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The 2003 Annual Meeting of OASYS_NEW |
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.