On September 9, 2021, Ascension St. John Head and Neck Surgeon, Changxing Liu, MD, PhD, performed Ascension St. John Medical Center’s first cervical esophageal cancer resection combined with pharyngolaryngectomy and reconstruction with a Jejunum Free Flap, together with Ascension St. John Medical Staff member, and OU Health General Surgeon, Geoffrey Chow, MD.
The Ascension St. John Otolaryngology – Head and Neck program includes two head and neck surgeons, Dr. Liu, who is board-certified by the American Board of Otolaryngology – Head and Neck Surgery and joined in 2020, and Dr. Mons, who is certified by American Osteopathic Board of Ophthalmology and Otolaryngology – Otolaryngology and Facial Plastic Surgery and joined in 2018.
Closely working with the radiation oncologists and medical oncologists at the Oklahoma Cancer Specialists and Research Institute (OCSRI), Ascension St. John Medical Center (ASJMC) provides state-of-the-art, clinical evidence-based, multidisciplinary treatments to provide patients with head and neck cancers excellent oncological care. “The care we provide wins trust from our patients,” says Dr. Liu.
Jejunum flaps are most commonly used for circumferential defects of the cervical esophagus when patient morbidity permits. Jejunum flaps offer the advantage of active transport of food by peristalsis. Studies suggest jejunal free flaps remain “an excellent first choice”(1) for pharyngo-laryngo-esophageal (PLO) defects and patients have a “significantly lower rate of stricture for reconstruction of circumferential pharyngeal defects when compared with RFF or ALT flaps”(2) when assessed using esophagogram and esophagoscopy.
“Our patient had a locally advanced invasive cancer (stage IV), but we were able to resect her cancer completely. It created a great advantage for the patient; most patients with this type of cancer have very dismal progress.”
“Jejunum free flaps are very useful, but a very rarely performed free flap. You can safely say that most head and neck surgeons in this country have never performed or been exposed to this type of tissue transfer and reconstruction due to its complexity and how surgically challenging it is to complete.” “Specifically, for this case, we folded the jejunum and parallelly connected the jejunum back-to-back to create a larger lumen for better swallow function. This made the surgery even more challenging but better for the patient. I believe this successful case further demonstrates our surgical services here really achieve at the top-level nationally,” says Dr. Liu.
Before surgery, the patient was found to have stage IV hypopharyngeal and upper esophageal squamous cell carcinoma, with an extensive invasion of her voice box from the back. She could not swallow any liquid or food and completely relied on a gastric feeding tube for nutrition.
“The patient placed her trust in us after her clinic visit. We had an extensive discussion with care planning. The surgery was completed in about eight hours. The incision on her stomach was small since we used a combined laparoscopic and open approach for the flap harvest.”
“We used an intraoperative angiogram to confirm we re-established blood perfusion to the jejunum graft. There was a small segment of the jejunum flap placed outside her neck for post-operative monitoring.” The patient stayed in the hospital for eleven days. “She had a swallow study and EGD study on day ten, showing complete healing of the jejunum free flap to her throat above and below her esophagus. She began eating immediately after the studies without any issues. At the patient’s post-operative appointment, the cancer was entirely resected. Her long-term quality of life still needs observation.”
In a study to assess long-term functional outcomes post-pharyngolaryngectomy and free jejunal reconstruction, “Eighteen of the nineteen patients were tolerating an oral diet, with one patient reliant on percutaneous endoscopic gastrostomy feeds” and 89 percent “having either no—or only a mild degree—of dysphagia, with no evidence of aspiration”(3) with a period of a mean time to follow up of four years.
Ascension St. John also provides multi-disciplinary care and rehabilitation services to assist with patient recovery. Ascension St. John’s Speech Pathology program includes inpatient and outpatient speech pathologists to help patients recover and treat dysphagia after surgery for esophageal cancer.
“We are proud to serve all head and neck cancer patients, especially those with very advanced head and neck cancers, with cutting edge surgical treatments throughout the state,” says Dr. Liu.
To learn more about Ascension St. John ENT and Head and Neck services, please visit this website or call (918) 403-6284.
(1) Koh HK, Tan NC, Tan BK, et al. Comparison of Outcomes of Fasciocutaneous Free Flaps and Jejunal Free Flaps in Pharyngolaryngoesophageal Reconstruction: A Systematic Review and Meta-Analysis. Ann Plast Surg. 2019;82:646–652. https://journals.lww.com/annalsplasticsurgery/Fulltext/2019/09000/Comparison_of_Outcomes_of_Fasciocutaneous
(2) Chye Tan N, Pao-Yuan L, et al. An objective comparison regarding rate of fistula and stricture among anterolateral thigh, radial forearm, and jejunal free tissue transfers in circumferential pharyngo-esophageal reconstruction. Microsurgery. 2015;35:345–349. https://onlinelibrary.wiley.com/doi/abs/10.1002/micr.22359
(3) Sharp DA, Theile DR, Cook R, Coman WB. Long-term functional speech and swallowing outcomes following pharyngolaryngectomy with free jejunal flap reconstruction. Ann Plast Surg. 2010 Jun;64(6):743-6. doi: 10.1097/SAP.0b013e3181af3019. PMID: 20489402. https://pubmed.ncbi.nlm.nih.gov/20489402/