The robotic-assisted free jejunal flap for neovaginal canal creation in gender-affirming vaginoplasties.

INTRODUCTION: One of the biggest challenges with gender-affirming vaginoplasty was the creation of a long-lasting, durable, patent, and self-lubricating neovaginal canal that allowed for spontaneous, pain-free sexual intercourse. The jejunum was a durable, physiologic, and intestinal option to create the neovaginal canal that minimizes the adverse effects of skin graft, peritoneal, and colonic vaginoplasties. Free jejunal vaginoplasties had been performed in cis females for congenital genitourinary anomalies like Mullerian agenesis or after gynecologic-oncologic surgery but had yet to be reported for gender-affirming vaginoplasties. The purpose of this report was to present a technique for a physiologic, intestinal, gender-affirming vaginoplasty without the disadvantages of colonic vaginoplasties. PATIENTS AND METHODS: This report presented six patients, all natal males who identified as female, undergoing robotic-assisted free jejunal flap gender-affirming vaginoplasty. Mean age was 35.8 years (range: 21-66). Mean body mass index was 33.2 kg/m2 (range: 28.0-41.0). The proximal aspect of the neovaginal canal was created intra-abdominally by elevating peritoneal flaps from the posterior bladder wall to be reflected downward into the external neovaginal canal. The jejunal flap was harvested. The greater saphenous vein was harvested to create an arteriovenous loop between the flap vessels and the recipient femoral artery in an end-to-side fashion and a branch of the femoral vein. The jejunal flap was passed intra-abdominally through the groin incision and then trans-peritoneally into the neovaginal canal. The jejunal segment was inset to the proximal peritoneal flaps and the distal inverted penoscrotal skin of the neovaginal introitus. RESULTS: Mean length of the harvest jejunal segment was 19.2 cm (range: 15-20). Mean time to ambulation, foley removal, and first vaginal dilation were 3.3 (range: 3-4), 4.0 (range: 3-5), and 4.5 days (range: 4-6), respectively. By a mean follow-up duration of 8.0 months (range: 1-14), mean vaginal depth and diameter were 7.0 and 1.3 cm (range: 1.0-1.5), respectively. Two (33.3%) patients experienced postoperative complications, including groin hematoma (n = 1, 16.7%) and reoperation for correction of dehiscence of the jejunal flap to the vaginal introitus (n = 1, 16.7%). CONCLUSION: Gender-affirming surgeons should consider a free vascularized segment of jejunum as an option to line the neovaginal canal in the correct patients.

Reconstruction techniques using free jejunal transfer for total pharyngolaryngectomy with total glossectomy.

BACKGROUND: Total pharyngolaryngectomy is sometimes combined with total glossectomy for advanced hypopharyngeal or cervical esophageal cancers involving the tongue base. The optimal reconstruction method for total pharyngolaryngectomy with total glossectomy has not been established due to a considerable diameter mismatch between the floor of mouth and the esophageal stump. This report describes two reconstruction methods using free jejunal transfer. METHODS: Five consecutive patients who underwent total pharyngolaryngectomy with total glossectomy were included, with a mean age of 67.0 (range 55-75) years. Primary tumors included tongue, hypopharyngeal, cervical esophagus, and laryngeal cancers. The mean defect size was 17.0 (16-19) × 6.8 (6-7) cm. Surgical techniques involved either a simple incision or a two-segment method to address the size mismatch between the jejunum and the floor of mouth. In the simple incision method, a longitudinal cut was made to the antimesenteric or paramesenteric border of a jejunum wall to expand the orifice. In the two-segment method, a jejunal graft was separated into two segments to reconstruct the floor of mouth and the cervical esophagus, and these segments were connected with a longitudinal incision to the cervical esophageal segment to form a funnel-shaped conduit. RESULTS: Of the five patients, three underwent the simple incision method and two the two-segment method. Postoperative pharyngoesophagography showed a smooth passage for all patients. Postoperative courses were uneventful except for one flap loss due to arterial thrombosis. Four patients achieved oral feeding, while one became gastric-tube dependent. At a mean follow-up of 22.1 (4-39) months, one patient required tube feeding, two tolerated full liquid, and two consumed a soft diet. CONCLUSIONS: Both the simple incision and two-segment methods achieved satisfactory swallowing function. The choice between these reconstruction methods may depend on the extent of resection of the posterior pharyngeal wall.

Reconstruction with free jejunal flap in dystrophic epidermolysis bullosa complicated with hypopharyngeal cancer: A case report.

Epidermolysis bullosa (EB) encompasses a range of rare genetic dermatological conditions characterized by mucocutaneous fragility and a predisposition to blister formation, often triggered by minimal trauma. Blisters in the pharynx and esophagus are well-documented, particularly in dystrophic EB (DEB). However, there have been few reports of mucocutaneous squamous cell carcinoma (SCC) in the head and neck region, for which surgery is usually avoided. This report presents the first case of free jejunal flap reconstruction after total pharyngolaryngoesophagectomy for hypopharyngeal cancer in a 57-year-old patient with DEB. The patient with a known diagnosis of DEB had a history of SCC of the left hand and esophageal dilatation for esophageal stricture. PET-CT imaging during examination of systemic metastases associated with the left-hand SCC revealed abnormal accumulation in the hypopharynx, which was confirmed as SCC by biopsy. Total pharyngolaryngoesophagectomy was performed, followed by reconstruction of the defect using a free jejunal flap. A segment of the jejunum, approximately 15 cm in length, was transplanted with multiple vascular pedicles. The patient made an uneventful recovery postoperatively and was able to continue oral intake 15 months later with no complications and no recurrence of SCC in the head and neck region. While cutaneous SCC is common in DEB, extracutaneous SCC is relatively rare. In most previous cases, non-surgical approaches with radiotherapy and chemotherapy were chosen due to skin fragility and multimorbidity. In the present case, vascular fragility and mucosal damage of the intestinal tract were not observed, and routine vascular and enteric anastomoses could be performed, with an uneventful postoperative course. Our findings suggest that highly invasive surgery, including free tissue transplantation such as with a free jejunal flap, can be performed in patients with DEB.

The Ischemic Tolerance up to Four Hours of Free Jejunum Flap: A Retrospective Cohort Study.

BACKGROUND: While free jejunum transfer (FJT) following total pharyngo-laryngo-esophagectomy (TPLE) is a reliable reconstruction technique, the jejunum flap is viewed as more susceptible to ischemia than a standard free flap. Animal studies have indicated that the jejunum can tolerate ischemia for as little as 2 to 3 hours. Clinical studies also reported increased complications after the FJT with more than 3 hours of ischemia. Traditionally, our institution has carried out FJT with an initial intestinal anastomosis, followed by a vascular anastomosis, which often results in extended jejunal ischemia time. In this study, we retrospectively examined the actual tolerance of the jejunum to ischemia, considering perioperative complications and postoperative dysphagia. METHODS: We retrospectively studied 402 consecutive cases involving TPLE + FJT. Patients were divided into five groups based on jejunum ischemia time (∼119 minutes, 120∼149 minutes, 150∼179 minutes, 180∼209 minutes, 210 minutes∼), with each variable and result item compared between the groups. Univariate and multivariate analyses were conducted to identify independent factors influencing the four results: three perioperative complications (pedicle thrombosis, anastomotic leak, surgical site infection) and dysphagia at 6 months postoperatively. RESULTS: The mean jejunal ischemia time was 164.6 ± 28.4 (90-259) minutes. When comparing groups divided by jejunal ischemia time, we found no significant differences in overall outcomes or complications. Our multivariate analyses indicated that jejunal ischemia time did not impact the three perioperative complications and postoperative dysphagia. CONCLUSION: In TPLE + FJT, a jejunal ischemia time of up to 4 hours had no effect on perioperative complications or postoperative dysphagia. The TPLE + FJT technique, involving a jejunal anastomosis first followed by vascular anastomosis, benefits from an easier jejunal anastomosis but suffers from a longer jejunal ischemia time. However, we found that ischemia time does not pose significant problems, although we have not evaluated the effects of jejunal ischemia extending beyond 4 hours.

Fasciocutaneous and jejunal free flaps for circumferential hypopharyngeal defect reconstruction: A 22-year multicenter cohort study.

BACKGROUND: It remains unclear whether a tubed fasciocutaneous or jejunal free flap (FCFF and JFF) is preferable for reconstruction of circumferential pharyngolaryngoesophageal defects. METHODS: All consecutive patients with circumferential pharyngolaryngoesophageal defects reconstructed with an FCFF or JFF between 2000 and 2022 were included. Outcomes of interest were rates of fistulas, strictures, and donor-site complications. RESULTS: In total, 112 patients were included (35 FCFFs and 77 JFFs). Fistula and stricture rates were significantly lower following JFF compared to FCFF reconstructions, with 12% versus 34% (p = 0.008) and 29% versus 49% (p = 0.04), respectively. Severe donor-site complications leading to surgical intervention or ICU admittance only occurred after JFF reconstructions (18%, p = 0.007). CONCLUSIONS: The high fistula and stricture rates in FCFF reconstructions and the rate of severe abdominal complications in JFF reconstructions illustrate inherent procedure-specific advantages and disadvantages. Relative pros and cons should be carefully weighed when tailoring treatments to the individual needs of patients.

Reconstruction using the colon or jejunum in patients with synchronous advanced esophageal and gastric cancers: a retrospective study from a single institutional database.

PURPOSE: The aim of this study was to evaluate the feasibility and efficacy of simultaneous resection of synchronous advanced esophageal and gastric cancers. METHODS: We retrospectively analyzed the clinical data of 16 patients who underwent resection of synchronous advanced esophageal squamous cell carcinoma (ESCC) and gastric adenocarcinoma from January 2009 to Dec 2021. Subtotal esophagectomy and total gastrectomy were performed using the Ivor-Lewis or McKeown approach. Reconstruction was performed using a pedicled jejunal graft or colon interposition. Perioperative and postoperative data of all patients were analyzed. RESULTS: There were no in-hospital mortalities following surgery, but 9 patients (56.3%) suffered major perioperative complications. Comparison of the groups that received reconstruction using the jejunum and the colon indicated similar incidences of perioperative complications, overall survival, and disease-free survival. Cox regression analysis indicated that lymph node metastasis of both cancers was independent risk factor for overall survival. CONCLUSION: The existence of synchronous tumors of the esophagus and stomach is not unusual, the radical surgical treatment could be carried out whenever possible.

Usefulness of intraoperative monitoring for mesenteric lymph node metastasis in transplanted free jejunum.

We herein report a rare case of a patient with hypopharyngeal squamous cell carcinoma (SCC) who presented with recurrent metastasis in the mesenteric lymph node of a transplanted jejunum. Removal of the metastatic lymph node required resection of the nutrient vessels which risked the current state of the transplanted jejunum. Importantly, although the nutrient vessels were resected, the jejunum did not become necrotic. This case and another similar case indicate that it may be possible to predict the viability of a transplanted jejunum where jejunal nutrient vessels must subsequently be resected. Key indicators for jejunal survival include determining jejunal blood flow by intraoperative indocyanine green fluorescence imaging, confirming good jejunal color and observation of peristaltic movement by intraoperative blood flow blockage of nutrient vessels. In conclusion, if intraoperative indocyanine green fluorescence imaging in the entire jejunum can be confirmed, there is a high possibility that the jejunum can be well preserved. The clinical presentation and clinical course are described with a proposed new schema of the resectable site of the transplanted jejunal mesentery.

Esofaguectomía cervical más resección traqueal e injerto de yeyuno libre como tratamiento de un tumor de células granulares esofágico / Cervical esophaguectomy plus tracheal resection and free jeyuno graft as treatment of esophageal granular cell tumor

El tumor de células granulares es una entidad muy infrecuente (0,03%) y con un manejo terapéutico controvertido debido a su escasa incidencia y a su comportamiento habitualmente benigno (98%). Su localización en el tracto digestivo es inusual (3-11%), y el esófago es el órgano más frecuentemente afectado, con unos 400 casos publicados. Sin embargo, la incidencia en el esófago cervical es anecdótica (20 casos publicados). Presentamos un paciente con un tumor de células granulares esofágico que invadía tráquea, tiroides y partes blandas, realizándose una resección en bloque de esófago cervical, dos anillos traqueales, tiroides y musculatura pretiroidea. Para la reconstrucción digestiva se empleó un injerto de yeyuno libre con anastomosis microvascular y reconstrucción traqueal mediante anastomosis termino-terminal. La importancia del caso es doble: aportar mayor casuística y describir una técnica quirúrgica altamente compleja nunca indicada en este tipo de tumores debido a su carácter raramente agresivo

Granular cell tumor is a very rare entity (0.03%) with controversial management, due to its low incidence and its usually benign behavior (98%). Its location in the digestive tract is unusual (3-11%), being the esophagus the most frequently affected organ, with about 400 published cases. However, the incidence in the cervical esophagus is anecdotal (20 published cases). We present a patient with an esophageal granular cell tumor that invaded trachea, thyroid and soft tissues, performing a block resection of the cervical esophagus, two tracheal rings, thyroid and prethyroid musculature. For digestive reconstruction, a free jejunum graft with microvascular anastomosis was made and tracheal reconstruction was performed using term-terminal anastomosis. The importance of the case is twofold: to contribute more casuistry, and to describe a highly complex surgical technique never indicated in this type of tumors, due to its rarely aggressive character

Near-infrared spectroscopy for monitoring free jejunal flap.

BACKGROUND: Although the free jejunal graft is commonly used for reconstruction after resection of a tumor of the pharynx or cervical esophagus, adequate monitoring for detecting graft failure is not available. We employed near-infrared spectroscopy to measure regional oxygen saturation (rSO2) in the graft. METHODS: In 25 consecutive cases who underwent reconstructive surgery using a free jejunal graft, the feasibility of postoperative rSO2 monitoring was examined along with the changes in rSO2 values following vascular clamping or reperfusion. RESULTS: No operative mortality occurred, and except for one case of subcutaneous hematoma that necessitated evacuation surgery, no complications related to surgery or graft failure occurred. Postoperative rSO2 monitoring was feasible for >50 hours in most cases. It mostly remained >55% with a stable hemoglobin index (HbI) which reflects tissue hemoglobin density. A marked increase in the HbI was noted in a patient with hematoma. Intraoperatively, the rSO2 of intact jejunal tissue was >60% in every case but dropped within a few minutes after arterial clamping because of decreased oxygenated hemoglobin concentration. With venous clamping, the HbI was elevated while the rSO2 remained unchanged or was slightly decreased. Upon graft reperfusion, the rSO2 rapidly recovered in all 18 cases because of the recovery of oxygenated hemoglobin concentrations. CONCLUSIONS: The near-infrared spectroscopic assessment sensitively and accurately reflected the condition of the jejunal graft. It appears to be a promising postoperative method for monitoring graft perfusion. An rSO2 value of 55% appears to be an adequate criterion for ischemia.

Engineering transplantable jejunal mucosal grafts using patient-derived organoids from children with intestinal failure.

Intestinal failure, following extensive anatomical or functional loss of small intestine, has debilitating long-term consequences for children1. The priority of patient care is to increase the length of functional intestine, particularly the jejunum, to promote nutritional independence2. Here we construct autologous jejunal mucosal grafts using biomaterials from pediatric patients and show that patient-derived organoids can be expanded efficiently in vitro. In parallel, we generate decellularized human intestinal matrix with intact nanotopography, which forms biological scaffolds. Proteomic and Raman spectroscopy analyses reveal highly analogous biochemical profiles of human small intestine and colon scaffolds, indicating that they can be used interchangeably as platforms for intestinal engineering. Indeed, seeding of jejunal organoids onto either type of scaffold reliably reconstructs grafts that exhibit several aspects of physiological jejunal function and that survive to form luminal structures after transplantation into the kidney capsule or subcutaneous pockets of mice for up to 2 weeks. Our findings provide proof-of-concept data for engineering patient-specific jejunal grafts for children with intestinal failure, ultimately aiding in the restoration of nutritional autonomy.

Correlation between blood flow, tissue volume and microvessel density in the flap.

The purpose of this study was to assess the correlation between tissue volume and blood flow of the flap in an animal model. Using animal model, tissue volume can be attenuated, and precise change of blood flow could be evaluated. We further investigate the relationship between blood flow and vascular density in the tissue. In this study, we assessed flap conductance (ml/min/mm Hg) as to evaluate the conductivity of blood flow into the flap. Japanese white rabbit was used (n = 7) for this study. The amount of blood flow of jejunal and latissimus dorsi muscle (LD) flaps was measured while removing the distal portion of the flap sequentially. Conductance at each time was calculated from blood pressure and blood flow volume. The tissue volume at each time was also measured. The correlation between conductance and volume was analyzed using a linear mixed model. Immunohistochemical evaluation of microvessel densities (MVD) in these tissues was also performed for CD31/PECAM1 positive area. Conductance and tissue volume were significantly correlated in both jejunal and LD flaps. As the volume increases by 1 cm3, the conductance increased significantly by 0.012 ml/min/mm Hg in jejunum, and by 0.0047 ml/min/mm Hg in LD. Mean MVD was 1.15 ± 0.52% in the jejunum and 0.37 ± 0.29% in the LD muscle. In this study, we revealed that flap conductance is proportional to volume and proportional constant is different between the type of tissue. It suggests that the difference of MVD creates the unique conductance of each tissue.

14 Years' experience of esophageal replacement surgeries.

BACKGROUND: Esophageal replacement is a challenge to the therapeutic skills of surgeons and a technically demanding operation in the pediatric age group. Various conduits and routes have been described in the literature, each with their specific advantages and disadvantages. We carried out this retrospective study to share our experience of esophageal replacement. METHODOLOGY: This study was conducted at the department of pediatric surgery The Children's Hospital and The Institute of Child Health, Lahore. The records of patients treated for esophageal replacement were reviewed. The patients under follow-up were called for clinical evaluation and assessed of long terms complications if any. RESULTS: A total of 93 patients with esophageal replacement were included in the study. Esophageal replacement was done with gastric transposition in 84 cases (90%), colon interposition in 7 cases (7.5%) including one case of redo colonic interposition, and jejunal interposition in 2 cases (2%). Routes of esophageal replacement were trans-hiatal in 71 (76%), retrosternal in 13 (14%), and trans-hiatal with thoracotomy in 9 (10%) patients. Postoperatively, all of the conduits maintained viability. Wound infection was seen in 10 (11%), wound dehiscence in 5 (5%), anastomotic leak in 9 (10%), anastomotic stenosis in 12 (13%), fistula formation in 4 (4%), aortic injury 1 (1%), dumping syndrome 8 (9%), reflux 18 (19%), dysphagia 15 (16%) and death occurred in 12 patients (13%). CONCLUSION: There are problems with esophageal replacement in developing countries. In this context, gastric conduit appeared as the best conduit for esophageal replacement, using the trans-hiatal route for replacement, in the authors' experience.

Morphological analysis of ischemia-reperfusion injury in a cold ischemia model of jejunal free flap for hypopharyngeal reconstruction.

BACKGROUND: Jejunal free flap (JFF) reconstruction is a popular treatment option for advanced hypopharyngeal cancer. Several factors including ischemia-reperfusion injury (IRI) can cause mucosal damage and progressive flap necrosis. We investigated the development and time-related progression of morphological and cellular changes in patients with JFF reconstruction including cold preservation of the graft. METHODS: Eleven patients were enrolled. Biopsies were taken during surgery from normally perfused tissue, before loop isolation (T0), at the end of back-table surgery (T1), immediately before reperfusion (T2), 15' after reperfusion (T3), and at the end of the digestive anastomoses (T4) and from the external monitor daily from the 1st to the 5th postoperative day (M1-M5). Histomorphological and immunohistochemical parameters in the intraoperative and postoperative samples were evaluated and compared. RESULTS: Delayed flap necrosis was observed in 2 patients. The cold ischemia phase did not negatively affect mucosal regeneration after reperfusion; morphological and cellular damage parameters returned to normal by the end of surgery or along the early postoperative period. Significant enterocyte replication activity was observed at the end of revascularization, which continued in the postoperative phase, leading to recovery of the epithelial morphological integrity and disappearance of apoptotic cells. An inflammatory infiltrate persisted in the M samples, and in a significant proportion of samples, mucosal fibrosis developed by the end of the postoperative observation. CONCLUSION: Cold perfusion and preservation of the JFF can effectively limit the negative effects of IRI and to prevent short- and medium-term complications that can compromise the final outcome.

Results of free flap reconstruction for patients aged 80 years or older with head and neck cancer.

OBJECTIVE: Free flap reconstruction in elderly patients is one of the most challenging surgeries in the treatment of head and neck cancers. The aim of this study was to examine the oncological and functional outcomes of free flap reconstruction for elderly patients with head and neck cancer. METHODS: We retrospectively reviewed elderly patients who underwent free flap reconstruction for the treatment of head and neck cancers. All patients were 80 years or older. Clinicopathologic features, surgical procedures, oncological and functional outcomes were obtained from medical records. RESULTS: Free flap reconstructions were performed in 13 patients (3 female, 10 male). The mean age was 82.6 ± 3.4 years (range: 80-91). The mean follow-up period was 23.3 months (range 4-41 months). The mean disease-free survival was 49 ± 6 months (range 4-60 months). All patients had been alive more than one year after surgery. Reconstruction was performed using free jejunum in 10 patients and radial forearm flap in 3 patients. Graft necrosis occurred in 2 patients. Other two patients experienced major postoperative medical complications. CONCLUSION: Free flap reconstruction in well-selected older adults is safe and effective. Advanced age should not preclude consideration of free flap reconstruction in those patients.

Clavien-Dindo classification for grading complications after total pharyngolaryngectomy and free jejunum transfer.

BACKGROUND: The frequency of postoperative complications is used as an indicator of surgical quality; however, comparison of outcomes is hampered by a lack of agreement on the definition of complications and their severity. A standard grading system for surgical complications is necessary to improve the quality of clinical research and reporting in head and neck reconstruction. METHODS: The aim of this study was to compare postoperative morbidity after microvascular head and neck reconstruction between patients with versus without a history of prior radiation therapy (RT) by using the Clavien-Dindo classification. A group of 274 patients was divided into two cohorts based on the history of prior RT: the RT group included 79 patients and the non-RT group included 195 patients. Postoperative (30-day) complications were compared between the groups with a nonstandardized evaluation system and the Clavien-Dindo classification. RESULTS: The grades of complications according to the Clavien-Dindo classification were significantly higher in the RT group than in the non-RT group. The frequency of postoperative complications did not differ significantly between the groups according to the nonstandardized evaluation system. CONCLUSIONS: The Clavien-Dindo classification could serve as a useful, highly objective tool for grading operative morbidity after microvascular head and neck reconstruction when comparing similar defects and methods of reconstruction. Widespread use of the Clavien-Dindo classification system would allow adequate comparisons of surgical outcomes among different surgeons, centers, and therapies.

Externalized Mesentery Monitoring of Vascularized Jejunum Transfers.

PURPOSE: The use of externalized jejunal monitoring flaps for jejunum transfers could be facilitative for the direct clinical assessment. Although this monitoring method would seem to be highly reliable, we modified this method and used mesentery only as a monitor to make it easy to manage the monitor more. METHODS: Between 2013 and 2018, 43 patients underwent vascularized jejunum transfer for reconstruction of laryngopharyngectomy using the externalized mesentery monitor. There were 39 men and 4 women, and patient ages ranged from 40 to 80 years (average, 66.6 years). The nursing staff monitored the externalized mesentery by using handheld Doppler ultrasonography every 2 hours for 7 days after surgery. RESULTS: Three patients had rather weak signal of handheld Doppler ultrasonography on the externalized mesentery monitors during operation, and handheld Doppler ultrasonography could not be applied. Of the remaining 40 patients using the externalized mesentery monitor with handheld Doppler ultrasonography, 39 had an uncomplicated postoperative period. In 1 patient, no signal of Doppler ultrasonography and lack of bleeding by pin prick from the monitor segment were noted in the immediate postoperative period, and revision of the vascular anastomosis was performed. Finally, the graft was salvaged. There was no case of infection in the monitoring flap or hypertrophic scar at the resected part of the flap. CONCLUSIONS: Using the externalized mesentery monitoring flaps, clinical monitoring by examining the exteriorized monitoring flap is possible, and only mesentery monitors were managed easily compared with jejunum monitoring flaps.

Ischemic Preconditioning and Iloprost Reduces Ischemia-Reperfusion Injury in Jejunal Flaps: An Animal Model.

BACKGROUND: Free jejunal flaps are among the most commonly used flaps for esophageal reconstruction. However, ischemia-reperfusion injury caused by warm ischemia seen during transfer limits their use. Iloprost, a prostacyclin analogue, has been shown to reduce ischemia-reperfusion injury in various organs. The authors investigated tissue damage in jejunal flaps with iloprost and ischemic preconditioning and compared the effectiveness of these two modalities. METHODS: Thirty-four Sprague-Dawley rats were randomized into five groups: sham, ischemia-reperfusion (control), ischemic preconditioning, iloprost, and ischemic preconditioning plus iloprost. All flaps, except those in the sham group, underwent ischemia for 60 minutes and reperfusion for 2 hours. Flap perfusion was assessed by laser Doppler perfusion monitoring. Histologic sections were scored using the Chiu scoring system. Superoxide dismutase and myeloperoxidase levels were measured spectrophotometrically. RESULTS: Animals that were administered iloprost and/or underwent ischemic preconditioning had better postischemic recovery of mesenteric perfusion (ischemic preconditioning, 78 percent; iloprost, 83 percent; ischemic preconditioning plus iloprost, 90 percent; versus ischemia-reperfusion, 50 percent; p < 0.05). All intervention groups showed improved histology of jejunal flaps following ischemia-reperfusion injury (ischemic preconditioning, 3; iloprost, 2.3; ischemic preconditioning plus iloprost, 3.2; versus ischemia-reperfusion, 4.7; p < 0.01, p < 0.001, and p < 0.05, respectively). Superoxide dismutase levels were higher in ischemic preconditioning, iloprost plus ischemic preconditioning, and iloprost groups (ischemic preconditioning, 2.7 ± 0.2; ischemic preconditioning plus iloprost, 2.5 ± 0.3; versus ischemia-reperfusion, 1.2 ± 0.1; p < 0.01; iloprost, 2.4 ± 1.1; versus ischemia-reperfusion, 1.2 ± 0.1; p < 0.05). Myeloperoxidase, a marker for neutrophil infiltration, was lower in the iloprost group (iloprost, 222 ± 5; versus ischemia-reperfusion, 291 ± 25; p < 0.05). CONCLUSIONS: This study showed that both iloprost and ischemic preconditioning reduced reperfusion injury in jejunal flaps. Based on histologic results, iloprost may be a novel treatment alternative to ischemic preconditioning.

Interposition of Retrosternal Pedicled Jejunum After Hypopharyngolaryngo-Esophagogastrectomy.

Reconstruction of the upper gastrointestinal tract presents a surgical challenge after esophagogastrectomy, especially when it includes hypopharyngolaryngectomy. Reconstruction is generally undertaken with interposed colon as a substitute conduit, but it carries several risks. Alternative reconstruction of the foregut with pedicled retrosternal jejunum anastomosed at the level of the base of the tongue is described.

Supercharged Jejunal Interposition: A Reliable Esophageal Replacement in Pediatric Patients.

BACKGROUND: There is no consensus for esophageal reconstruction in the pediatric population. Long defects are commonly repaired with gastric pull-up or colonic interposition; however, jejunal interposition offers several potential advantages in children. One historical concern with jejunal interposition has been the risk of flap infarction following transposition. The use of neck and intrathoracic vessels to "supercharge" the jejunum has been reported in adults. This study reports outcomes of supercharged jejunal interposition in pediatric and young adult patients with long esophageal defects. METHODS: The authors reviewed the medical records of patients who underwent supercharged jejunal interposition for esophageal reconstruction at their institution from 2013 to 2017. The authors collected data pertaining to patient characteristics, operative technique, and postoperative outcomes. RESULTS: Twenty patients, 10 female and 10 male, aged 1.4 to 23.8 years, underwent esophageal reconstruction with supercharged jejunal interposition and were followed for a median of 1.4 years. Seventeen patients had a primary diagnosis of long-gap esophageal atresia, and three required reconstruction following caustic ingestion. Eighty percent of patients had undergone prior attempts at surgical reconstruction. Postoperatively, all conduits demonstrated coordinated peristalsis, and no flap losses were noted. Major complications occurred in seven patients, stricture dilation was performed in four patients, and there was no mortality. CONCLUSIONS: Jejunal interposition with supercharging can be safely performed for management of long esophageal gaps in the pediatric setting; it is useful where the stomach or colon has been used previously or is unavailable. Long-term outcome studies are required to determine whether jejunal interposition provides a more durable and safe conduit than gastric pull-up or colonic interposition over time. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.