jejunum asc presentation
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TRANSCRIPT
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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
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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
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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.
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Method
• Retrospective chart review of all patients who underwent jejunal free flap reconstruction of circumferential pharyngoesophageal defects
• March 2000 and September 2009
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Patient Study Group
• 43 patients– 31 male and 12 female
• Mean age of 62 (+/- 9 years, 1SD)
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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.
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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:
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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.
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Results
• 43/43 (100%) acute flap survival
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Radiotherapy and the incidence and location of fistula formation in patients having undergone hypopharygeal reconstruction with
a free jejunal flap
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Fistula
• Overall benign fistula rate– 2/43 (4.7%)
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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).
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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.
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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
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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).
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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.
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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
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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%
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Murray D, Novak C, Neligan P. Fasciocutaneous free flaps in pharyngolarngo-oesophageal reconstruction: A critical review of literature. J Plast Reconstr
Aesthet Surg. 2008
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Overall benign stricture rate was 6/43 (14%).
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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
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• 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
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•
Yu P, et al. Plast Reconstr Surg. 2006
8/26 (31%) of the ALT groupand 2/31 (6%) Jej group used the TEP prosthesis as the
primary mode of communication.
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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
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Conclusion