum formation. Secondly, as soon as patients begin to eat one can observe active peristalsis beginning when a skin graft has been applied directly onto the intestinal serosa. Thirdly, some patients say that dyspha-
gia is worse when they take liquids than when they eat solid food. The technique we have described was developed to overcome this problem. Even after the intestine is split longitudinally peristalsis persists but contractions occur only along the hemicircumference of the reconstructed oesophagus and do not completely obliterate the intestinal lumen. Moreover, the reconstructed lumen is nearly double the original size so it is quite reasonable to expect that dysphagia should not occur. It is difficult to prove that this new method is better than the conventional technique but our limited clinical experience has been encouraging. We are also carrying out comparative studies on dogs which we hope to publish in due course. This technique has a few disadvantages compared with the conventional method of free jejunal transfer. These include a slightly longer operating time, slightly increased blood loss and a greater
RECONSTRUCTION
OF CERVICAL
OESOPHAGUS
WITH FREE
DOUBLE-FOLDED
INTESTINAL
487
GRAFT
before the intestinal graft was transferred to the neck wound. After release of the vascular clamps profuse bleeding occurred from inside the lumen and we were obliged to open it and search for the bleeding points. Since then we have felt it advisable to suture only one side wall, do the vascular anastomoses and control all bleeding points before the second side wall is sutured. The two patients on whom we have operated in this way have made uneventful recoveries.
Acknowledgement This work was supported Cancer Research (Y-23) Welfare.
in part by the Grant-in-Aid from the Ministry of Health
for and
References Harashina, T., Kakegawa, T., Imae, T. and Suguro, Y. ( 1981). Secondary reconstruction of oesophagus with free revascularised ileal transfer. British Juurnol [~~-Piu~~jc St~r~wy, 34, 17.
Meyers, W. C., Seigfer, Ii. F., Hanks, J. B., Thompson, W. M., Postlethwait, M. D., Jones, R. S., Akwari, 0. K. and Cole, T. B. (1980). Postoperative function of “free” jejunal transplants for replacement Surgwy. 192,439.
of the cervical
oesophagus.
Atznal.s of
Surkin, M. C., Lawson, W. and Biller, H. F. (1984). Analysis the methods of pharyn~oesophag~di utzd Neck Surgery, 6,953.
r~~ollstruction.
of Htwd
The Authors
Fig. 5 Figure S---Barium vical oesophagus.
study shows widely patent reconstructed
cer-
theoretical risk of leakage because of the long suture fines. In our first patient who had a haematemesis postoperatively, both side walls had been sutured and the lumen constructed on the table
Takao Harashina, MD, Associate Professor. Takeo Inoue, MD, Instructor. Chitoh Sugimoto, MD, Assistant Professor. Toyomi Fujino, MD, Professor. All of the Department of Plastic and Reconstructive Surgery, Keio llniversity School of Medicine Toshinobu Andoh, MD, Instructor, Department of General Surgery, Keio University School of Medicine. Tokyo. Japan. Requests for reprints to: Takao Harashina. MD. Department of Plastic and Reconstructive Surgery. Keio University School of Medicine, 35 Shinanomachi. Shinjuku-ku. Tokyo. 160. Japan.
Reconstruction of cervical oesophagus with free double-folded intestinal graft T. HARASHINA, Departments Tokyo
T. INOUE, T. ANDOH,
of Plastic and Reconstructive
C. SUGIMOTO
and T. FUJINO
Surgery and General Surgery, Keio University School of Medicine,
Summary-Reconstruction of cervical oesophagus with free revascularised small intestine is a reliable and effective technique but a common complication is dysphagia. This paper presents a method of splitting the wall of the intestine longitudinally, folding it and suturing it to double the size of the lumen of the reconstructed conduit and to abolish effective peristalsis. The method has proved to be useful in three clinical cases,
Developments in microvascular surgery have renewed interest in reconstructing the cervical oesophagus with free revascularised intestinal grafts and the procedure has proved to be reliable and effective (Harashina et al., 1981). However, the worst shortcoming of the technique is the resulting dysphagia which may be due to persistent peristalsis in the transplanted intestine. We have developed a new technique to avoid this complication. Operative method In primary reconstruction appropriate recipient vessels are identified and tagged after the pharyngolaryngo-oesophagectomy. In secondary reconstruction both stumps of the remaining oesophagus are exposed and freshened, and recipient vessels selected and prepared. The length of the defect in the cervical oesophagus is measured. Through an upper midline abdominal incision the jejunum is exposed and a segment is harvested which is nourished by one pair of jejunal vessels and is twice as long as the defect. The graft is placed on the table and the entire jejunal wall is split longitudinally along a line about halfway between the mesentery and antimesenteric border and the jejunal lumen is opened (Figs 1 and 2). The mucosal surface is cleaned with a mild antiseptic and the whole graft is washed with normal saline solution. The jejunal wall and mesentery are then folded upon themselves so that the mucosal surfaces face each other (Fig. 3). The cut edge of the jejunum which is closer to the mesentery is sutured in two layers. The transplant
is fixed in the neck wound
temporary sutures and the microvascular anastomoses are performed. After completion of the anastomoses and release of vascular clamps profuse bleeding occurs from the cut edges of the jejunal wall and all these bleeders are coagulated with the bipolar diathermy or underrun with sutures. The sutured jejunal edge is also carefully checked for bleeding. After haemostasis is complete the superior and inferior visceral anastomoses are performed. The inferior anastomosis between the transplanted jejunum and retained oesophageal stump can be performed with an EEA stapler. After both visceral anastomoses are completed a nasogastric tube is inserted and the still unsutured side wall is closed in two layers. When the skin wounds are closed it is advisable to leave a small window through which the colour of the transplanted intestine can be observed or the probe of a Doppler flowmeter can be applied directly to the serosal surface. If primary skin closure cannot be obtained due to skin flap shortage in secondary reconstruction. a split skin graft can be used directly on the serosa. Case reports Case 1. A 60-year-old male patient who had previously had reconstruction of his cervical oesophagus with a retrosternal colon interposition was diagnosed as having recurrence of cancer and had received 4000 rads of Co 60 therapy. After radiotherapy had proved ineffective he was scheduled for reconstruction of the cervical oesophagus with free revascularised intestinal transfer. He had already had four laparotomies and a segment of jejunum was harvested for free transfer with considerable difficulty. Reconstruction was performed as described except
with 483
BRITISH JQURNAI. OF PLASTIC SURGERY
Fig. 1
Figure i-The
harvested jejunum and mesentery with a single nutrient artery and
vein.A
dotted line shows the fine af *spiiti.ing.
Excess jejnnal wall and mesentery will be discarded.
that both side walls of the new oesophagus were sutured before the vascular anastomoses. His postoperative course was stormy due to septicaemia, transient lymphorroea from the neck wound and haematemesis 10 days after the surgery. Endoscupy showed that a baematoma had formed along the suture line in the newly reconstructed oesaphagus. It is now 7 months after the reconstruction and he can enjoy a normal diet freely. Curse2. A 70”year-old male patient who had already had a gastrectomy for gastric ulcer and a right upper lobectomy for lung cancer was diagnosed as having cancer of the hypopharynx and the remaining stomach. Caryngopharyngo-oesophagectomy combined with bilateral neck dissections and total gastrectumy were performed. Continuity of the abdominal digestive tract was restored with the Roux-en-Y method and the cervical oesophagus was reconstructed with a double-folded intestinal graft. He had an uneventfut recovery and was able to enjoy a normal diet 6 weeks after the reconstruction. Case 3. A 67”year-old male patient had previously undergone reconstruction of the cervical oesophagus with a
presternal colon swing procedure. Due to poor circulation the distal tip of the transferred colon necrosed, leaving a 10 cm oesophageal defect on the anterior chest. The deficient oesophagus was reconstructed with a daublefolded intestinal graft which measured I.5 cm long. A split skin graft was applied directly over the serosa to compensate for skin flap shortage. The transfer itself was successful but the patient cannot eat freely due to poor run-off of food through the raised colon and is being scheduled for further surgery.
Discussion Methods of reconstruction of the cervical oesophagus have been analyscd by Surkin ct al. (1984). The use of free, revascularised small intestine has a number of advantages over other methods; in particular it is a one stage procedure with a low incidence of anastomotic leak, fistula formation or stricture and involves minimal sacrifice of normally functioning tissue.
RECONSTRUCTION
OF CERVICAL
OESOPHAGUS
WITH
FREE DOUBLE-FOLDED
INTESTINAL
GRAFT
485
Fig. 2 Figure Z-The
entire length of the jejunal wali is split longitudinally
and the lumen is opened.
Fig. 3 Figure 3.-Opened jejunum and mesentery are folded upon themselves and the cut edge of the jejunal wall which is closer to the mesentery is sutured transversely in two layers. The other edge is sutured at the end of the operation after revascularisation and complete haemostasis has been achieved.
BRITISH JOURNAL OF PLASTIC SURGERY
486
Fig. 4
Figure b-Reconstructed
cervical oesophagus. Tips of forceps indicate vascular anastomoses.
There are also several disadvantages such as dysphagia in some patients possibly due to persistent peristalsis, the need for special skills for a laparotomy, and a long operating time. Of these the first is the real problem. So far we have performed seven cases of reconstruction of the cervical oesophagus with aconventional free intestinal graft; all of them showed some degree of dysphagia and some of them required almost 1 hour to finish a meal of average size. The cause of this dysphagia has not yet been clarified (Meyers et al., 1980) but for a number of reasons we consider that peristalsis may play a significant role. First, dysphagia may exist even when a barium swallow shows smooth passage of contrast material through the reconstructed oesophagus, without stricture or diverticulum formation. Secondly, as soon as patients begin to eat one can observe active peristalsis beginning when a skin graft has been applied directly onto the intestinal serosa. Thirdly, some patients say that dyspha-
gia is worse when they take liquids than when they eat solid food. The technique we have described was developed to overcome this problem. Even after the intestine is split longitudinally peristalsis persists but contractions occur only along the hemicircumference of the reconstructed oesophagus and do not completely obliterate the intestinal lumen. Moreover, the reconstructed lumen is nearly double the original size so it is quite reasonable to expect that dysphagia should not occur. It is difficult to prove that this new method is better than the conventional technique but our limited clinical experience has been encouraging. We are also carrying out comparative studies on dogs which we hope to publish in due course. This technique has a few disadvantages compared with the conventional method of free jejunal transfer. These include a slightly longer operating time, slightly increased blood loss and a greater
RECONSTRUCTION
OF CERVICAL
OESOPHAGUS
WITH FREE
DOUBLE-FOLDED
INTESTINAL
487
GRAFT
before the intestinal graft was transferred to the neck wound. After release of the vascular clamps profuse bleeding occurred from inside the lumen and we were obliged to open it and search for the bleeding points. Since then we have felt it advisable to suture only one side wall, do the vascular anastomoses and control all bleeding points before the second side wall is sutured. The two patients on whom we have operated in this way have made uneventful recoveries.
Acknowledgement This work was supported Cancer Research (Y-23) Welfare.
in part by the Grant-in-Aid from the Ministry of Health
for and
References Harashina, T., Kakegawa, T., Imae, T. and Suguro, Y. ( 1981). Secondary reconstruction of oesophagus with free revascularised ileal transfer. British Juurnol [~~-Piu~~jc St~r~wy, 34, 17.
Meyers, W. C., Seigfer, Ii. F., Hanks, J. B., Thompson, W. M., Postlethwait, M. D., Jones, R. S., Akwari, 0. K. and Cole, T. B. (1980). Postoperative function of “free” jejunal transplants for replacement Surgwy. 192,439.
of the cervical
oesophagus.
Atznal.s of
Surkin, M. C., Lawson, W. and Biller, H. F. (1984). Analysis the methods of pharyn~oesophag~di utzd Neck Surgery, 6,953.
r~~ollstruction.
of Htwd
The Authors
Fig. 5 Figure S---Barium vical oesophagus.
study shows widely patent reconstructed
cer-
theoretical risk of leakage because of the long suture fines. In our first patient who had a haematemesis postoperatively, both side walls had been sutured and the lumen constructed on the table
Takao Harashina, MD, Associate Professor. Takeo Inoue, MD, Instructor. Chitoh Sugimoto, MD, Assistant Professor. Toyomi Fujino, MD, Professor. All of the Department of Plastic and Reconstructive Surgery, Keio llniversity School of Medicine Toshinobu Andoh, MD, Instructor, Department of General Surgery, Keio University School of Medicine. Tokyo. Japan. Requests for reprints to: Takao Harashina. MD. Department of Plastic and Reconstructive Surgery. Keio University School of Medicine, 35 Shinanomachi. Shinjuku-ku. Tokyo. 160. Japan.