In cancer patients who undergo esophagectomy or laryngopharyngectomy, restoration of digestive continuity is essential to quality of life. Although time-tested reconstructive techniques can reestablish digestive continuity in most patients, patients who undergo total or near-total esophagectomy or who undergo laryngopharyngectomy and have damaged neck tissue due to prior surgery or radiation therapy require specialized procedures. Two such procedures, supercharged jejunal flap surgery for esophageal reconstruction and chimeric free flap transfer for pharyngoesophageal reconstruction and neck resurfacing, are available at only a few centers worldwide.
Neither chimeric flap nor supercharged jejunal flap surgery is new, but these procedures are so seldom needed that very few surgeons are experienced in performing them. Surgeons at The University of Texas MD Anderson Cancer Center were among the first to perform the procedures and have reported results from relatively large patient cohorts for both operations. On the basis of this experience, the surgeons have continually refined their techniques and the selection criteria for both procedures so that digestive continuity can be restored in as many patients as possible.
In patients with cancer in the thoracic esophagus or the upper part of the gastroesophageal junction, surgeons can resect a part or nearly all of the esophagus and connect the stomach directly to the remaining esophagus to restore digestive continuity. However, this procedure cannot be used in patients in whom tumor involvement has also necessitated removal of all or part of the stomach. In other situations, the stomach is not available because of previous surgery.
“In these scenarios, when the stomach is not available or can’t reach far enough, we use the supercharged jejunal flap,” said Peirong Yu, M.D., a professor in the Department of Plastic Surgery. The flap is considered to be “supercharged” because it both maintains part of its original blood supply like a pedicled flap and is connected to a new blood supply like a free flap.
The supercharged jejunal flap is created by taking a long (about 30-cm) piece of the jejunum and dividing the mesentery to straighten the segment. One set of the mesentery vessels, usually the second branch of the superior mesenteric artery and vein, is divided and later anastomosed to the recipient vessels in the neck (often the left internal mammary artery and vein) to supply blood to the superior portion of the flap. The third branch is often divided to lengthen the mesentery. The blood supply from the fourth branch of the superior mesenteric artery is maintained as a pedicle for the inferior portion of the flap.
To place the flap, surgeons first remove small portions of the first rib, clavicle, and manubrium to allow access to the recipient site and the internal mammary vessels. The surgeons then attach the superior portion of the flap to the upper digestive tract and anastomose the blood vessels. Although the inferior portion of the jejunal flap can be connected to the stomach in cases in which a portion of the stomach remains viable, this can cause gastric reflux. In most cases, therefore, the remaining stomach is bypassed, and the flap is attached to the small bowel using a Roux-en-Y technique.
The supercharged jejunal flap surgery is an extremely complicated procedure that requires close coordination between the plastic surgeon and thoracic surgeon. “The surgical teamwork required to execute the supercharged jejunal flap successfully is a highly orchestrated event,” said Jesse Selber, M.D., an associate professor in the Department of Plastic Surgery. “Everyone must not only know his or her own role but also understand the roles of the other team members.”
Dr. Selber added that the procedure involves significant time pressure. “Once the bowel is disconnected in the abdomen, you have about an hour to pass it through the chest into the neck and reconnect the blood supply under the microscope,” he said. “If that doesn’t happen, the bowel flap may die and the result can be disastrous.”
“This is a major operation, and there are potential complications,” said Wayne Hofstetter, M.D., a professor and director of the esophageal surgery program in the Department of Thoracic and Cardiovascular Surgery. “But the vast majority of patients who undergo this procedure are able to become independent of feeding tubes.”
Pharyngoesophageal reconstruction and neck resurfacing
Patients who undergo laryngopharyngectomy have several options for pharyngoesophageal reconstruction. These include surgery with free tissue flaps from the anterolateral thigh, radial forearm, or jejunum and surgery with pedicled flaps from the supraclavicular region or the pectoralis major muscle. But many patients who have had prior surgery or radiation therapy to the neck have scarring and hypovascularity that make it difficult or impossible to close the neck incision primarily after pharyngoesophageal reconstruction.
“We need two flaps for these patients,” Dr. Yu said. “We need one to rebuild the esophagus so the patient can eat again, and then we need another to cover the outside. This is important because if you don’t have reliable coverage, the carotid arteries and other critical structures are at risk.”
For such reconstructions, plastic and reconstructive surgeons at MD Anderson use a chimeric flap, which is usually taken from the anterolateral thigh but can be taken from other donor sites if necessary. The chimeric flap is so named because it is composed of two (or more) semi-independent components, all of which are supplied by a common artery and vein that are anastomosed to recipient vessels in the neck.
“We use part of the flap to reconstruct the esophagus and the other part to cover the neck,” Dr. Selber said. “And they are dissected in a way that retains a common blood supply to all components.”
“In the flap used for resurfacing, we include a little bit of muscle to protect the carotid and subclavian arteries,” Dr. Yu said. “This helps prevent disastrous complications.”
Another advantage of the anterolateral thigh flap is that it facilitates the restoration of speech function. The skin flap used to reconstruct the upper esophagus is firm, which allows the vibration necessary for esophageal or tracheoesophageal speech. “The skin flap is tight, and it vibrates like the material used in a drum. The jejunal flaps are soft and produce mucus, which makes speech restoration more difficult,” Dr. Yu said. That is why the thigh or other skin flaps are preferred for upper esophageal reconstruction and the jejunum or stomach is used for lower esophageal reconstruction.
To assess the complication rate of chimeric flap surgery, Dr. Selber and colleagues recently compared the outcomes of 179 patients who received chimeric flaps for pharyngoesophageal reconstruction and neck resurfacing with those of 115 patients who underwent pharyngoesophageal reconstruction but did not require neck resurfacing. Compared with the patients who underwent pharyngoesophageal reconstruction alone, those who also underwent neck resurfacing had a significantly lower rate of pharyngocutaneous fistula formation and similar rates of other complications. The rate of fistula formation was highest in patients who had undergone prior surgery or radiation therapy but who did not receive neck resurfacing because they had adequate tissue to close the incision. Because of the impact of this work, Dr. Selber received the 2017 James Barret Brown Award from the American Association of Plastic Surgeons for the best clinical paper in plastic surgery.
“Before this study, the decision of whether to use a chimeric flap was based on whether we could actually close the skin,” Dr. Selber said. “But now we’re armed with the information that if the patient has had previous radiation or surgery, the patient will have a lower complication risk if a resurfacing procedure is performed, regardless of the ability to close. This will help reconstructive surgeons make important decisions that will have a direct impact on patient outcomes.”
Quality of life
Esophageal or pharyngoesophageal reconstruction is an important step toward the overall goal of restoring patients’ quality of life. In particular, reestablishing digestive continuity is essential to achieving this goal.
“The ability to maintain nutrition and hydration totally by mouth, taste food, and have meals socially are all quality-of-life issues that can be fixed when esophageal continuity is restored,” Dr. Hofstetter said.
Because speech and swallowing are also important quality-of-life factors in patients who have undergone surgery and/or radiation therapy to the neck, MD Anderson has speech pathologists on staff to help patients recover these functions (see “Therapy Preserves Swallowing Function” below).
Patients who are cured of their cancer appreciate the quality of life that successful reconstruction enables. Dr. Yu said, “One patient I treated 10 years ago comes back every year to say hello to me.”
For more information, contact Dr. Wayne Hofstetter at 713-563-9130 or firstname.lastname@example.org, Dr. Jesse Selber at 713-794-1247 or email@example.com, or Dr. Peirong Yu at 713-794-1247 or firstname.lastname@example.org.
Sharaf B, Xue A, Solari MG, et al. Optimizing outcomes in pharyngoesophageal reconstruction and neck resurfacing: 10-year experience of 294 cases. Plast Reconstr Surg. 2017; 139:105e–119e.
OncoLog, August 2018, Volume 63, Issue 8