RECONSTRUCTIVE Motility Differences in Free Colon and Free Jejunum Flaps for Reconstruction of the Cervical Esophagus Hung-Chi Chen, M.D. Background: Free colon and jejunal flaps have been described as reliable and Antonio Rampazzo, M.D. safe conduits for pharyngoesophageal reconstruction. Compared with free co- Bahar Bassiri Gharb, M.D. lon flaps, free jejunum flaps have a smaller diameter and intrinsic peristaltic Marcus T. C. Wong, M.D. movement, both of which are considered possible causes of dysphagia. In this Samir Mardini, M.D. investigation, the authors evaluated motility differences in free jejunum and Hue-Yong Chen, M.D. colon flaps using radionuclide esophageal scintigraphy. Christopher J. Salgado, M.D. Methods: Patients who received free jejunum flaps (n ϭ 12) or free colon (n ϭ 1) Kaohsiung, Taiwan; Rochester, Minn.; or ileocolon flaps (n ϭ 13) for reconstruction after pharyngoesophagectomy for and Cleveland, Ohio cancer were included. Radionuclide esophageal scintigraphy was performed using technetium-99m–labeled sulfur colloid. Transit rate was evaluated at 1 second (pharyngeal or initial clearance) and 10 seconds (esophageal or clearance through- out). Clinical progression of swallowing was recorded postoperatively. Statistical analysis was performed using the t test. Results: Mean pharyngeal clearance was 61 Ϯ 20 percent for free colon and ileocolon flaps and 70 Ϯ 16 percent for free jejunum flaps. Mean esophageal clearance was 50 Ϯ 27 percent for free colon and ileocolon flaps and 69 Ϯ 17 percent for free jejunum flaps. Esophageal transit rate was significantly shorter in patients who underwent reconstruction with free jejunum flaps (p ϭ 0.04). At 1 year, 10 of 12 free jejunum patients and eight of 14 patients were tolerating solid foods. Conclusions: Although neither flap showed normal swallowing characteristics, free jejunum flaps displayed greater esophageal clearance and should represent the first choice in hypopharyngeal reconstruction. Free colon and ileocolon flaps should be reserved for very proximal oropharyngeal defects and when simultaneous voice reconstruction is desired. (Plast. Reconstr. Surg. 122: 1410, 2008.) esection of extensive tumors of the hypo- the cervical esophagus following resection for be- pharynx and cervical esophagus represents nign and malignant causes. The choice of flap Ra reconstructive challenge for the plastic sur- seems to be dependent on the surgeon’s training, geon. The ideal reconstructive technique should experience, and the assessment of the defect after be a single-stage procedure with low morbidity extirpation. When comparing, the free jejunum and mortality, and provide rapid restoration of flap to the free colon flap, the small diameter of swallowing function. Both free colon1 and free the jejunum commonly requires end-to-side anas- jejunum2 flaps provide reliable reconstruction of tomosis or some fashioning either to the pharynx or esophagus.3 In addition, the intrinsic cyclic mo- From the Department of Plastic Surgery and the Department of Radiology, E-Da Hospital, I-Shou University; the Division of Plastic Surgery, Mayo Clinic; and the Department of Plastic Surgery, University Hospitals Cleveland, Case West- ern Reserve University. Disclosure: None of the authors has any commer- Received for publication January 29, 2008; accepted March cial associations that might pose or create a conflict 19, 2008. of interest with the information presented in this Presented at the 2008 Meeting of the American Society for article. This includes consultancies, stock ownership Reconstructive Microsurgery, in Los Angeles, California, or other equity interests, patent licensing arrange- January 12 through 15, 2008. ments, and payments for conducting or publicizing Copyright ©2008 by the American Society of Plastic Surgeons the study described in the article. DOI: 10.1097/PRS.0b013e31818820f4 1410 www.PRSJournal.com Volume 122, Number 5 • Free Colon versus Free Jejunum Flap tility of the free jejunum flap may cause spasm on an interrupted suture technique and microscope. swallowing or intussuseption.4,5 Anastomosis of All flaps were inset in an isoperistaltic direction the remnant small bowel in the abdomen, how- and sutured end to end, in two layers, to the phar- ever, reportedly has fewer complications because ynx or distal esophagus. of the better vascularity of the small bowel.6 Free colon and ileocolon flaps, in contrast, conform and shape better, enabling an end-to-end anasto- Radionuclide Esophageal Scintigraphy: Transit mosis with both the pharynx and the esophagus. Scan Study Anastomotic leakage and postoperative ileus are, The study was performed on average after 10 however, more common for large bowel surgery and 11 weeks after the cervical esophageal recon- and may therefore increase donor-site morbidity.5 struction with free jejunum and free colon/ileo- Although manometry has been considered the colon flaps, respectively. All of the patients were standard examination for the evaluation of oe- informed to stop the medications that could have sophageal dysmotility, it gives little information on influenced esophageal motility and were asked to morphology and has low patient acceptance.7 Ra- fast for at least 6 hours before the study. dionuclide oesophageal scintigraphy stands out as Patients were placed in the sitting position with a frequently used alternative to manometry be- their chest and neck against a large-field-view cause it is a safe, noninvasive, and sensitive method gamma camera (Siemens E-CAM double-head cam- that allows quantitative assessment of esophageal era; Siemens Medical Solutions, Malvern, Pa.) to motility.8 The aims of this study were to objectively visualize the mouth, hypopharynx, entire esoph- assess and compare the clinical outcome and agus, and proximal portion of the gastric fundus esophageal motor function of patients who un- in the same field. A radioactive marker was placed derwent cervical esophageal reconstruction with on the cricoid cartilage to show the junction be- free jejunum or free colon or ileocolon flaps using tween the pharynx and the cervical esophagus. radionuclide oesophageal scintigraphy. Patients swallowed a 10-cc liquid bolus of radio- nuclide labeled with 0.3 to 0.6 mCi of technetium- PATIENTS AND METHODS 99m sulfur colloid (CIS-US, Inc., Bedford, Mass.) A prospective study was carried out evaluating delivered into the mouth using a syringe with a the hypopharyngeal conduit motility in patients blunt plastic tip while sitting in front of the col- undergoing reconstruction of the hypopharynx limator head of the gamma camera (140 KeV, with free intestinal flaps following tumor ablation collimator HiResPar, zoom 1). The transit scan between 2001 and 2004. Patients requiring hypo- evaluation was performed after swallowing the ra- pharyngectomy underwent reconstruction with dioagent and subsequent dry swallowing every 15 free jejunum flaps. Patients with proximal hypo- seconds. The swallowing sequences were recorded pharyngeal defects and thus requiring a better cal- by the microprocessor at 0.5-second intervals and iber match received a free colon flap. Hypophar- then stored on a computer disk. Recordings were yngolaryngectomy defects were treated with free analyzed taking into consideration the cricoid re- ileocolon flaps for simultaneous voice reconstruc- gion and gastroesophageal junction. Initial bolus tion. All of the patients received postoperative transit rate (after 1 second) was recorded as pha- radiotherapy. Transit scan studies were performed ryngeal clearance or pharyngeal transit rate and before postoperative radiotherapy on 26 patients the global esophageal transit rate was recorded who underwent a free jejunum flap (n ϭ 12) or a after 10 seconds to study the entire esophagus free colon (n ϭ 1) or ileocolon flap (n ϭ 13). (esophageal clearance or “throughout” transit There were 24 men and two women. The mean rate). Transit rate was determined based on the amount of residual activity in the segment using age was 55 years. Patient consent was obtained for ϭ Ϫ all studies, and this study was approved by our the following formula: C(t) Emax E(t)/E hospital committee review board. max, where C(t) represents the percentage of pharynx and esophagus emptying at 1 second and 10 seconds, respectively; E max represents the Operative Procedure maximal count rate in the pharynx and esopha- Free colon, ileocolon, and jejunum flaps were gus, respectively; and E(t) represents the segment harvested in a standard fashion. Recipient vessels count rate at 1 second and 10 seconds, respec- were the transverse cervical artery and external tively. Ninety percent was considered the physio- jugular vein (if available) or end-to-side to the logic transit rate in both segments. Progression of internal jugular vein or one of its branches using deglutition training was recorded and compared, 1411 Plastic and Reconstructive Surgery • November 2008 as was the nature of food the patient could tolerate after 4 weeks and 12 months after surgery. Statistical Analysis Transit rate data with standard deviations were calculated. For the statistical analysis, patients re- ceiving free colon and free ileocolon flaps were treated as one group. The t test (two-sided, 95 percent confidence interval) for samples with dif- ferent variances was used to compare pharyngeal and esophageal transit rates between the two groups and the differences considered significant for values of p Յ 0.05. RESULTS There were no free flap losses in either group or reexplorations