2. Reconstruction of pharyngolaryngectomy
defects using the jejunal free flap: A 10-year
experience from a single reconstructive team
Moradi P, Glass GE, Atherton DD, Eccles S, Coffey
M, Majithia A, Speirs A, Clarke P M, Wood S H

3. Introduction
• Reconstruction following
pharyngolaryngectomy presents a complex
reconstructive challenge.
• Goals of reconstruction:
– a single stage, reliable reconstruction
– prompt discharge from hospital
– return of swallowing and speech function

4. Introduction
• We present our 10-year experience of 43
jejunal free flaps for pharyngolaryngectomy
reconstruction by a single team and outline our
operative algorithm to minimise post-operative
morbidity.

5. Method
• Retrospective chart review of all patients who
underwent jejunal free flap reconstruction of
circumferential pharyngoesophageal defects
• March 2000 and September 2009

6. Patient Study Group
• 43 patients
– 31 male and 12 female
• Mean age of 62 (+/- 9 years, 1SD)

7. Patient Study Group
• 23 patients (53%) were reconstructed for
primary disease
• 20 patients (47%) for recurrence or a second
primary.
• 21 cases (49%) were undertaken for
recurrence having had previous radiotherapy.

8. Method
 All flaps were performed by the two senior
authors (PC and SW) at Charing Cross Hospital
 Surgical protocols were based on the
standard principles of free jejunal transfer
with 2 major modifications:

9. 1. Gastrointestinal bowel stapler was favoured for
both the proximal and distal anastomosis where
possible
2. All patients who had been exposed to previous
radiotherapy received a prophylactic pedicled
pectoralis major muscle flap to cover both
bowel anastomoses unless both anastomoses
were performed using the stapler.

17. Results
• 43/43 (100%) acute flap survival

18. Radiotherapy and the incidence and location of fistula formation
in patients having undergone hypopharygeal reconstruction with
a free jejunal flap

19. Fistula
• Overall benign fistula rate
– 2/43 (4.7%)

20. Radiotherapy
• Chang et al reported that those patients who
received preoperative radiation therapy had a
higher incidence of fistula formation than
patients who had not, but this did not reach
significance (16.3 percent versus 11.4 percent
p=0.36).

21. Fistula
• 14/21 cases (67%) who underwent
radiotherapy had a prophylactic pedicled
pectoralis major muscle flap to cover the
anastomosis.
• Of these 14 patients:
– 0 had a pharyngocutaneous fistula.

22. D.W. Chang, et al Plast Reconstr Surg 109 (2002), pp. 1522–1527)
Reported a leak rate of 43.5% in the distal anastomosis sutured with a double layer
closure

23. Proximal anastomosis
 34 of 43 cases (79%) double layer sutures.
 2 of 34 (6%) developed a leak.
 The remaining 9 were closed with the
gastrointestinal stapler.
 There were no leaks among the 9 stapled proximal
anastomoses (P=NS).

24. Distal anastomosis
• 39 of 43 (91%) were performed with the
stapler.
– There were no leaks identified from the distal
anastomosis
• The remaining 4 cases were sutured.

25. Anastomosis
• 48/86 (56%) of the anastomosis were
performed with the stapler
– 0/48 developed a fistula
• 2/38 hand sutured anastomosis developed
a fistula

26. Literature Review
• Nelligan (J Plast Reconstr Aesthet Surg. 2008)
reported a fistula rate of:
– 13% for all fasciocutaneous flaps
• ALT flap 16.4%
• radial forearm free flap 14.4%.
– Jejunum 9.4%

27. Murray D, Novak C, Neligan P. Fasciocutaneous free flaps in pharyngolarngo-
oesophageal reconstruction: A critical review of literature. J Plast Reconstr
Aesthet Surg. 2008

28. Overall benign stricture rate was 6/43
(14%).

29. Voice Restoration
• 22 of 42 received a
primary (TEP)
• 14 of 42 received a
secondary TEP
• 36/42 (85%) received
either a primary or
secondary TEP

30. • Speech was analysed in 39 patients.
• Voice was reported as:
– Good in 17 of 39
– Fair in 11 of 39.
– 28 of 39 (72%) used their tracheoesophageal
puncture as their primary mode of communication

31. Yu P, et al.
Plast Reconstr Surg. 2006
8/26 (31%) of the ALT group
and 2/31 (6%) Jej group used the TEP prosthesis as the
primary mode of communication.

32. Swallowing
• Swallowing was analysed in 41 patients,
– 27/41 (66%) had a “good” swallow,
• regular diet.
– 9/41 (22%) had a “moderate” swallow
• pureed diet
– 5/12 (12%) had a “poor” swallow,
• partially or totally dependent on tube feeding

33. Conclusion