One superior thyroid arterywas carefully dissected. These techniques overcame some of the problems but created to preserve as much of the vessel as required ...
.4nnials of the Royal College of Surgeons of England (1983) vol. 65 ASPECTS OF TREATMENT*
Microvascular free jejunal transfer reconstruction following pharyngolaryngectomy J P BIRCHALL FRCSt Registrar
M HATTAB MIBChB Research .4ssistant
K PEARMAN FRCSt First Assistant
D B MATHIAS FRCS Consultant EXT Surgeon
M J M BLACK FRCS Consultant Plastic Surgeon
Departments of Otolaryngology and Plastic Surgery Royal Victoria Infirmary, Newcastle upon Tyne Key words: PHARY.NO()-LARYNGECTONIY; RECONSTRUCTION; FREE JEJUNAL GRAFT
Summary Case histories of six patients who underwent pharyngo-laryngectomy for hypopharyngeal carcinoma with jejunal microvascularfree transfer reconstruction are presented. The potential advantages of this technique over other reconstructive methods are discussed. Introduction Billroth and others carried out laryngectomies in the latter part of the nineteenth century. In the 1940's Wookey established the operation of pharyngo-laryngectomy with reconstruction (1). This suffered several major complica-
tions, namely, persistent salivary fistulae, delayed healing, necrosis of skin flaps and strictures. Reconstructive procedures involving either the use of stomach or large bowel were developed in the 1960's and are still in use today (2). These techniques overcame some of the problems but created others. Stomach pull-ups inevitably involve a high morbidity as a result of intra-thoracic manipulation and colonic pullups are hampered by the extent of the intra-abdominal surgery together with the presence of two intra-abdominal anastamoses.
In 1965 Bakamjian popularised the two-stage method of pharyngo-oesophageal reconstruction using a delto-pectoral skin flap (3). This operation was less traumatic than viscus repositioning but had two main drawbacks. Firstly it imposed definite limitations on the level of transection of the oesophagus below the lesion and, secondly, it was a two-stage procedure. Recent advances in microvascular surgical techniques in many centres throughout the world now permit the use of free jejunal and colonic transplants with microvascular anastomoses in the neck (4). This technique is a one-stage
tPresent appointment: ENT Senior Registrar, Addenbrookes Hospital, Cambridge. $ Present appointment: Consultant ENT Surgeon, East Birmingham Hospital.
procedure, less traumatic than pull-up operations and does not limit the lower end of the resection. This paper deals with the reconstructive techniques and does not dwell on the extirpative aspects of the surgery. The latter followed standard surgical principles and in no way differed from the accepted principles of surgery for malignant disease of the pharynx and larynx.
Operative technique All operations were performed under general anaesthesia. In all cases pharyngo-laryngectomy was performed through a 'U' flap with an infero-lateral extension across the posterior triangle if a radical neck dissection was to be performed. No modification of the radical nature of the cancer surgery was required. One superior thyroid artery was carefully dissected to preserve as much of the vessel as required to ensure a good anastomosis with the mesenteric artery. The artery being prepared was either on the opposite side to the neck dissection when performed or on the opposite side to the tumour. The distal end of the artery was closed and marked with a silver artery clip. A laparotomy was performed through a midline abdominal incision and a carefully measured length of proximal jejunum, with a suitable vascular arcade was selected. The bowel and its mesent-ery were divided and the resultant defect closed before separation of the excised jejunal segment from its blood supply. The isolated jejunal segment was then transferred to the neck and anastomosed to the cervical oesophagus in an isoperistaltic direction by means of a bowel anastomosis gun with a 26 mm diameter staple head. In each case ajejunal segment supplied by a single branch of the superior mesenteric artery with its accompanying vein was selected for resection. The arteries were approximately 3 mm in diameter and the veins 4 mm. Although there is a choice of recipient vessels, the superior thyroid artery and the external jugular vein were found to be most suitable and their diameters matched those of the donor vessels. The
The Editor would welcome any comments on this paper by readers Fellows and Members interested in submitting papers for consideration for publication should first write to the Editor
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J P Birchall, Al1 Hattab, K Pearman, D B Mathias, and M J M Black
TABLE. Summary oJ cases Case no.
Sex
.4ge
1
NIale
47
Larynx
Primary lesion
Primary treatment
Recurrence months
Resumption of oralfeeds
Discharged home
Radiotherapy 6600 cGys
36
15 days
4 weeks
days
4 weeks
21 days
5 weeks
days
2 weeks
2
F
emale
62
Post cricoid
Surgery
Nil
3
Female
55
Pyriform fossa
One
4
Female
56
5
Male
53
Larynx and pyriform fossa Larynx and pyriform fossa
Radiotherapy 6600cGvs Surgery Radiotherapy 6600 cGys
Nine
15 days
31 weeks
6
Female
63
Post cricoid
Six
12 days
10 weeks
Radiotherapy 6300cGvs
external jugular vein was divided superiorly and swung across to meet the donor vein after partial division of the belly of the sterno-mastoid muscle to prevent compression of the vein by the overlying skin flap. The vessels were carefully arranged to avoid tension, twisting or distortion. Using the operating microscope, the anastomosis was performed with interrupted 10/0 nylon on 75 micron needles. On completion of both anastomoses, the vessel clamps were released. No systemic antithrombotic agents were used other than routine preoperative Heparin (5000 units) subcutaneously. Total ischaemic times ranged from 1 hr 5 min to 1 h 40 min. At this stage, a naso-gastric tube was passed through the transposed bowel and into the stomach. The upper anastomosis was then fashioned in layers with continuous catgut for the mucosal layer and interrupted silk for the muscle layer. In cases 4 and 5 the upper anastomosis was made using the bowel anastomosis gun introduced through the mouth. The neck was closed in layers with suction drainage. In order to avoid any danger of the external jugular vein being compressed by tapes around the neck, laryngectomy tubes were secured with adhesive tape to the skin. Prophylactic antibiotics were given in all cases. All operations entailed a total thyroidectomy and, postoperatively, calcium gluconate was required. Clinical cases All six patients had squamous cell carcinomas, the sites are given in the Table. Four of the patients had primary radiotherapy with salvage surgery for recurrence. Where this included neck nodes a block dissection was also performed. Patient 1 could swallow normally until two weeks prior to death. Patient 2 had right-sided neck nodes at presentation. A block dissection was performed and postoperative radiotherapy given (4000 cGys). Patient 3 developed a salivary fistula which healed spontaneously. Patient 4 was given elective postoperative radiotherapy (6600cGys). Patient 5 had unilateral mobile neck glands. Radical neck dissection was performed. Patient 6 had a prolonged convalescence, in part due to dysphagia postoperatively. This was related to a malfunction of the bowel gun on the lower anastomosis. The stricture has been successfully treated with bouginage.
Discussion The five year survival rate of patients undergoing pharyngolaryngectomy for hypopharyngeal carcinoma is in the order of 20 to 300o (5). The operation cannot be regarded as curative. In addition, the patients are usually elderly and debilitated by months of inadequate food intake and the effiects of radiotherapy. Because of this, any method of surgical reconstruction should ideally combine the benefits of minimising operative morbidity and mortality while restoring normal swallowing rapidly. The reconstructive methods most commonly used at present are either repair by means of
Nil
11
11
Outcome Dead carotid rupture 6 months postoperatively Well at 18 months Well at 16 months Well at 18 months Dead neck recurrence 5 months postoperatively Well at 4 months postoperatively
delto-pectoral skin flaps or by transposition of an abdominal viscus. The former method, being staged, almost invariably means a lengthy stay in hospital for the patient, particularly if there are complications. The latter involves extensive abdominal, thoracic and neck surgery and inevitably carries a higher operative morbidity. The method of microvascular free jejunal transfer seems to have the advantages of both methods without their disadvantages (6). Although it necessitates a laparotomy, this is a much less extensive operation than mobilisation of a gastric or colonic pedicle and, because the graft is isolated, it is without the risks involved in passing a pedicled viscus through the thorax or subcutaneously. The vitality of the transposed jejunal segment appears to be good. Ischaemic times in the present series have ranged from I h 5 min to 1 h 40 min but in each case the grafts became flushed and resumed segmentation movements within thirty seconds of removal of the vascular clamps. Of the forty-three cases so far described in the world literature, there have been only three reports of necrosis of the transposed segment (7). In one of the cases who died, permission for post-mortem was given. The examination showed that the anastomosed vessels were still patent six months postoperatively (Fig.). Breakdown of the jejunum in the neck would be a very serious complication but the situation is at least potentially salvageable since a later stomach pull-up or skin flap reconstruction could be performed. One of the criticisms of skin flap reconstruction is the necessity of leaving an oesophageal stump long enough to be anastomosed to the skin flap. This could result in an inadequate margin of excision of postcricoid tumours which are prone to spread down the cervical oesophagus via submucosal lymphatics. The use of the bowel stapling gun in the present technique enables a jejunooesophageal anastomosis to be made much lower than would be possible by conventional suturing techniques, and there is no theoretical reason why the anastomosis should not be intra-thoracic. The mucosal layer of the oesophagus tends to retract down the oesophageal lumen and care must be taken to anchor this with sutures and it is imperative that an adequate purse string through all layers of the oesophageal wall be made around the obturator of the gun in order to make a leakproof anastomosis. By contrast, the upper anastomosis is technically easier, asjejunal mucosa tends to evert when cut and may need to be trimmed. The distensible nature of the jejunum makes it possible to match its size to that of the oropharynx without difficulty. The length used must be accurately measured to avoid a long redundant loop. In the present series there has been no case of permanent stenosis at the lower anastomosis. A survey of the literature shows no case elsewhere where this has occurred. Perfusion of the transplant appears unnecessary and has not been performed in any of the present series. It is our routine to administer Heparin 5000 units subcutaneously to all patients undergoing head and neck surgery.
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Microvascular free jejunal transfer reconstruction References
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211
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FIG. The photomicrograph shows the patent mesenteric artery and vein from a post-mortem specimen six months postoperatively. (x 150).
Of the surviving patients in the present series, two have developed very limited alaryngeal speech. Six of McKee and Peters' cases did develop good oesophageal speech and if this experience is repeated in larger numbers of cases it will represent a considerable improvement over previous reconstructive measures (8).
I Wookey H. The surgical treatment of carcinoma of the pharynx and upper oesophagus. Surg Gynaecol Obstet 1942; 75:499-506. 2 Ranger D. Visceral replacement after laryngo-pharyngectomy. J Laryngol Otol 1971 ;5:1218-21. 3 Bakamjian VY. A two-stage method for pharyngoesophageal reconstruction with a primary pectoral skin flap. Plast Reconstr Surg 1965;36: 173-84 4 Hester RT, McConnel FMS, Nahai F, Jurkiewicz MJ, Brown RG. Reconstruction of cervical Esophagus, hypopharynx and oral cavity using free jejunal transfer. Am J Surg 1980;140: 487-91. 5 Slaney G, Dalton GA. Problems of viscus replacement following pharyngo-laryngectomy. J. Laryngol Otol 1973;87:539-46. 6 Roberts RE, Douglass FM. Replacement of the cervical esophagus and hypopharynx by a revascularised free jejunal autograft. N Eng J Med 1961 ;264:342-4. 7 Nakamura T, Inokuchi K, Sugimachi K. Use a revascularised jejunum as a free graft for cervical esophagus. Japanese Journal of Surgery 1975;5:92-102. 8 McKee DM, Peters CR. Reconstruction of the hypopharynx and cervical esophagus with microvascular jejunal transplant. Clin Plast Surg 1978;5:305-12.
We would like to thank Dr J H McCarthy for his help and Mrs A Jenkin for typing the manuscript.
Sir Alan Parks Memorial Fund A further notice about this Fund will be found in the College and Faculty news section of this month's Annals. It is hoped that all readers will wish to study this and to contribute towards a Fund that is designed to commemorate a great surgeon and distinguished President.
