Abstract
Free jejunal flaps are now commonly used for reconstruction after resection of hypopharyngeal cancer and cervical esophageal cancer. Although other skin flaps are found to be well revascularized from surrounding tissue, the jejunal flap is poorly revascularized. We report on one patient who presented with ischemic stenosis of a transferred free jejunum after resection of a mesenteric lymph node. A 67-year-old man developed advanced hypopharyngeal carcinoma and underwent pharyngolaryngectomy, neck dissection on both sides, and free jejunal transfer at our hospital. After two years, mesenteric lymph node metastasis was discovered via FDG-PET scan and the metastatic lymph node was resected. However, after the operation, the transferred free jejunum developed ischemic stenosis, and the stenosis became so severe that, after five years, the patient could not eat any food. The previously transferred free jejunum was resected and replaced with a new jejunal flap. The resection had a full circumferential stenosis in part of the free jejunal flap. The pathological findings indicated that the mucosa had atrophied and been lost, while the submucosal tissue had fibrous tissue growth. The muscular layer, however, was found to have less fibrous tissue.
Unlike skin flaps, the jejunal flap is considered to be less tolerant to ischemic conditions, i.e., the ischemic time is shorter in jejunal flaps than in skin flaps. In several experimental animal studies, it has been reported that fibrous tissue easily grows in mucosal and submucosal tissue of the jejunum under ischemic conditions. The mesenteric vessels are terminal vessels near the jejunum and no communications are sent between vessels. In this case study, the susceptibility of the combination of mucosal and submucosal tissues to ischemia and the mesenteric vessels’ decreased network may have contributed to the full circumferential stenosis of the free jejunal flap.
