Feasibility and reliability of supermicrosurgical vasa recta anastomosis for double-pedicled free jejunum transfer

Abstract

Background: Although free jejunal transfer is an established and reliable procedure for reconstruction after total pharyngolaryngectomy (TPL), vascular thrombosis remains a surgical challenge. To reduce the risk, a double-pedicled free jejunal flap transfer has been attempted using a root jejunal artery and an arcade artery, although several drawbacks exist. The vasa recta are terminal straight vessels that arborize from an arcade artery without branching. We present a novel double-pedicled free jejunum transfer using vasa recta anastomosis. Methods: Between 2011 and 2015, we performed 14 double-pedicled free jejunal flap transfers for reconstruction after TPL. Vasa recta were used for second arterial anastomosis in 5 out of 14 patients. Others include a root artery in three patients and an arcade artery in six patients. Indocyanine green (ICG) angiography was performed to confirm the patency and perfusion of the entire flap by the second artery alone. Results: The flaps survived completely in all cases. The vasa recta (average diameter; 0.8 mm) were anastomosed to the superior thyroid artery and transverse cervical artery in four and one cases, respectively. Supramicrosurgical end-to-side anastomosis was performed in two cases. ICG angiography showed sufficient perfusion of the entire flap with the second artery alone in all cases. Conclusion: As vasa recta were confirmed as being capable of perfusing the entire flap up to 25 cm, the double-pedicle method using vasa recta might be an option to reduce the risk of flap necrosis, particularly in high-risk patients. Keywords: Vasa recta, Free jejunum, Double pedicle, Supermicrosurger