Reconstruction of partial laryngopharyngectomy defects

As our contributors to this section have pointed out, there are at present two main methods of reconstructing defects of the pharynx and cervical esophagus: free jejunal transfer (FJT) and tubed radial forearm flap. The advantage of the FJT is that it is a tube, thus limiting the enteric suture lines to proximal and distal. The radial forearm flap requires not only the proximal and distal suture lines but a long longitudinal suture line to create the tube. This increase the possibility for fistula formation. The controversy surrounding this case concerns what to do with a remaining mucosal strip after a subtotal laryngectomy. Traditional reconstructive principles would dictate that normal tissue should not be sacrificed, but some would argue that the remaining mucosa should be sacrificed to allow for use of a FJT. The other alternative would be use of a radical forearm skin flap tubed to 270 degrees. At the University of Texas M. D. Anderson Cancer Center, we preferentially use the FJT for almost all defects and would probably have sacrificed the remaining mucosal strip in this particular case. We have used skin flaps to patch pharyngeal defects and prevent stricture in a number of cases. This is usually done however when the remaining pharyngeal mucosa approaches 50% or greater. Although we do not routinely use the tubed radial forearm flap because of the increased rate of fistula formation, there are some definite indications for its use. The first important indication is in patients in whom speech rehabilitation is desired or indicated. The skin flap provides a stiffer resonating chamber for the speech production and does not have the peristalsis or the mucus production associated with the jejunal flap. Another indication for use of radial forearm flap would be when there is a contraindication to celiotomy, ie, patients with hepatic cirrhosis and associated ascites or other abdominal conditions precluding abdominal exploration. In this situation, avoiding an intra-abdominal procedure would limit operative morbidity. In conclusion, one should use whichever procedure obtains a healed wound and re-establishes continuity of the upper gastrointestinal tract. In our hands, retention of the remaining mucosal segment would not be critical in this particular case and in fact would present a hindrance to use of the FJT.