LAUSR

Betel nut has a long history in South and Southeast Asia and Pacific Basin. Many people chew betel nut for energy boost it produces or in social activities. Betel nut is carcinogenic. In Taiwan, an average of seven patients die of oral cancer per day (2000 cases/year), and about 300 patients die of hypopharyngeal cancer per year (0.8 patient/day). Patients with hypopharyngeal cancer often need total pharyngolaryngectomy following ablative surgery. Some patients of thyroid cancer with posterior extension may also need total pharyngolaryngectomy. A common reconstruction now utilizes skin flap for cervical esophagus and voice prosthesis for voice restoration (Chen et al., 2010) after total pharyngolaryngectomy. In this letter, we want to share our preliminary results from a study of comparison between ileocolon flap and jejunum flap for voice reconstruction. After total pharyngolaryngectomy, transferring a segment of the intestine (ileocolon flap or jejunum flap) can be accomplished to reconstruct both cervical esophagus and voice. In our medical unit, patients with hypopharyngeal cancer receiving total pharyngolaryngectomy were divided into two groups: voice reconstruction with either ileocolon flap (206 cases) or jejunum flap (42 cases). The retrospective study and the corresponding statistics were performed according to the examination on voice quality, complications, antibiotics given, and etc. (Chen et al., 2018). Jejunum flap had the advantages of good swallowing function and short recovery period (Chen et al., 2018). However, when it was used for voice reconstruction, more cases (6 out of 42 total cases vs. 3 out of 206 in the ileocolon group) were reported choking and aspiration pneumonia. We could use either elephant trunk shunt or nipple-valve anastomosis to prevent this problem. Furthermore, a natural valve like the ileocecal valve in ileocolon flap, offered one-way shunting of air from trachea to esophagus and thus minimized risk of aspiration, especially when the ileocecal valve was narrowed down to 0.5 cm (Chen et al., 2018). Jejunum had a higher amount of secretion than ileum, and therefore it caused more wetness of speech, leading to relatively lower voice quality. Although ileum had more bacterial counts (10 vs. 10 cells/g in jejunum), we always washed the ileocolon flap before transfer (Chen et al., 2020). As a consequence, bacteria were not a concern in our study (El Kafsi, 2014). It is noted that antibiotics treatment after the operation is important to prevent infection. The selection of antibiotics should bemade according to different compositions of bacterial flora in jejunum and ileum. Gram-positive bacteria are predominant microorganisms in jejunum, while in ileocolon flap the composition of flora is gram-negative and anaerobic. Hence, post-operative antibiotics covering gram-negative, and anaerobic organisms were indispensable after transferring ileocolon flap. An ileocecal valve could minimize regurgitation and thus provide better quality of life. To resemble a natural valve, using jejunum flap required either nipple-valve anastomosis or elephant trunk shunt during inset of the second limb of free jejunum flap. Nipple-valve anastomosis was initially designed to reduce the regurgitation from coloileal reflux. After ileocolic resection operation, the ileum was then everted for about 4–5 cm in length with 3–4 longitudinal sutures in order to stabilize the nipple (Kåre, 2009). Elephant trunk shunt, originally designed by Dr. Motohiro Nozaki, created a connection between tracheal stump and neohypopharynx to shunt the airflow which prevented regurgitation to afford a better voice quality. This technique modified two jejunal segments with the same vascular pedicle to make a side tube mimicking the trunk of an elephant (Nozaki et al., 2007). However, we found that the usage of jejunum flap displayed a higher risk of aspiration pneumonia than that of ileocolon flap. In this study, six cases were identified to show aspiration pneumonia among 42 total cases in the jejunum-flap group. In contrast, only three had the same problem in the ileocolon-flap group (206 cases in total). Voice quality of jejunum flap was also inferior to that of ileocolon flap. We herein evaluated voice quality according to the five-point Likert scale (from 1: unable to speak, to 5: nearly free communication with people). In the jejunum flap group, 52% of the patients showed a good result, 25% moderate, 18% poor, and 5% failure (that included one failure of free jejunum flap, and the other one of no speech training due to cancer recurrence). The ileocolon group apparently did a better job in loudness and maximal phonation time. 64% of the group patients showed a good result, 21% moderate, 6% poor, and 9% failure (due to flap failure, mortality, or cancer recurrence). Additionally, complication rate of jejunum flap was higher than that of ileocolon flap. There were four major complications in the jejunum flap group (corresponding to 9.5% of the total), including one failure of free jejunum flap, another cancer recurrence, another hematoma, and the other one requiring split-thickness graft to release tightness of wound closure. Eighteen complications were found in the ileocolon flap group (8.7%), including six cases of flap failure, one mortality, and 11 of esophagocutaneous fistula (Chen et al., 2018). In summary, we conclude that ileocolon flap is a superior choice to jejunum flap, owing to a better speech quality, less risk of aspiration pneumonia, and less complications.