Survival of a Free Jejunal Flap with Early Venous Obstruction

Free jejunal flap transfer is common in head and neck reconstruction, but necrosis remains a complication. A 77-year-old man underwent total pharyngo-laryngo-esophagectomy, bilateral neck dissection, and free jejunal flap transfer. We anastomosed 3 arteries (facial, transverse cervical, and superior thyroid) and 1 vein (jejunal) because the recipient site’s arterial status was poor. On day 2, ultrasonography and visualization revealed that the anastomosed vein was obstructed in the cranial jejunum but the remainder was viable. The region recovered by day 7 and the patient began oral intake on day 30. Ultrasonography revealed that the anastomosed jejunal vein showed no waveform, the facial and transverse cervical arteries showed arterial waveforms, and the superior thyroid artery showed a retrograde venous waveform. The flap had survived because the blood exited through the superior thyroid artery and vein. Thus, additional vascular and arterial anastomoses are options for free flap survival if the vascular status is poor.

RA02.07: A TWO-STAGE OPERATION USING A FREE JEJUNAL FLAP FOR GASTRECTOMIZED ESOPHAGEAL CANCER

Background The stomach is not available as a reconstruction organ in previously and synchronously gastrectomized esophageal cancer patients. In these patients, a pedicled jejunum or colon is mainly used for the reconstruction organ instead of the stomach, however, its reconstruction procedure is different among the institutes. In our department, a two-stage operation using a free jejunal flap (FJF) is performed when the stomach is unavailable. Methods A two-stage operation using a FJF for gastrcectomized esophageal cancer performed between 2010 and 2016 were retrospectively analyzed to evaluate a safety and feasibility of our operation. Results A two-stage operation using a FJF was performed for 30 cases, 19 for previously gastrectomized cases, and 11 for synchronous cases, respectively. Among 30 cases, thoracic and cervical esophageal cancer cases were 25 and 5, respectively. For 25 cases of the thoracic esophageal cancer, a subtotal esophagectomy, making a cervical esophagostomy and a jejunal tube placement was performed at the first stage, a reconstruction through the subcutaneous route using a FJF with vascular anastomoses by plastic surgeons was performed at the second stage. Median operation time of first and 2nd stage was 334 and 503 minutes, respectively. An internal thoracic artery was used for a recipient artery in all cases. In 4 of 5 cases of cervical esophageal cancer, a subtotal esophagectomy, esophago-jejuno anastomosis, making a jejunostoma using a FJF was performed at the first stage, the reconstruction of the anal side of a jejunostoma was performed by using a pedicled intestine at the second stage. Median operation time of first and second stage was 640 and 260 minutes, respectively. Clavien-Dindo grade IIIb or IV postoperative complication was seen in 3 cases (10%) after the first stage, 3 cases (10%) after the second stage. Necrosis of a FJF and anastomotic leakage was seen in 0 (0%) and 5 cases (17%), respectively. Conclusion A two-stage operation using a FJF needs plastic surgeon's cooperation, but is considered to be safe and feasible operation when a stomach is not available. Disclosure All authors have declared no conflicts of interest.

PS01.127: SURGICAL RECONSTRUCTION OF ESOPHAGO-INTESTINAL CONTINUITY IN PATIENTS WITH SURGICAL CONDUIT FAILURE AFTER ESOPHAGEAL RESECTION AND RECONSTRUCTION

Background Surgical restoration of gastrointestinal tract integrity for failed esophageal conduit is technically challenging with significant morbidity and mortality. The purpose of this study was to evaluate the feasibility and safety of restored esophago-intestinal integrity for the failed reconstructed esophagus. Methods From January 1990 to July 2017, a total of 1923 patients underwent esophageal cancer surgery. 29 patients (1.5%) presented with a clinical picture of failed conduits secondary to frank conduit necrosis, tracheoesophageal fistula, conduit stricture, and conduit cancer. We retrospectively analyzed 22 patients who planned to go for surgical reconstruction for a failed esophageal conduit. Results The median age was 62.5 (14–72) years old, and all of the patients were males. The underlying pathology was esophageal squamous cell carcinoma for all patients. The interval between the first esophagectomy and the surgery for failed conduits was 14 days for conduit necrosis (n = 9), 43 days for TEF (n = 7), 1256 days for conduit stricture and 1520.5 days for conduit cancer(n = 4). Of the 22 patients, 18 patients (81.8%) underwent a successful surgical restoration of the esophago-intestinal integrity. Three of the remaining 4 patients who planned for reconstructive surgery died of pneumonia-related complications within 30 days and one patient elects to have a cervical esophagostomy.Among reconstructed patients, 14 patients had failed gastric conduit and 4 had failed colon conduit. For the gastric group, restoration of the gastrointestinal continuity achieved using esophagocolostomy in 12 patients, free jejunal flap in 1 patient and colon with a free jejunal flap in 1 patient. While in the colon group, restoration was accessible using free jejunal flaps in 2 patients, ileocolon in 1 patient and gastric conduit in 1 patient. During post-operative follow-up, 7 patients died with pneumonia or mediastinitis related complications, 3 died of cancer progression, and 1 unknown origin. The median survival time after conduit reconstruction was 36 months. Conclusion Once a failed esophageal conduit is diagnosed, the decision of surgical reconstruction of gastrointestinal continuity can be feasible with a relatively good outcome if efficiently treated. In our study, reconstruction was possible in 81.8% of patients with a median survival time of 36 months after esophago-intestinal integrity restoration. Disclosure All authors have declared no conflicts of interest.