Dysphagia after an L-shaped reconstruction technique of the free jejunum graft

https://doi.org/10.1016/j.bjps.2009.11.007Get rights and content

Summary

Background

The free jejunum graft is a well-established reconstruction technique after total laryngopharyngectomy. However, besides necrosis of the jejunum graft, the two most important complications are pharyngocutaneous fistula formation and dysphagia due to stricture formation.

Objectives

This study aims to develop an L-shaped reconstruction technique of the free jejunum graft to decrease pharyngocutaneous fistula formation and long-term stricture formation after total laryngopharyngectomy.

Methods

An L-shaped side-to-end anastomosis was performed at the proximal end of the jejunum graft in six patients treated for piriform sinus carcinoma. Patient and operation characteristics and follow-up were recorded.

Results

A successful jejunum transfer was performed in all six patients. No pharyngocutaneous fistula or stricture formation occurred during a median follow-up of 23 months (range: 18–30 months). Swallowing rehabilitation started at the median 12th postoperative day (range: 5–150 days). Four patients developed dysphagia at a median of 2 months (range: 1–6 months) after oral intake was started. X-barium swallow revealed a redundant pouch of the transferred jejunum graft, which resulted in compression on the jejunum interposition during swallowing. In three patients, an operation was required to resolve these problems. After the revision operation, no dysphagia occurred during a median follow-up of 12 months (range: 7–13 months).

Conclusions

Because of dysphagia complaints in the majority of our patients, we cannot recommend the described technique and should find other means to improve direct postoperative results and long-term quality of life in this difficult-to-treat group of patients.

Section snippets

Materials and methods

Between January 1990 and April 2008, 51 patients were treated at the Erasmus Medical Center for malignant tumours of the larynx, hypopharynx, oropharynx or cervical oesophagus with a jejunum interposition. A total laryngopharyngectomy was performed, followed by a jejunum interposition using an L-shaped side-to-end anastomosis in the last six consecutive patients. In these six patients, the patient history and demographics; tumour stage and location; and previous and adjuvant treatment were

Results

A successful jejunum transfer was performed in all six patients treated with an L-shaped anastomosis. The median duration of the operation was 410 min (range: 313–440 min) and the median hospital stay was 16 days (range: 10–83 days). No flap failure occurred, but one patient had abdominal complications due to an enterocutaneous fistula, which required three abdominal surgical procedures. In a second patient, multiple intra-abdominal serosa lesions and abdominal dehiscence developed, which

Discussion

Reconstruction of defects after resection of extensive tumours in the laryngopharyngeal region and cervical oesophagus remains a surgical challenge. The development of a surgical technique that adequately manages the mismatch between the lumen of the oropharynx and the transferred graft to prevent stricture resulting in dysphagia without an increased risk of pharyngocutaneous fistula formation has been subject to debate for a long time.13, 14, 15, 16, 17, 18, 19, 20

Since the prognosis of

Financial disclosure

No financial conflicts reported.

Conflict of interest

None.

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