Master Techniques in Otolaryngology - Head and Neck Surgery: Reconstructive Surgery, 1ed.

33. Free Segmental and Pedicled Supercharged Jejunal Transfer

Jesse C. Selber

INTRODUCTION

Esophageal reconstruction is a demanding and highly coordinated multidisciplinary effort. It requires meticulous planning, exacting intraoperative execution, and vigilant postoperative management. Complications are common but often avoidable. Speech and swallowing function, which are the goals of esophageal reconstruction, can be restored in most, but not all, cases.

In this chapter, I first examine indications, focusing on what types of reconstruction are appropriate based on defect characteristics. I then describe the operative technique in detail for both the free jejunal segment and the pedicled supercharged jejunum. There is a certain amount of overlap in the abdominal approach, recipient vessel identification, and bowel and microvascular anastomoses, but there are also critical differences. I conclude with a discussion of postoperative management, results, and complications.

HISTORY

The most important aspect of the history when considering a jejunal reconstruction is a careful history of previous abdominal surgery. When there has been extensive abdominal surgery, the jejunum may be compromised. Injury to the vascular mesentery or excessive adhesions can preclude the use of the jejunal flap.

PHYSICAL EXAMINATION

The physical examination should include a careful evaluation of the recipient site within the neck and the abdomen. The examination of the recipient site should include an evaluation of the distal defect. If the distal esophageal defect is too inferior in the neck or in the chest, a gastric pull-up or colonic interposition may be more appropriate. An examination of the abdomen may reveal surgical scarring which may impact the choice of the donor site.

INDICATIONS

The most important factor in selecting the appropriate reconstructive method is the length and location of the esophageal defect. If the defect is limited to the cervical esophagus, the two choices are to reconstruct using a jejunal free flap or a tubed fasciocutaneous flap, either a radial forearm or anterolateral thigh flap. If just a patch rather than a circumferential conduit is required, a radial forearm flap is more than adequate to provide reconstruction. For circumferential defects of the cervical esophagus, I prefer to use an anterolateral thigh flap. The reasons for this are multiple. The radial forearm flap is well known to have a significantly higher fistula rate (approximately 17%) than either the anterolateral thigh flap or the free jejunal flap (both approximately 9%). Patients who have cancer of the head and neck often have multiple medical comorbidities. The thigh donor site is less taxing on the patient than is the intra-abdominal donor site, which may result in significant fluid shifts and increased cardiopulmonary complications, not to mention the associated risks of a bowel anastomosis. The anterolateral thigh flap can be harvested in a trapezoidal shape to form a wider opening to accommodate the pharyngeal anastomosis if a laryngopharyngectomy is performed, and in these cases, speech outcomes following tracheoesophageal puncture (TE) puncture are better than with a free jejunal segment. Finally, a second skin paddle can be designed, perforator anatomy permitting, to resurface the neck in cases of injury secondary to radiation therapy (Fig. 33.1).

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FIGURE 33.1 Pharyngoesophageal deconstruction using the anterolateral thigh flap. A. The design of a two-skin island flap permits a trapezoidal design for the conduit and an elliptical design for the skin resurfacing. B. The proximal skin island based on the proximal perforator is tubed or used as a patch to form the conduit. C. This is sutured into the base of the tongue and posterior pharynx proximally and distally into the esophageal inlet. D. The external skin island is used for monitoring and resurfacing the defect in the neck.

Occasionally, circumferential defects of the cervical esophagus occur in patients in whom the anterolateral thigh donor site is unavailable. Reasons include previously harvested flaps, previous hemicorpectomies, obese thighs, critical atherosclerotic damage to the profunda femoris, or critical atherosclerotic disease of the superficial femoral artery, which is being effectively bypassed via the descending branch of the lateral femoral circumflex artery. In these cases, a jejunal free flap is the best option. Jejunal free flaps, which are often used in cases of cancer of the hypopharynx and cervical esophagus, are limited to short esophageal defects due to the segmental blood supply. The flap is based on a single branch of the superior mesenteric artery and vein. Generally speaking, one mesenteric branch supplies 15 to 20 cm of bowel. Therefore, in defects of 15 cm or less, for which the distal portion of the esophagus is accessible through the neck, the jejunal free flap is an excellent option.

For defects greater than 15 cm and for which the distal esophagus is inaccessible due to its intrathoracic location, a gastric conduit is the first choice for reconstruction due to its robust blood supply and requiring only one bowel anastomosis to reestablish continuity; however, in certain situations, the stomach is unusable. Colon interposition has been employed for several decades as an alternative to the gastric conduit; however, patients with atherosclerosis, inappropriate vascular anatomy, previous colon resection, or intrinsic colon disease, such as inflammatory bowel disease, cancer, or diverticulosis, are not candidates.

The pedicled supercharged jejunum is the preferable alternative because it closely approximates the size of the native esophagus, possesses peristaltic activity, and is typically free of intrinsic diseases. The addition of microsurgical techniques has allowed for the replacement of the entire esophagus using longer conduits through “supercharging.” Longmire described the first supercharged jejunal flap for reconstruction of the esophagus in 1947. Since then, the field of microsurgery has advanced significantly and the use of these techniques has become more widespread, making the supercharged jejunal flap the best option for total esophageal reconstruction when the stomach is unavailable.

CONTRAINDICATIONS

Total esophageal reconstruction using a free, segmental, or pedicled, supercharged jejunal flap is technically challenging and requires a multidisciplinary approach. Relative contraindications include a surgeon who is not working with a team to manage the patient and patients with prior extensive abdominal or specifically jejunal surgery.

PREOPERATIVE PLANNING

These procedures can be successfully performed as an alternative reconstruction when the stomach is unavailable with good long-term function and acceptable morbidity. Thorough surgical planning is critical to the success of this operation. When using the jejunum, preoperative planning requires that a careful operative history is taken to assess the potential for abdominal adhesions that may hinder the harvest of a jejunal segment.

SURGICAL TECHNIQUE

The initial approach to the abdomen is the same for both the free segmental and pedicled supercharged jejunum. Once resection is complete, the ligament of Treitz is identified and the small bowel with its mesentery is explored to ensure that no intrinsic abnormalities or iatrogenic injuries exist. The length of the esophageal defect is measured to estimate the length of the conduit needed (Fig. 33.2). The mesentery of the proximal and mid jejunum are closely examined using a fiberoptic light to transilluminate the tissues and elucidate the vascular anatomy (Fig. 33.3).

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FIGURE 33.2 In esophageal reconstruction, the length of the conduit is measured by the distance from the proximal portion to the distal portion, often through the thoracic inlet and outlet.

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FIGURE 33.3 Transillumination of the small bowel is used to demonstrate the vascular anatomy of the inferior mesenteric artery and vein and identify the most appropriate vessels to divide and transfer.

Free Jejunal Segment

If a free jejunal segment is the reconstructive option of choice, a single mesenteric vessel is selected around 40 cm from the ligament of Treitz, which usually corresponds to the second or third mesenteric branch. The choice of these vessels yields the largest arc of mesentery and thus the longest vascular pedicle. Once the appropriate vessel is identified, it is dissected free from the mesentery. The secondary arcade emerging from this single mesenteric vessel must be kept intact to ensure vascularity of the entire segment. This is done by harvesting the wedge of mesentery between the pedicle and the jejunal segment (Fig. 33.4). Dissection through the mesentery can be assisted by transillumination. The mesenteric vessels are extremely friable, and great care should be taken to avoid rough dissection, which will result in a hematoma of the mesentery and obfuscate the dissection. This dissection is taken up to the serosal border distally, and the superior mesenteric artery and vein proximally, insuring maximum pedicle length and caliber.

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FIGURE 33.4 For a free jejunal segment, the mesenteric vessel that will yield the longest arc of mesentery is selected and dissected free from the mesentery. The secondary arcade emerging from this single mesenteric vessel must be kept intact to ensure vascularity of the entire segment. This is done by harvesting the wedge of mesentery between the pedicle and the jejunal segment.

Prior to dividing the bowel, the proximal or isoperistaltic portion of the jejunum is marked. This insures appropriate orientation in the neck. The bowel is divided with a standard endostapler. The pedicle is then ligated, and the flap is transferred to the head and neck. A stapled, side-to-side anastomosis of the remaining jejunum in the abdomen is performed, or a two-layer, hand-sewn end-to-end anastomosis, depending on surgeon preference, and the midline incision is closed in standard fashion.

Once in the neck, heparinized saline is run through the flap as is customary for all free flaps. The bowel is oriented appropriately, usually in an isoperistaltic fashion. Generally, I like to perform at least the distal esophageal anastomosis prior to the microvascular anastomosis since this will set the tension on the bowel. The proximal 3 to 5 cm of jejunum, based on one or two terminal arcade vessels, is exteriorized as a postoperative monitoring segment. The esophagojejunal anastomoses are then performed in the neck using a single layer of 3-0 Vicryl or polydioxanone suture (PDS) in an end-to-end fashion. In patients with a total laryngopharyngectomy, the proximal pharynx or the base of the tongue is larger than the jejunal diameter, so an end-to-side anastomosis is performed to accommodate the size discrepancy.

Recipient vessels are prepared prior to dividing the vascular pedicle and passing the jejunal conduit. The transverse cervical vessels (if the neck has been significantly damaged due to prior surgery and/or radiation), the external carotid system (the facial, lingual, or superior thyroid arteries), and jugular veins are common recipient vessels depending on the clinical scenario (Fig. 33.5). Arterial anastomoses are performed under the operating microscope using 9-0 Nylon sutures. Venous anastomoses are commonly completed using a venous coupling device (Synovis Surgical Innovations, St. Paul, MN).

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FIGURE 33.5 Recipient vessels are prepared prior to dividing the vascular pedicle and passing the jejunal conduit. The transverse cervical vessels (if the neck has been significantly damaged due to prior surgery and/or radiation), the external carotid system (the facial, lingual, or superior thyroid arteries), and jugular veins are common recipient vessels depending on the clinical scenario. In this case, the vessel loop is around the jugular vein, and the Ackland clamp is on the facial artery.

Pedicled Supercharged Jejunum

For total or near total esophageal replacement, the supercharged jejunum is the best option. The esophagectomy and gastrectomy, when necessary, are performed by the thoracic and/or general surgeons. The surgical approach is through either two incisions (abdominal and cervical) as in a transhiatal esophagectomy or three incisions with the addition of a right thoracotomy. The initial abdominal approach mirrors that for the jejunal segment: the ligament of Treitz is identified, and the small bowel with its mesentery is explored to ensure that no intrinsic abnormalities or iatrogenic injuries exist. The length of the esophageal defect is measured to estimate the length of the conduit needed. The mesentery of the proximal and mid jejunum is closely examined using a fiberoptic light to transilluminate the tissues and identify the vascular anatomy.

The next steps are unique to the pedicled flap and are the most technically sensitive part of the procedure. The first mesenteric branch beyond the ligament of Treitz is identified and preserved to maintain blood supply to the distal duodenum and most proximal portion of jejunum, which is used to reestablish enteric continuity.

Typically, the second mesenteric branch is dissected down to the level of the superior mesenteric artery and vein, and ultimately divided to serve as the vascular pedicle for supercharging the proximal flap (Fig. 33.6). In the simplest cases, the mesentery between the second and third branches is divided up to the serosal border, allowing the jejunal segment to unfurl (Fig. 33.7). This step helps straighten the natural sinusoidal properties of the small bowel and reduce redundancy. If more length is required, the third mesenteric branch is ligated and divided (Fig. 33.8). Secondary arcade vessels between the third and fourth mesenteric branches are preserved so that the segment of bowel normally supplied by the third branch is now supplied by the pedicled fourth branch through intact arcade vessels. This approach is the most commonly used technique.

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FIGURE 33.6 In planning the supercharged jejunum, typically, the second mesenteric branch is dissected down to the level of the superior mesenteric artery and vein and ultimately divided to serve as the vascular pedicle for supercharging the proximal flap.

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FIGURE 33.7 In the simplest cases of supercharged jejunums, the mesentery between the second and third branches is divided up to the serosal border, allowing the jejunal segment to unfurl. This step helps straighten the natural sinusoidal properties of the small bowel and reduce redundancy.

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FIGURE 33.8 If more length is required on the jejunum, the third mesenteric branch is ligated and divided. Secondary arcade vessels between the third and fourth mesenteric branches are preserved so that the segment of bowel normally supplied by the third branch is now supplied by the pedicled fourth branch through intact arcade vessels.

If still greater length is required, such as in patients with a very long torso or a concomitant total laryngopharyngectomy, the fourth mesenteric branch can also be ligated. In these cases, only the mesentery between the third and fourth branches is divided to the serosal border while the arcade connections are preserved between the second and third, and between the fourth and fifth branches (Fig. 33.9). The third segment receives perfusion from the supercharged second segment, and the fourth segment receives perfusion from the pedicled fifth branch. Once adequate length is achieved, the jejunum is divided proximally with a linear cutting stapler, typically 30 to 40 cm distal to the ligament of Treitz.

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FIGURE 33.9 A. If still greater length is required, such as in patients with a very long torso or a concomitant total laryngopharyngectomy, the fourth mesenteric branch can also be ligated. B. In these cases, only the mesentery between the third and fourth branches is divided to the serosal border while the arcade connections are preserved between the second and third, and between the fourth and fifth branches.

There are two potential routes for transferring the jejunal flap to the neck: retrocardiac, which is the orthotopic route, or substernal, which is the heterotopic route (Fig. 33.10). The former is used in patients undergoing immediate reconstruction. The latter is usually reserved for patients undergoing a delayed reconstruction after previous failed esophageal reconstruction. In these cases, a portion of the manubrium, clavicular head, and first rib are removed to enlarge the thoracic inlet and avoid constriction on the jejunal conduit. Whether the retrocardiac or substernal route is selected, transfer is accomplished using a sterile laparoscopic camera bag to protect the conduit and prevent traction and shearing forces on the delicate arcade vessels.

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FIGURE 33.10 There are two potential routes for transferring the jejunal flap to the neck: retrocardiac, which is the orthotopic route, or substernal, which is the heterotopic route. The former is used in patients undergoing immediate reconstruction. The latter is usually reserved for patients undergoing a delayed reconstruction after previous failed esophageal reconstruction.

Recipient vessels are again prepared prior to dividing the vascular pedicle and passing the jejunal conduit. As in the free jejunal segment, the transverse cervical vessels, the external carotid system, and jugular veins are common recipient vessels depending on the clinical plan. The internal mammary vessels are used much more frequently in the supercharged flap because a manubriumectomy created for ease of conduit passage often leaves these vessels exposed. Once the jejunal flap is passed, arterial anastomoses are performed under the operating microscope using 9-0 Nylon sutures. Venous anastomoses are commonly completed using a venous coupling device (Synovis Surgical Innovations, St. Paul, MN). A vein graft is used in some cases to bridge the gap between the jejunal vascular pedicle and the recipient vessels.

Once the proximal jejunum is revascularized, any excess length of jejunal conduit is removed in order to minimize redundancy in the neck. As in the free segmental jejunum, the proximal 3 to 5 cm of bowel is exteriorized based on secondary arcade vessels as a postoperative monitoring segment (Fig. 33.11). The esophagojejunal anastomosis is then as described above. Intestinal continuity is reestablished in the abdomen by the thoracic or general surgical team through a gastrojejunal anastomosis using the posterior wall of the stomach or through a Roux-en-Y jejunojejunal anastomosis if a gastrectomy was performed. A feeding jejunostomy tube is routinely placed.

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FIGURE 33.11 As in the free segmental jejunum, the proximal 3 to 5 cm of bowel in the supercharged jejunum is exteriorized based on secondary arcade vessels as a postoperative monitoring segment.

Advanced Techniques and Tips for Supercharging

After passing the bowel through the chest and into the neck, tension on the mesentery may compromise the perfusion of the middle jejunal segment. This segment should be carefully inspected before closing the abdomen. If the perfusion is questionable, it can be revascularized by anastomosing its mesenteric branch to the gastroepiploic, right gastric, or mesocolonic vessels or even the stump of the superior mesenteric vessels with or without a vein graft. Revascularization of the middle segment was successfully performed in four patients in my series.

Typically, three surgical services are involved in this type of cases: thoracic surgery, general surgery, and plastic surgery. To minimize the operating time, it is important to establish a coordinated flow between the various teams. If a thoracotomy is required, the patient is first placed in lateral decubitus position and then switched to supine. While the ablative surgical team is operating in the abdomen, the reconstructive surgeons can start to prepare recipient vessels in the neck. The teams then change positions. The reconstructive surgeons now prepare the jejunal flap while the ablative surgeons expose the proximal esophagus through the neck incision and remove the manubrium and clavicular head if a substernal approach is desired. The jejunal conduit is then passed through the chest and into the neck, and the teams switch positions again. The reconstructive surgeons revascularize the proximal jejunum, complete the esophagojejunal anastomosis, and fashion the monitoring segment while the other surgical team restores gastrointestinal continuity in the abdomen. When properly organized, no time is wasted for any of the teams involved. Clear communication between surgical teams and anesthesia regarding fluid resuscitation and avoidance of vasopressor medications is imperative as different disciplines may manage these issues differently.

Technically, three key steps are required in such a complex reconstruction: selecting the appropriate jejunal segment, choosing the optimal recipient vessels for microsurgical anastomosis, and creating a suitable conduit passageway.

Careful consideration of the mesenteric anatomy is the most critical component in surgical planning. If possible, the most proximal jejunum beyond the first mesenteric branch should be included to avoid wasting of the proximal bowel. Thus, the second mesenteric branch is often selected for supercharging. However, this selection also depends on the anatomy of the mesentery since it is the arc length of the mesentery between branches, not the bowel itself, that determines the reach of the flap. Therefore, the segment of bowel with longer mesenteric vessels and wider mesenteric intervals between the vessels should be selected so the conduit can be adequately unfurled and lengthened. Transillumination of the mesentery can help to determine the vascular anatomy.

Choice of recipient vessels is another critical factor in the decision-making algorithm. In general, recipient vessels in the inferior part of the neck (transverse cervical vessels) or in the chest (internal mammary vessels) are preferred to facilitate reach of the mesenteric pedicle. The choice of recipient vessels also depends on conduit pathway, which is dictated by the clinical scenario of each individual patient (e.g., immediate vs. delayed reconstruction). A reconstructive algorithm is created to assist with surgical planning (Fig. 33.12).

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FIGURE 33.12 In general, recipient vessels in the inferior part of the neck (transverse cervical vessels) or in the chest (internal mammary vessels) are preferred to facilitate reach of the mesenteric pedicle. The choice of recipient vessels also depends on conduit pathway, which is dictated by the clinical scenario of each individual patient (e.g., immediate vs. delayed reconstruction). A reconstructive algorithm is created to assist with surgical planning.

For delayed reconstruction, the substernal pathway is chosen because the retrocardiac route is scarred from previous surgery or infection. The left manubrium and clavicular head are resected and the internal mammary vessels are easily exposed, making them the recipient vessel of choice. The vascular anastomosis is then completed in the upper chest in the space where the manubrium and clavicular head were removed. The left transverse cervical vessels are an alternate option.

For immediate reconstruction, the native retrocardiac pathway is available and preferred to avoid unnecessary resection of the manubrium and clavicular head. This pathway is also slightly shorter than the substernal pathway. The internal mammary vessels, which are located anteriorly, are not a good option with this pathway. The transverse cervical vessels lower in the neck are preferred to avoid vein grafting to the external carotid system. The substernal pathway, however, should be considered during an immediate reconstruction in the following clinical circumstances: (1) the transverse cervical vessels are unavailable, which may occur in 23% of the unilateral necks and (2) the patient suffers from severe kyphosis. One contraindication for choosing the substernal pathway is in patients with previous coronary artery bypass surgery where the internal mammary artery was used as the bypass graft. Therefore, for immediate reconstruction, I now prefer exploring the left transverse cervical vessels first. If they are adequate, the retrocardiac pathway is chosen. If not, then I opt for the substernal pathway and the use of the internal mammary vessels. The second option is to proceed with the retrocardiac pathway and use the external carotid system, such as the superior thyroid artery and internal jugular vein as recipient vessels. This option is less desirable because a vein graft is often necessary, making an already complex reconstruction even more so.

POSTOPERATIVE MANAGEMENT

Patients are recovered first in the intensive care unit and then transferred to the ward. The externalized monitoring segment of the jejunum is observed for 7 to 10 days postoperatively at which time its mesentery is ligated and the segment removed. If the patient’s postoperative course is uneventful, a modified barium swallow (MBS) is performed 7 to 14 days postprocedure (Fig. 33.13). If no leak is detected, the patient is started on a liquid diet and slowly advanced to a postgastrectomy diet, as tolerated.

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FIGURE 33.13 If the patient’s postoperative course is uneventful, an MBS is performed 7 to 14 days postprocedure. If no leak is detected, the patient is started on a liquid diet and slowly advanced to a postgastrectomy diet, as tolerated.

COMPLICATIONS

Major postoperative respiratory complications are particularly common and difficult to manage due to the involvement of multiple organs and body cavities, major fluid shifts, frequent need for fluid resuscitation, and the relative contraindications to using vasopressors in the setting of microvascular reconstruction.

Our conduit-related complications are comparable to those reported in the literature and the majority of those occurred in our early experience. All subclinical radiographic leaks healed spontaneously within 2 weeks. Once a leak is identified on the initial MBS, the patients are kept NPO for additional 2 weeks and then an MBS is repeated. Most clinical fistulas also heal with conservative management. Major leaks or anastomotic breakdowns should be surgical explored and possibly reconstructed to prevent catastrophic complications. Anastomotic strictures are typically managed with endoscopic dilatation, and repeated dilatations may be required. Two patients in my series developed a stricture in the watershed jejunal segment in the middle of the conduit requiring surgical intervention, which highlights the importance of selecting the appropriate jejunal segment based on the mesenteric anatomy and understanding the extent to which arcade vessels can be divided.

RESULTS

Supercharged jejunal transfer is a technically demanding surgery, yet reasonable functional outcomes can be achieved. I published the largest series of supercharged jejunal flaps for total esophageal reconstruction to date. The majority of his patients were able to achieve a regular diet (90%) and discontinue their tube feeds (80%), which has a tremendous psychological and physical benefit to the patient. Reflux was infrequent and mild.

My overall success rate using an super-charged jejunal flap (SCJF) for total esophageal reconstruction was 94%, with three flap failures in my early experience. Two patients died during their hospitalization and medical and surgical complications occurred in 65% of patients, reflecting the fact that the SCJF is a challenging and complex procedure. Patients often have significant comorbid diseases and therefore need be nutritionally and medically optimized prior to surgery.

PEARLS

• For defects greater than 15 cm and for which the distal esophagus is inaccessible due to its intrathoracic location, a gastric conduit is the first choice for reconstruction.

• Free jejunal segments, which are often used in cases of hypopharyngeal and cervical esophageal carcinoma, are limited to short esophageal defects due to the segmental blood supply.

PITFALLS

• When using the jejunum, preoperative planning requires that a careful operative history is taken to assess the potential for abdominal adhesions that may hinder the harvest of a jejunal segment.

• If a leak is identified on the initial MBS, the patients are kept NPO for additional 2 weeks and then an MBS is repeated.

• Anastomotic strictures are typically managed with endoscopic dilatation, and repeated dilatations may be required.

INSTRUMENTS TO HAVE AVAILABLE:

• Abdominal surgical instruments

• Standard head and neck surgical set

ACKNOWLEDGMENTS

I gratefully acknowledge the contributions of Melissa M. Poh and Peirong Yu.

SUGGESTED READING

Anthony JP, Singer MI, Mathes SJ. Pharyngoesophageal reconstruction using the tubed free radial forearm flap. Clin Plast Surg 1994;21:137–147.

Reece GP, Schusterman MA, Miller MJ, et al. Morbidity and functional outcome of free jejunal transfer reconstruction for circumferential defects of the pharynx and cervical esophagus. Plast Reconstr Surg 1995;96:1307–1316.

Cho BC, Kim M, Lee JH, et al. Pharyngoesophageal reconstruction with a tubed free radial forearm flap. J Reconstrt Microsurg 1998;14:535–540.

Scharpf J, Esclamado RM. Reconstruction with radial forearm flaps after ablative surgery for hypopharyngeal cancer. Head Neck 2002;25:261–266.

Disa JJ, Pusic AL, Mehrara BJ. Reconstruction of the hypopharynx with the free jejunum transfer. J Surg Oncol 2006;94:466–470.

Yu P, Hanasono M, Skoracki R, et al. Pharyngoesophageal reconstruction with the anterolateral thigh flap after total laryngopharyngectomy. Cancer 2010;116(7):1718–1724.



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