Free Jejunal Interposition following Pharyngolaryngectomy: Report on 25 Consecutive Cases

Free jejunal interposition has become a common procedure for reconstruction of circumferential defects following pharyngolaryngectomy. Methods: Retrospective analysis of 25 consecutive free jejunal interposition grafts performed in the Department of Surgery, Kwong Wah Hospital between 1995 and 2002. The median age was 65 (range 45–74). There were 22 men and three women. The median follow up was 20 months. The most common site was the hypopharynx (n=17), followed by larynx (n=2), neopharynx (n=2), tongue base (n=2), recurrent carcinoma thyroid (n=1) and intractable gastritis post PLO secondary to radiotherapy (n=1). They were all either T3 or T4 tumours. Three patients had received prior radiotherapy as initial treatment or for another previous primary. Twenty patients received postoperative radiotherapy. The jejunum interposition grafts were harvested from the second or third arcade. Esophago-jejunal and pharyngo-jejunal anastomoses were performed in sequence and in the end to end manner. Sentinel loops were used to monitor flap viability in the majority of cases. Results: There was no peri-operative mortality. Major complications include six anastomotic leakages treated conservatively, one delayed flap failure(1/25) due to infection and one post operative myocardial infarction. Donor site morbidity includes one intra-abdominal haemorrhage due to slipped mesenteric ligatures and one jejuno-jejunal anastomotic stricture. There was no fistula or stricture formation. Nineteen patients were available for assessment and 94% were able to maintain solid (11/18) and soft diet (7/18) at 1 year postoperatively. Voice rehabilitation includes electrolaryx (6), pneumatic devices (3) and Provox (5). Kaplan-Meyer was used to estimate survival and the 1- and 3-year survival rates were 70 and 46.9%, respectively. Nine patients died of loco-regional recurrence; one with carotid blowout. One patient died of systemic metastases. Two patients succumbed to another aero-digestive primary tumour and two to unrelated medical problem. Conclusion: In conclusion, the free jejunal interposition graft is a safe and predictable method of reconstruction following total pharyngolaryngectomy and expeditiously providing return of function in patients with late stage disease.