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Ninety-Degree Transposed Free Jejunal Patch Transfer for Hypopharyngeal Reconstruction following Partial Hypopharyngectomy

Okazaki, Mutsumi M.D.; Asato, Hirotaka M.D.; Sarukawa, Shunji M.D.; Okochi, Masayuki M.D.; Suga, Hirotaka M.D.

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Plastic and Reconstructive Surgery: November 2008 - Volume 122 - Issue 5 - p 143e-144e
doi: 10.1097/PRS.0b013e318186ca8a
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Sir:

Noncircumferential hypopharyngeal defects following partial hypopharyngectomy with preservation of the larynx have been reconstructed with free jejunal patch grafts or forearm flaps.1–3 Conventionally, the free jejunal patch graft was transferred in an isoperistaltic fashion (Fig. 1), but pooling of food was occasionally seen because of the peristaltic constriction and circular folds of the jejunum. To overcome this disadvantage, we transferred the jejunal patch in a 90-degree transposed fashion, positioning the oral side of the jejunum in correspondence with the anterior side of the defect (Figs. 1 and 2).

Fig. 1.
Fig. 1.:
Illustrations of the conventional method (below) and our new procedure (above).
Fig. 2.
Fig. 2.:
Intraoperative view of a 64-year-old man with a hypopharyngeal cancer arising on the right pyriform sinus. When the jejunal patch was sutured to the posterior, oral, and anal sides of the hypopharyngeal defect, the mucosal folds extended from the oral to anal sides vertically as the jejunal patch was set in the 90-degree transposed fashion.

Between August of 2004 and January of 2006, six patients underwent free jejunal patch transfer using our new procedure at the University of Tokyo Hospital. This was the study group and consisted of six men aged 57 to 64 years (average, 60 years). Before this term, seven patients underwent the operation with the conventional method. This was the control group and consisted of one woman and six men aged 50 to 75 years (average, 63 years). During cancer ablation, the superior laryngeal nerve was cut, although the recurrent nerve was preserved. The validity of our new procedure was assessed compared with our conventional method based on the time required for initiation of oral intake and swallow function (presence of pooling and misswallowing) at the time when the edema of the jejunal flap resolved.

On the first videofluorographic study performed on postoperative day 10, pooling of contrast medium was noted in no patients in the study group and in five of seven patients in the control group. The patients in the study group achieved oral intake 6 days earlier on average than patients in the control group. As a result, all six patients in the study group achieved adequate oral intake, with rare dysphagia or regurgitation (Fig. 3), whereas in the control group, five of seven patients had dysphagia or regurgitation to some extent.

Fig. 3.
Fig. 3.:
Videofluorographic study performed 3 months postoperatively shows smooth passage without misswallowing or pooling of contrast medium (same patient as shown in Fig. 2).

Reconstruction with the radial forearm flap has the advantage of not requiring celiotomy; however, it leaves an ugly scar on the forearm. Furthermore, patients who have undergone reconstruction with the forearm flap often complain of swallowing difficulties and often need the aid of liquids to swallow foods smoothly.1 The jejunal patch graft, in contrast, has the advantages of having a wet mucosal surface with early wound healing and less scar contracture, allowing the remaining pharynx to move physiologically during swallowing. Although our new procedure is merely a directional alteration of the graft, a disadvantage of the conventional jejunal patch graft can be overcome. In the study group, misswallowing was noted in two patients on the first videofluorographic study and was probably caused by swelling of the jejunal graft (confirmed by the endoscopic study). However, in our experience, misswallowing can be overcome when the flap edema has resolved, although pooling of food persists. Regarding early-stage hypopharyngeal cancer, radiotherapy is effective for preservation of speech and swallowing function.4 However, partial hypopharyngectomy with preservation of the larynx is one of the options for localized cancer.1–3,5 We believe that our procedure is one of the suitable options for reconstruction of noncircumferential hypopharyngeal defects following the partial pharyngectomy, provided the patient’s general condition permits celiotomy.

Mutsumi Okazaki, M.D.

Department of Plastic and Reconstructive Surgery

Kyorin University

Tokyo, Japan

Hirotaka Asato, M.D.

Department of Plastic and Reconstructive Surgery

Dokkyo University School of Medicine

Tochigi, Japan

Shunji Sarukawa, M.D.

Division of Plastic and Reconstructive Surgery

Jichi Medical School

Tochigi, Japan

Masayuki Okochi, M.D.

Hirotaka Suga, M.D.

Department of Plastic and Reconstructive Surgery

Graduate School of Medicine

University of Tokyo

Tokyo, Japan

REFERENCES

1. Nakatsuka, T., Harii, K., Ueda, K., et al. Preservation of the larynx after resection of a carcinoma of the posterior wall of the hypopharynx: Versatility of a free flap patch graft. Head Neck 19: 137, 1997.
2. Disa, J. J., Pusic, A. L., Hidalgo, D. A., and Cordeiro, P. G. Microvascular reconstruction of the hypopharynx: Defect classification, treatment algorithm, and functional outcome based on 165 consecutive cases. Plast. Reconstr. Surg. 111: 652, 2003.
3. Schwager, K., Hoppe, F., Hagen, R., and Brunner, F. X. Free-flap reconstruction for laryngeal preservation after partial laryngectomy in patients with extended tumors of the oropharynx and hypopharynx. Eur. Arch. Otorhinolaryngol. 256: 280, 1999.
4. Lefebvre, J. L., Chevalier, D., Luboinski, B., Kirkpatrick, A., Collette, L., and Sahmoud, T. Larynx preservation in pyriform sinus cancer: Preliminary results of a European Organization for Research and Treatment of Cancer phase III trial. EORTC Head and Neck Cancer Cooperative Group. J. Natl. Cancer Inst. 88: 890, 1996.
5. Spiro, R. H., Kelly, J., Vega, A. L., Harrison, L. B., and Strong, E. W. Squamous carcinoma of the posterior pharyngeal wall. Am. J. Surg. 160: 420, 1990.

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