Adequate venous drainage: the most critical factor for a successful free jejunal transfer

Reconstruction of the cervical esophagus with free jejunum can yield excellent functional results. Flap survival alone, however, does not guarantee satisfying functional outcomes. Critical factors that determine the level of function of the flap include the duration of ischemia and degree of venous congestion. An attempt is made in this study to evaluate the degree that these 2 factors influence outcome and to establish safe methods for avoiding suboptimal functional results. Out of 71 patients that underwent free jejunal transfer for the reconstruction of the cervical esophagus between January 1995 and December 1999, 60 patients with available chart records were included into this study. A retrospective chart review was performed on all 60 patients to evaluate the degree of venous congestion in those patients and the choice of recipient veins and method of anastomosis of those veins (end-to-end versus end-to-side). A more detailed review was performed on the 8 patients that underwent reexploration and detailed history, operative method, ischemia time, choice of recipient vessels, technique of anastomosis, immediate postoperative course, and outcome were determined. Following exploration of the flaps, all flaps survived. Two developed partial necrosis. When smaller veins were used as recipient vessels, the chances of venous congestion were found to be higher than when larger recipient veins were used (chi2 analysis, P <0.02). Method of anastomosis and previous radiotherapy were both found to be significant determinants of venous congestion (chi2 P <0.05 for both). Venous problems accounted for 87.5% (7/8) of all reexplorations. In 75% (6/8) of the reexplored patients, pharyngocutaneous fistula formation or stricture formation was noted.The degree of venous congestion and previous radiotherapy are factors that influence the functional outcome of free jejunal flaps. Proper selection of the recipient veins is a critical factor in providing adequate venous outflow and minimizing venous congestion. End-to-side anastomosis to large vessels is a more reliable method that was found to have a significant influence on minimizing venous congestion and is a useful method for the salvage of venous congested flaps.