802. TECHNICAL DETAILS: FREE JEJUNAL GRAFT AND REVERSE SAPHENOUS VEIN GRAFT FOR RECONSTRUCTION AFTER TOTAL PHARYNGO-LARYNGECTOMY AND PROXIMAL ESOPHAGECTOMY
Authors: Caballero Javier Martínez , Cuéllar Elías Rodríguez , Gavilanes-Plasencia Javier , González Esther García , Pena Israel Iglesias , Torrado Cristina Alegre , Rodríguez Pilar Gómez , Beltrán Pablo Vázquez , Herrero Eduardo Ferrero 
Published: September 2024

Abstract

Background
We would like to show our tips for free jejunal graft and vascular reconstruction after pharyngo-laryngectomy and proximal esophagectomy.

Methods
65 years-old man with history of hypopharynx squamous cell carcinoma cT3 cN0 cM0 who underwent radical Qt/Rt with initially complete response. After 2 years follow-up, he presented dysphagia and recurrence of squamous cell carcinoma proven by histology. Upper endoscopy shows cervical esophageal stenosis due to tumor infiltration. Rescue surgery was decided after systemic dissemination was ruled out with PET-CT.

Results
Pharyngo-laryngectomy, total thyroidectomy and proximal esophagectomy was performed. Free margin tumor was confirmed by frozen section.
Jejunal segment with adequate vascular supply is selected, preferable with a single artery and vein. Peristaltic direction of the jejunum is marked to avoid mistakes during graft transposition. Division of mesenteric branches to prevent postoperative bleeding. Before jejunal section we recommend administration of hyoscine butilbromide 20 mg iv to avoid jejunal spams. Measuring the length graft needed before dividing the jejunum to avoid redundant or short graft is recommended. We must carefully isolate the pedicle avoiding damaging blood supply. To reduce time of ischemia, jejunal graft pedicle should not be ligated until cervical dissection is completed and we have ruled out if venous graft may be needed.
After cervical artery and vein dissection, we ensure adequate blood flow and heparinize vessels before clipping.
When dividing the pedicle, artery should be divided before the vein to avoid venous congestion, posteriorly we must heparinize the vessels. Povidone-iodine intraluminal washing is recommended. Jejuno-jejunal anastomosis for GI tract restoration.
GI reconstruction first is recommended to avoid unnecessary traction on the vascular anastomosis. After ensuring adequate direction of the jejunal graft jejuno-esophageal anastomosis is performed with interrupted suture. Pharyngo-jejunal anastomosis is performed with barbed 3-0 running suture for anterior and posterior layer. Methylene blue test is performed for check the anastomosis.
Vascular reconstruction technique depends on the vascular anatomical variations and availability. In this case, superior thyroid artery and sublingual vein were available. Saphenous vein graft might be needed, this graft must be used in reverse way to avoid the vein valves and length must be adjusted. Venous anastomosis should be performed before than arterial reconstruction after heparinize solution in both vessels to avoid thrombosis.

Conclusion
Free jejunal graft is a highly complex procedure that must be extremely coordinated and protocolized to avoid longer time of ischemia and risk of thrombosis that might compromise the graft viability.
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