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Reconstruction of the Defect of the Oropharynx Using Free Jejunum
A uris . Nasus· Larynx (Tokyo) 12 (Suppl. lI) S J-S 4, 1985
RECONSTRUCTION OF THE DEFECT OF THE OROPHARYNX USING FREE JEJUNUM Masatoshi HORIUCHI, M.D., Hirosato MIYAKE, M.D., and Takao HARASHINA, M.D.* Department of Otolaryngology. Tokai University, /sehara, 259-11 Japan *Department of Plastic Surgery, Keio University, Tokyo, 160 Japan
Reconstruction of oropharyngeal defect using free jejunum was carried out in two patients with selected situation. One patient had problem of donor site, which was developed breast. Another patient had problem ofrecipient site, which required the flap with thin subcutaneous tissue. Reconstruction with free jejunal transfer was successful in both cases. The major advantage of the free jejunal transfer for oropharyngeal defects was discussed in comparison with cutaneous flaps. In conclusion this safety procedure is recommended for reconstruction of oropharyngeal defect.
Reconstruction of the oropharyngeal defects after cancer surgery is major problem of the head and neck oncology. Recent development of reconstructive technique with cutaneous flaps produced the possibility of wide resection of the advanced cancer and elevation of the curability. During last decade after Bakamjian, pedicle cutaneous flaps as deltopectolar or pectolaris major flap were most useful method of reconstructive surgery for defects of the head and neck. Recent reports described the disadvantage of conventional skin flaps. Second deformity of the donor site, bulky mass and difficulty in the woman with developed breast were the problem of the skin flap (ARIAN, 1980; SOUTAR et al., 1983; FABIAN, 1984). Patient with selected situation may be required one of other than the conventional pedicle skin flap. This is a case report of two cases of clinical experiment with free jejunal transfer for oropharyngeal reconstruction.
Material and Method Materials of this study were patients with advanced oropharyngeal cancer. One-stage primary reconstruction of large defects of oropharynx carried out after radical surgery. The microvascular flap transfer of the free jejunum was used as tissue for reconstruction of the oropharyngeal defects (GLUCKMAN et al., 1981; MCCONNEL et al., 1981; REUTHER et aI., 1984). Two-team approach was used. The patient underwent resection of the primary lesion with neck dissection by extirpation team. The segment of jejunum was removed at the time just before completion of en bloc operation of the head and neck (Fig. 1). An incision was made on anti mesenteric border of the bowel. Careful preparation of identified donor vessel and triming was performed. Jejunal loop was sutured side by side for making wide mucosal flap (Fig. 2). Ischemic period should be as short as possible. Perfusion of donor vessel was not used. Anastomosis of vessels between donor flap and recipient tissue was done initially (Fig. 3). The anastomosis was carried out using a Zeiss microscope and vascular clamps. Fine monofilament of nylon 9-0 was used for anastomosis. Case Report Case I: First case was 44-year-old woman who presented with sore throat and difficulty of the swallowing. Workup revealed a large tumor of base of tongue invading into tonsil fossa and epiglottis. Nodal metastasis was found in both side of the neck. Our choice of treatment was surgery with total
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Fig. 1. The segment of jejunum was removed.
Fig. 3. Anastomosis of vessel between donor flap and recipient tissue.
Fig. 2. Jejunal loop was sutured side by side for making wide mucosal flap.
glossectomy and laryngectomy with bilateral neck dissection and then immediate reconstruction of the defect. A problem of this patient was selection of the donor site for reconstruction. Because she had developed large breast, usual preparation of pectoralis major flap will be difficult. Free jejunal transfer was recommended. Case 2: Second case was 54-year-old man, who visited hospital with complaint of the neck mass. Workup revealed cancer of the posterior wall of the oropharynx and bilateral cervical metastasis. This patient received induction chemotherapy with cisplatin and bleomycin. Response to chemotherapy was poor, then surgical treatment was recommended. The partial pharyngeal resection
Fig. 4. Revascularized jejunal flap was sutured with pharyngeal mucosa.
and bilateral neck dissection was considered as curative modality. Problem of this patient was preservation of laryngeal function after radical surgery. For this purpose the flap without bulky mass was indicated. Conventional pectolaris major flap may not be suitable for this situation. Free jejunal transfer was recommended. Results Free jejunal transfer into oropharynx was carried out in two cancer patients. The large defects of oral cavity and pharynx were able to be covered without any tension or
M. HORIUCHI et al.
Fig. 5. Case 1: Tongue-like jejunal graft was placed into the defect of oral cavity.
Fig. 6. Case 2: Jejunal flap in oropharynx at I year after surgery.
dead space. A bulky mass of mesenteric fat was filled up into the space under mandibular arc. The revascularized jejunal flap was sutured with pharyngeal mucosa (Fig. 4). The technique of suturing was easy even in this complicated area. Vessels of recipient side were internal jugular vein of opposite side and external carotid artery in the first case. In the second case transverse cervical artery and external jugular vein were used. On fifth postoperative day free flap adapted well in the new locations. No complication was presented in both donor site and recipient site. Tongue-like jejunal graft was placed into the defect of case I (Fig. 5). Oral alimentation was possible on 14th postoperative day. She could take liquid of 2 liter per day, being able to keep good nutritional condition and body weight. Postoperative radiotherapy began on 4 weeks after surgery. Excellent tolerance of radiotherapy was observed. Recurrent disease was found in pri-
S3
mary and lung within half year. Those were not controlled. The laryngeal function was preserved in second case. His tracheostoma was closed 10 days postoperatively. Oral alimentation was started on 14th postoperative day. But he complained aspiration during swallowing of liquid food . His vocal cords did not paralysed. On 4 weeks after operation he had no episode of aspiration. This patient received postoperative radiotherapy of dose of 5,000 rad. Treatment completed without any complication. This patient is alive without evidence of disease for one year follow-up period. Figure 6 shows recent picture of his oropharynx. Comment Reconstruction of oropharyngeal defects using free jejunum was carried out in two patients with selected situation. One patient had problem of doner site, which was developed breast. Another patient had problem of recipient site, which required the flap with thin subcutaneous tissue. Reconstruction with free jejunal transfer was preferable to those patients with special situation. Recent development of reconstructive surgery makes the possibility of the wide selection of the donor tissue and its surgical modality. Advantage and disadvantage of those flap and surgical technique were described in recent reports. Selection of the flaps should be dependent on situation of the patient. The major advantages of the free jejunal transfer for oropharyngeal defects should be determined by comparison with other surgical modalities. Free jejunal transfer is onestage surgical procedure that is performed at the time of major resection. Excellent vascular supply leads rapid wound healing of flap even in complicated anatomical site. Postoperative radiotherapy, if indicated, can be started at early time after surgery. No significant complication was found in jejunal graft of our series. Donor site for reconstruction of posterior wall of oropharynx should be provided with
S4
M. HORIUCHI et al.
thin subcutaneous tissue. Bulky pectolaris major may not be suitable for cases with this situation of reconstruction. The dorsalis pedis flap or fore arm chinese flap can be useful (ACLAND and FLYNN, 1978; SOUTAR et al., 1983). For those flaps also microvascular technique is necessary. Myocutaneous flaps and free cutaneous flaps had problem of the deformity of donor site. Free jejunal transfer technique does not make large defect of the body surface. It does not lead cosmetic problems. At the abdominal surgery no complications were observed. Free jejunal transfer is a safety procedure. We recommend this modality for reconstruction of oropharyngeal defect after cancer surgery. References ACLAND, R.D., and FLYNN, M.B.: Immediate reconstruction of oral cavity and oropharyngeal defect using microvascular free flaps. Am. J. Surg. 136: 419-423, 1978.
ARIAN, S.: Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck reconstruction. Clin. Piast. Surg. 7: 89-109, 1980. FABIAN, R.L.: Reconstruction of the laryngopharynx and cervical esophagus. Laryngoscope 94: 1334-1350, 1984. GLUCKMAN, J.L., McDONOUGH, J., OLIVER DONEGAN, J., CRISSMAN, J.D., FULLEN, W., and SHUNRICK, D.A.: The free jejunal graft in head and neck reconstruction. Laryngoscope 91: 1887-1894, 1981. MCCoNNEL, F.M.S., HESTER, T.R., NAHAl, F., JURKIEWICZ, M.J., and BROWN, R.G.: Free jejunal grafts for reconstruction of pharynx and cervical esophagus. Arch. Otolaryngol. 107: 476--481, 1981. REUTHER, J.F., STEINAU, H.U., and WAGNER, R.: Reconstruction of large defects in the oropharynx with a revascularized intestinal graft: An experimental and clinical report. Plast. Reconstr. Surg. 73: 345-358, 1984. SOUTAR, D.S., SCHEKER, L.R., TANNER, N.S.B., and MCGREGOR, LA.: The radial forearm flap: a versatile method for intraoral reconstruction. Br. J. Piast. Surg. 36: 1-8, 1983.
RECONSTRUCTION OF THE DEFECT OF THE OROPHARYNX USING FREE JEJUNUM Masatoshi HORIUCHI, M.D., Hirosato MIYAKE, M.D., and Takao HARASHINA, M.D.* Department of Otolaryngology. Tokai University, /sehara, 259-11 Japan *Department of Plastic Surgery, Keio University, Tokyo, 160 Japan
Reconstruction of oropharyngeal defect using free jejunum was carried out in two patients with selected situation. One patient had problem of donor site, which was developed breast. Another patient had problem ofrecipient site, which required the flap with thin subcutaneous tissue. Reconstruction with free jejunal transfer was successful in both cases. The major advantage of the free jejunal transfer for oropharyngeal defects was discussed in comparison with cutaneous flaps. In conclusion this safety procedure is recommended for reconstruction of oropharyngeal defect.
Reconstruction of the oropharyngeal defects after cancer surgery is major problem of the head and neck oncology. Recent development of reconstructive technique with cutaneous flaps produced the possibility of wide resection of the advanced cancer and elevation of the curability. During last decade after Bakamjian, pedicle cutaneous flaps as deltopectolar or pectolaris major flap were most useful method of reconstructive surgery for defects of the head and neck. Recent reports described the disadvantage of conventional skin flaps. Second deformity of the donor site, bulky mass and difficulty in the woman with developed breast were the problem of the skin flap (ARIAN, 1980; SOUTAR et al., 1983; FABIAN, 1984). Patient with selected situation may be required one of other than the conventional pedicle skin flap. This is a case report of two cases of clinical experiment with free jejunal transfer for oropharyngeal reconstruction.
Material and Method Materials of this study were patients with advanced oropharyngeal cancer. One-stage primary reconstruction of large defects of oropharynx carried out after radical surgery. The microvascular flap transfer of the free jejunum was used as tissue for reconstruction of the oropharyngeal defects (GLUCKMAN et al., 1981; MCCONNEL et al., 1981; REUTHER et aI., 1984). Two-team approach was used. The patient underwent resection of the primary lesion with neck dissection by extirpation team. The segment of jejunum was removed at the time just before completion of en bloc operation of the head and neck (Fig. 1). An incision was made on anti mesenteric border of the bowel. Careful preparation of identified donor vessel and triming was performed. Jejunal loop was sutured side by side for making wide mucosal flap (Fig. 2). Ischemic period should be as short as possible. Perfusion of donor vessel was not used. Anastomosis of vessels between donor flap and recipient tissue was done initially (Fig. 3). The anastomosis was carried out using a Zeiss microscope and vascular clamps. Fine monofilament of nylon 9-0 was used for anastomosis. Case Report Case I: First case was 44-year-old woman who presented with sore throat and difficulty of the swallowing. Workup revealed a large tumor of base of tongue invading into tonsil fossa and epiglottis. Nodal metastasis was found in both side of the neck. Our choice of treatment was surgery with total
S2
M. HORIUCHI et al.
Fig. 1. The segment of jejunum was removed.
Fig. 3. Anastomosis of vessel between donor flap and recipient tissue.
Fig. 2. Jejunal loop was sutured side by side for making wide mucosal flap.
glossectomy and laryngectomy with bilateral neck dissection and then immediate reconstruction of the defect. A problem of this patient was selection of the donor site for reconstruction. Because she had developed large breast, usual preparation of pectoralis major flap will be difficult. Free jejunal transfer was recommended. Case 2: Second case was 54-year-old man, who visited hospital with complaint of the neck mass. Workup revealed cancer of the posterior wall of the oropharynx and bilateral cervical metastasis. This patient received induction chemotherapy with cisplatin and bleomycin. Response to chemotherapy was poor, then surgical treatment was recommended. The partial pharyngeal resection
Fig. 4. Revascularized jejunal flap was sutured with pharyngeal mucosa.
and bilateral neck dissection was considered as curative modality. Problem of this patient was preservation of laryngeal function after radical surgery. For this purpose the flap without bulky mass was indicated. Conventional pectolaris major flap may not be suitable for this situation. Free jejunal transfer was recommended. Results Free jejunal transfer into oropharynx was carried out in two cancer patients. The large defects of oral cavity and pharynx were able to be covered without any tension or
M. HORIUCHI et al.
Fig. 5. Case 1: Tongue-like jejunal graft was placed into the defect of oral cavity.
Fig. 6. Case 2: Jejunal flap in oropharynx at I year after surgery.
dead space. A bulky mass of mesenteric fat was filled up into the space under mandibular arc. The revascularized jejunal flap was sutured with pharyngeal mucosa (Fig. 4). The technique of suturing was easy even in this complicated area. Vessels of recipient side were internal jugular vein of opposite side and external carotid artery in the first case. In the second case transverse cervical artery and external jugular vein were used. On fifth postoperative day free flap adapted well in the new locations. No complication was presented in both donor site and recipient site. Tongue-like jejunal graft was placed into the defect of case I (Fig. 5). Oral alimentation was possible on 14th postoperative day. She could take liquid of 2 liter per day, being able to keep good nutritional condition and body weight. Postoperative radiotherapy began on 4 weeks after surgery. Excellent tolerance of radiotherapy was observed. Recurrent disease was found in pri-
S3
mary and lung within half year. Those were not controlled. The laryngeal function was preserved in second case. His tracheostoma was closed 10 days postoperatively. Oral alimentation was started on 14th postoperative day. But he complained aspiration during swallowing of liquid food . His vocal cords did not paralysed. On 4 weeks after operation he had no episode of aspiration. This patient received postoperative radiotherapy of dose of 5,000 rad. Treatment completed without any complication. This patient is alive without evidence of disease for one year follow-up period. Figure 6 shows recent picture of his oropharynx. Comment Reconstruction of oropharyngeal defects using free jejunum was carried out in two patients with selected situation. One patient had problem of doner site, which was developed breast. Another patient had problem of recipient site, which required the flap with thin subcutaneous tissue. Reconstruction with free jejunal transfer was preferable to those patients with special situation. Recent development of reconstructive surgery makes the possibility of the wide selection of the donor tissue and its surgical modality. Advantage and disadvantage of those flap and surgical technique were described in recent reports. Selection of the flaps should be dependent on situation of the patient. The major advantages of the free jejunal transfer for oropharyngeal defects should be determined by comparison with other surgical modalities. Free jejunal transfer is onestage surgical procedure that is performed at the time of major resection. Excellent vascular supply leads rapid wound healing of flap even in complicated anatomical site. Postoperative radiotherapy, if indicated, can be started at early time after surgery. No significant complication was found in jejunal graft of our series. Donor site for reconstruction of posterior wall of oropharynx should be provided with
S4
M. HORIUCHI et al.
thin subcutaneous tissue. Bulky pectolaris major may not be suitable for cases with this situation of reconstruction. The dorsalis pedis flap or fore arm chinese flap can be useful (ACLAND and FLYNN, 1978; SOUTAR et al., 1983). For those flaps also microvascular technique is necessary. Myocutaneous flaps and free cutaneous flaps had problem of the deformity of donor site. Free jejunal transfer technique does not make large defect of the body surface. It does not lead cosmetic problems. At the abdominal surgery no complications were observed. Free jejunal transfer is a safety procedure. We recommend this modality for reconstruction of oropharyngeal defect after cancer surgery. References ACLAND, R.D., and FLYNN, M.B.: Immediate reconstruction of oral cavity and oropharyngeal defect using microvascular free flaps. Am. J. Surg. 136: 419-423, 1978.
ARIAN, S.: Pectoralis major, sternomastoid, and other musculocutaneous flaps for head and neck reconstruction. Clin. Piast. Surg. 7: 89-109, 1980. FABIAN, R.L.: Reconstruction of the laryngopharynx and cervical esophagus. Laryngoscope 94: 1334-1350, 1984. GLUCKMAN, J.L., McDONOUGH, J., OLIVER DONEGAN, J., CRISSMAN, J.D., FULLEN, W., and SHUNRICK, D.A.: The free jejunal graft in head and neck reconstruction. Laryngoscope 91: 1887-1894, 1981. MCCoNNEL, F.M.S., HESTER, T.R., NAHAl, F., JURKIEWICZ, M.J., and BROWN, R.G.: Free jejunal grafts for reconstruction of pharynx and cervical esophagus. Arch. Otolaryngol. 107: 476--481, 1981. REUTHER, J.F., STEINAU, H.U., and WAGNER, R.: Reconstruction of large defects in the oropharynx with a revascularized intestinal graft: An experimental and clinical report. Plast. Reconstr. Surg. 73: 345-358, 1984. SOUTAR, D.S., SCHEKER, L.R., TANNER, N.S.B., and MCGREGOR, LA.: The radial forearm flap: a versatile method for intraoral reconstruction. Br. J. Piast. Surg. 36: 1-8, 1983.