Double Vascular Anastomosis for Safer Free Jejunal Transfer in Unfavorable Conditions

ABSTRACT

Free jejunum was transferred to a patient with recurrent hypopharyngeal carcinoma under unfavorable cervical conditions, caused by prior therapeutic chemoradiotherapy for hypopharyngeal carcinoma and gastric pull-up with cervical leak, resulting from treatment for thoracic esophageal cancer. The cervical recipient vessels were buried in extensively scarred fibrous tissues, so they were thought to be less reliable. Because postoperative vascular occlusion was anticipated, in addition to the ordinary single vascular anastomosis to the damaged cervical vessels, secondary vascular anastomosis to the healthy chest vessels was performed. We designed the graft to have double vascular pedicles that communicated with each other through arcade vessels. This made it possible to anastomose doubly to an intact thoracoacromial artery in the chest by elongating the vascular pedicles of the mesentery without the need for an interpositional vein graft, in addition to ordinary anastomosis in the damaged neck. The flap is nourished by the vessels from two different origins (carotid and axillary arteries, internal jugular and axillary veins) at two different places (damaged and healthy areas). This method increases the quantity of feeding vessels while improving the quality of the recipient vessels within the local area and flow sources. It is one treatment option when conditions are unfavorable for safer jejunal transfer.

KEYWORDS

Thoracoacromial artery - cephalic vein - radiation - microsurgery - head and neck reconstruction

REFERENCES

• 1 Reece G P, Bengtson B P, Schusterman M A. Reconstruction of the pharynx and cervical esophagus using free jejunal transfer.  Clin Plast Surg. 1994;  21 125-136
• 2 Sarukawa S, Sakuraba M, Kimata Y et al.. Standardization of free jejunum transfer after total pharyngolaryngoesophagectomy.  Laryngoscope. 2006;  116 976-981
• 3 Booi D I, Debats I BJG, Boeckx W D, van der Hulst R RWJ. Risk factors and blood flow in the free transverse rectus abdominis (TRAM) flap: smoking and high flap weight impair the free TRAM flap microcirculation.  Ann Plast Surg. 2007;  59 364-371
• 4 Temple C L, Strom E A, Youssef A, Langstein H N. Choice of recipient vessels in delayed TRAM flap breast reconstruction after radiotherapy.  Plast Reconstr Surg. 2005;  115 105-113
• 5 Sarukawa S, Asato H, Okazaki M, Nakatsuka T, Takushima A, Harii K. Clinical evaluation and morbidity of 201 free jejunal transfers for oesophagopharyngeal reconstruction during the 20 years 1984–2003.  Scand J Plast Reconstr Surg Hand Surg. 2006;  40 148-152
• 6 Mulholland S, Boyd J B, McCabe S et al.. Recipient vessels in head and neck microsurgery: radiation effect and vessel access.  Plast Reconstr Surg. 1993;  92 628-632
• 7 Nahabedian M Y, Singh N, Deune E G, Silverman R, Tufaro A P. Recipient vessel analysis for microvascular reconstruction of the head and neck.  Ann Plast Surg. 2004;  52 148-155 discussion 156-7
• 8 Nasso G, Canosa C, De Filippo C M et al.. Thoracic radiation therapy and suitability of internal thoracic arteries for myocardial revascularization.  Chest. 2005;  128 1587-1592
• 9 Schulman H E, Korr K S, Myers T J. Left internal thoracic artery graft occlusion following mediastinal radiation therapy.  Chest. 1994;  105 1881-1882
• 10 Chang L D, Buncke G, Slezak S, Buncke H J. Cigarette smoking, plastic surgery, and microsurgery.  J Reconstr Microsurg. 1996;  12 467-474
• 11 Okazaki M, Asato H, Sarukawa S, Takushima A, Nakatsuka T, Harii K. Availability of end-to-side arterial anastomosis to the external carotid artery using short-thread double-needle microsuture in free-flap transfer for head and neck reconstruction.  Ann Plast Surg. 2006;  56 171-175
• 12 Jose B, Banis J, Flynn M et al.. Irradiation and free tissue transfer in head and neck cancer.  Head Neck. 1991;  13 213-216
• 13 Urken M L, Weinberg H, Buchbinder D et al.. Microvascular free flaps in head and neck reconstruction: report of 200 cases and review of complications.  Arch Otolaryngol Head Neck Surg. 1994;  120 633-640
• 14 Nakatsuka T, Harii K, Asato H et al.. Analytic review of 2372 free flap transfers for head and neck reconstruction following cancer resection.  J Reconstr Microsurg. 2003;  19 363-368 discussion 369
• 15 Numajiri T, Fujiwara T, Nishino K et al.. Clinical evaluation of free jejunal transfer for esophagopharyngeal reconstruction.  , [in Japanese] J Kyoto Pref Univ Med. 2007;  116 559-565
• 16 Salgado C J, Smith A, Kim S et al.. Effects of late loss of arterial inflow on free flap survival.  J Reconstr Microsurg. 2002;  18 579-584
• 17 McDonough J J, Gluckman J L. Microvascular reconstruction of the pharyngoesophagus with free jejunal graft.  Microsurgery. 1988;  9 116-127
• 18 Sidorov V B, Minachenko V K, Rekhter M D, Pshenisnov K P, Mironov A A, Bauman O A. The influence of radiotherapy and chemotherapy on regeneration at arterial microanastomoses: an experimental and clinical study.  Ann Plast Surg. 1994;  32 45-51
• 19 Bengtson B P, Schusterman M A, Baldwin B J et al.. Influence of prior radiotherapy on the development of postoperative complications and success of free tissue transfers in head and neck cancer reconstruction.  Am J Surg. 1993;  166 326-330
• 20 Seidenberg B, Rosenak S S, Hurwitt E S, Som M L. Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment.  Ann Surg. 1959;  149 162-171
• 21 McKee D M, Peters C R. Reconstruction of the hypopharynx and cervical esophagus with microvascular jejunal transplant.  Clin Plast Surg. 1978;  5 305-312
• 22 Hester T R, McConnel F M, Nahal F, Jurkiewicz M J, Brown R G. Reconstruction of cervical esophagus, hypopharynx and oral cavity using free jejunal transfer.  Am J Surg. 1980;  140 487-491
• 23 Chang T S, Hwang O L, Wang-Wei . Reconstruction of esophageal defects with microsurgically revascularized jejunal segments: a report of 13 cases.  J Microsurg. 1980;  2 83-94
• 24 Inoue Y, Tai Y, Fujita H et al.. A retrospective study of 66 esophageal reconstructions using microvascular anastomoses: problems and our methods for atypical cases.  Plast Reconstr Surg. 1994;  94 277-284 discussion 285-7
• 25 Tan E, O'Brien B M, Brennen M. Free flap transfer in rabbits using irradiated recipient vessels.  Br J Plast Surg. 1978;  31 121-123
• 26 Cunningham B L, Shons A R. Free flap transfers in rats using an irradiated recipient site.  Br J Plast Surg. 1979;  32 137-140
• 27 Renner S M, Massel D, Moon B C. Mediastinal irradiation: a risk factor for atherosclerosis of the internal thoracic arteries.  Can J Cardiol. 1999;  15 597-600
• 28 Reece G P, Schusterman M A, Miller M J et al.. Morbidity and functional outcome of free jejunal transfer reconstruction for circumferential defects of the pharynx and cervical esophagus.  Plast Reconstr Surg. 1995;  96 1307-1316
• 29 Germain M A, Hartl D M, Boutin P, Marandas P, Luboinski B. Total esophagoplasty using a doubly vascularized free jejunal transplant: a last resort in two patients.  Plast Reconstr Surg. 2003;  111 801-804
• 30 Takushima A, Momosawa A, Asato H, Aiba E, Harii K. Double vascular pedicled free jejunum transfer for total esophageal reconstruction.  J Reconstr Microsurg. 2005;  21 5-10
• 31 Ueda K, Kajikawa A, Suzuki Y, Hirose T. The standard technique of the free jejunal transfer for the reconstruction of the cervical esophagus.  , [in Japanese] Jpn J Plast Surg. 2004;  47 1187-1194
• 32 Harii K. Reconstruction of the cervical esophagus with a vascularized free intestinal transport.  , [in Japanese] Jpn J Gastroenterol Surg. 1991;  24 2303-2307
• 33 Sekido M, Yamamoto Y, Minakawa H et al.. Use of the “supercharge” technique in esophageal and pharyngeal reconstruction to augment microvascular blood flow.  Surgery. 2003;  134 420-424
• 34 Kompatscher P, Manestar M, Schuster A, Lang A, Beer G M. The thoracoacromial vessels as recipient vessels in microsurgery and supermicrosurgery: an anatomical and sonographic study.  Plast Reconstr Surg. 2005;  115 77-83
• 35 Hefel L, Schwabegger A, Ninkovic M et al.. Internal mammary vessels: anatomical and clinical considerations.  Br J Plast Surg. 1995;  48 527-532
• 36 Ninkovic M, Anderl H, Hefel L, Schwabegger A, Wechselberger G. Internal mammary vessels: a reliable recipient system for free flaps in breast reconstruction.  Br J Plast Surg. 1995;  48 533-539
• 37 Mathes S J, Nahai F. Classification of the vascular anatomy of muscles: experimental and clinical correlation.  Plast Reconstr Surg. 1981;  67 177-187
• 38 Reid C D, Taylor G I. The vascular territory of the acromiothoracic axis.  Br J Plast Surg. 1984;  37 194-212
• 39 Harashina T, Kakegawa T, Imai T, Suguro Y. Secondary reconstruction of oesophagus with free revascularised ileal transfer.  Br J Plast Surg. 1981;  34 17-22
• 40 Takamatsu A, Harashina T, Inoue T. Selection of appropriate recipient vessels in difficult, microsurgical head and neck reconstruction.  J Reconstr Microsurg. 1996;  12 499-507
• 41 Fujita H, Inoue Y, Kakegawa T et al.. Esophageal reconstruction using microvascular anastomosis to the thoracoacromial artery and cephalic vein.  Jpn J Surg. 1991;  21 512-516
• 42 McCready R A, Hyde G L, Bivins B A, Mattingly S S, Griffen Jr W O. Radiation-induced arterial injuries.  Surgery. 1983;  93 306-312
• 43 Matsumine H, Sakurai H, Honda T, Nozaki M. A retrospective study of postoperative complications in free flaps for the repair of head and neck tumor defects.  , [in Japanese] J Jpn PRS. 2005;  25 739-745
• 44 Aitasalo K, Relander M, Virolainen E. Microvascular free tissue transfers after preoperative irradiation in head and neck reconstructions.  Acta Otolaryngol Suppl. 1997;  529 247-250