Hypopharynx reconstruction

Surgical techniques

For reconstructive tissue to bypass the short stenosis a free jejunum flap could be considered. We use the jejunum as a patch with re-orientation of the tube to avoid twisting of kinking of the flap. 

 
Postchemoradiation hypopharyngeal stenosis. (Click on the links to view/hide the consecutive images)

a. Schematic presentation of postcricoid stenosis from posterior. The left side (L) of the pharynx is shown after opening ; white double arrows show the midline incision and the incision at the upper and lower site of the stenosis. The postcricoid area shows a complete stenosis. The incisons indicated by the white double arrows are made for didactic reasons and are not made during the actual operation.

Hypopharyngeal stenosis

b. During operation, an opening is made in the left lateral hypopharynx at the upper site of the stenosis. At the site of the hypopharyngeal opening (1), the lamina of the thyroid cartilage is removed with a burr. The cervical esophagus is incised at the lower site of the stenosis (2).

Hypopharyngeal stenosis

c. A loop is constructed between the upper pharyngeal opening and the lower esophageal stump. To bypass the postcricoid stenosis, the loop needs a length of 6-7 cm. The width (6-7 cm) of an incised segment of jejunum is used to bridge the length of the stenosis.

Hypopharyngeal stenosis

Free jejunum to bypass the postcricoid stenosis. (Click on the links to view/hide the consecutive images)

a. Tube of jejunum. A segment of 14 cm is taken on the vascular pedicle.

Free jejunum graft

b. Patch of jejunum. The jejunum is completely divided in a longitudinal fashion along its antimesenteric border. Circular mucosal folds are visible. The patch is divided (white double arrows) in a segment of 10 cm and 2 segments of 2 cm. The width of the patch measures 6-8 cm.

Free jejunum graft

c. Formation of tube (arrows) with longitudinal oriented mucosal folds. First, the upper side of the patch is tubulated and this side is sutured to the pharyngeal opening (1). The patch is progressively made into a tube (2) and the reconstruction is completed by suturing the lower end (3) to the stump of the cervical esophagus. The circumference of the newly formed tube measures 10 cm with a length between 6 and 8 cm (width of jejunum patch). A 2 cm segment of jejunal mucosa is removed and the distal 2 cm of the jejunal patch will serve as the monitor flap.

Free jejunum graft

d. Presentation of jejunum after tubulation (U= upper end of tube; L= lower end of tube). The monitor flap will be placed in the neck incision to allow for direct observation

Free jejunum graft