It has been well established that microvascular free jejunal transfer is the method of choice for reconstruction of the hypopharynx and the cervical esophagus. On the other hand, gastric pull-up and colon interposition are the preferred methods for reconstructing the thoracic esophagus. There are rare instances when neither the stomach nor an adequate segment of colon is available to provide appropriate length for a tension-free proximal anastomosis. The purpose of this paper is to illustrate a technique of composite esophageal reconstruction that may be employed when conventional methods are inadequate.

Three cases of composite esophageal reconstruction are reviewed. In these difficult cases, the limited colon or gastric segment was used as a pedicle graft to reconstruct the distal, thoracic esophagus while the more proximal reconstruction was composed of a free jejunal transfer. Two patients had colo-jejunal reconstructions while one patient underwent esophagoplasty combining a jejunal free graft with a short gastric tube. In all of these cases, the esophageal reconstruction was simplified by performing the colo-jejunal or gastro-jejunal anastomosis intra-abdominally, prior to division of the jejunal vascular pedicle. This key maneuver eliminates the challenge of performing a retro-sternal, intra-thoracic anastomosis, during the ischemic period. The composite conduit can then be passed through the mediastinum, as a single unit, and the proximal jejunal and vascular anasomoses may then be performed.

All patients ultimately progressed to a regular diet. There were no instances of flap loss and no evidence of stricture. One patient required re-operation in the early post-operative period for mechanical obstruction of the jejunum at the thoracic inlet. This was resolved with partial sternectomy. This same patient developed a cervical fistula that resolved spontaneously with expectant management. Another patient was admitted three months after surgery for non-operative management of an intra-abdominal partial small bowel obstruction.

We demonstrate that this one-staged, composite, retro-sternal approach is a safe and reliable method for restoring esophageal continuity. Prefabrication of the composite colo-jejunal or gastro-jejunal conduit, within the peritoneal cavity, is the key maneuver. This minimizes ischemic time and allows for a technically easy distal anastomosis, within the abdominal cavity, prior to retro-sternal transfer.