Jejunum

Transfer of jejunal free graft was the first microsurgical flap reported in the literature.89 Currently the jejunal free graft is used as a mucosal tube or mucosal patch (depending on the configuration of the defect) for reconstruction of the hypopharynx or cervical esophagus.90 The jejunal free flap has proved

Figure 18-32. A, Defect of anterolateral mandible, lateral tongue, lateral floor of mouth and lateral cheek after surgical resection of squamous cell carcinoma. B, Mandible reconstruction with fibula osseocutaneous free flap prior to inset of skin island. C, Preoperative appearance. D, Postoperative appearance after reconstruction and external beam radiation therapy.

Figure 18-32. A, Defect of anterolateral mandible, lateral tongue, lateral floor of mouth and lateral cheek after surgical resection of squamous cell carcinoma. B, Mandible reconstruction with fibula osseocutaneous free flap prior to inset of skin island. C, Preoperative appearance. D, Postoperative appearance after reconstruction and external beam radiation therapy.

Figure 18-33. Composite scapula flap demonstrating osseous component (single arrow), cutaneous component (double arrow), latissimus muscle component (triple arrow) all based upon single vascular pedicle.

to be superior to pedicled visceral flaps such as stomach or colon that are transferred to reconstruct the cervical esophagus. Advantages of microsurgical transplantation of a jejunal segment, over the gastric pull-up procedure to reconstruct defects of the upper aerodigestive tract, include no limitations on reaching the neck and a predictable blood supply. In addition, there is no need for extensive abdominal and thoracic dissections, which are often fraught with complications. Finally, postoperative adjuvant radiotherapy can be administered without significant risk of complication.91

The caliber of the jejunum lumen matches the esophagus in most individuals. However, for reconstruction of pharyngoesophageal defects the pharynx opening may be considerably larger. For such defects, the cephalad portion of the free jejunum can be opened along its antimesenteric border to increase the caliber.90

The small intestine segment to be transferred is usually 40 cm distal to the ligament of Treitz. The isolated portion of bowel is supplied by a single vas-

Figure 18-34. A, Defect after total laryngopha-ryngectomy. B, Jejunal free flap. C, Pharynx reconstruction with jejunal free flap.

cular arcade arising from large nutrient vessels coming from the superior mesenteric artery and vein (Figure 18-34). Due to limited tolerance of the jejunum to ischemia, it is advisable to prepare the recipient vessels before dividing the vascular pedicle and to complete the vascular anastomoses in less than 120 minutes.

Postoperative monitoring of the blood supply to the jejunal segment buried under the neck flaps is facilitated by exteriorizing a small segment of jejunum that remains attached to the large segment of bowel except through its vascular connections to the main vascular pedicle. The exteriorized jejunum is divided under local anesthesia 5 to 7 days after surgery. A barium swallow is usually performed between day 7 and 12 postoperatively, to assess permeability of the jejuno-esophageal anastomoses. Recently, the utility of this routine study has been questioned in our institution and is not considered 100 percent accurate.92

Complications at the donor site have been reported to occur in approximately 5.8 percent of patients.93 These include bowel obstruction, abdominal wound dehiscence, gastrointestinal hemorrhage, G-tube leakage and prolonged ileus.

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