The Ischemic Tolerance up to Four Hours of Free Jejunum Flap: A Retrospective Cohort Study

Abstract

Background While free jejunum transfer (FJT) following total pharyngo-laryngo-esophagectomy (TPLE) is a reliable reconstruction technique, the jejunum flap is viewed as more susceptible to ischemia than a standard free flap. Animal studies have indicated that the jejunum can tolerate ischemia for as little as two to three hours. Clinical studies also reported increased complications after the FJT with more than three hours of ischemia. Traditionally, our institution has carried out FJT with an initial intestinal anastomosis, followed by a vascular anastomosis, which often results in extended jejunal ischemia time. In this study, we retrospectively examined the actual tolerance of the jejunum to ischemia, considering perioperative complications and postoperative dysphagia. Methods We retrospectively studied 402 consecutive cases involving TPLE+FJT. Patients were divided into five groups based on jejunum ischemia time (~119 min, 120~149 min, 150~179 min, 180~209 min, 210 min~), with each variable and result item compared between the groups. Univariate and multivariate analyses were conducted to identify independent factors influencing the four results: three perioperative complications (pedicle thrombosis, anastomotic leak, surgical site infection (SSI)), and dysphagia at six months postoperatively. Results The mean jejunal ischemia time was 164.6±28.4 (90 -259) minutes. When comparing groups divided by jejunal ischemia time, we found no significant differences in overall outcomes or complications. Our multivariate analyses indicated that jejunal ischemia time did not impact the three perioperative complications and postoperative dysphagia. Conclusion In TPLE+FJT, a jejunal ischemia time of up to four hours had no effect on perioperative complications or postoperative dysphagia. The TPLE+FJT technique, involving a jejunal anastomosis first followed by vascular anastomosis, benefits from an easier jejunal anastomosis but suffers from a longer jejunal ischemia time. However, we found that ischemia time does not pose significant problems, although we have not evaluated the effects of jejunal ischemia extending beyond four hours.