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Supercharged Intestinal Interposition for Reconstruction after Complicated Esophagectomy

Davis, Harrison D.
; 
Honig, Stephanie E.
; 
Habarth-Morales, Theodore E.
; 
Amro, Chris
; 
Broach, Robyn B.
; 
Ibrahim, Kareem
; 
Walker, Michael J.
; 
Carp, Ned Z.
; 
Serletti, Joseph M.
; 
Piccinini, Pedro S.
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2024-01-01
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https://doi.org/10.1097/01.gox.0001005980.78736.4b
Abstract
Background: Intestinal interposition for esophageal reconstruction (ER) is an uncommon procedure but can be used as a conduit during esophagectomy if the stomach is not available. We present a series of esophagectomy with gastric conduit complicated by anastomotic leak, now in need of a secondary reconstructive option or patients with prior bariatric surgery or gastrectomy resulting in lack of an available gastric conduit. Methods: A single-institution retrospective review of intestinal interposition grafts for complicated esophagectomy reconstruction (2019-2022) was performed. Demographics and medical history was recorded. Surgical approach via a transcervical and abdominal incision; all arterial and venous anastomoses utilized a saphenous vein graft (SVG) between the donor and recipient vessels; a retrosternal graft route was used in all cases, and a monitoring flap of disconnected intestinal segment was exteriorized in the neck for flap monitoring (TABLE). All patients underwent barium swallow post-operatively (FIGURE). Results: Seven patients underwent supercharged intestinal interposition graft for ER. Mean age was 60 years, mean BMI was 28.3. Medical history included hypertension (n=4), GERD or Barrett’s esophagus (n=4), and former smokers (n=6). Six patients underwent esophagectomy for malignancy, one underwent esophagogastrectomy for caustic ingestion. Six patients required secondary reconstruction due to failed primary ER after esophagectomy. One patient required supercharged jejunal interposition as their primary reconstruction as the stomach was unavailable due to prior gastric bypass surgery. Three patients received neoadjuvant chemoradiation. Early postoperative outcomes showed no occurrences of graft ischemia or graft loss. Late postoperative complications included an anastomotic leak, and one anastomotic stricture. Four patients experienced aspiration events. Two required prolonged ventilation and eventually died from complications of aspiration. Conclusion: ER after failure of gastric pull-through is complex; supercharged intestinal interposition is an option we found has complication rates similar to other options such as colon interposition without microvascular anastomosis. Use of a SVG allows for improved flap accommodation in the neck without placing undue tension on the microvascular anastomosis. Future directions using supercharged gastric pull-through to decrease gastrointestinal anastomotic breakdown and leak. It remains to be seen whether performing supercharged flaps as a primary ER method may be superior to traditional gastric pull-through.
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Davis, Harrison D. BS1,2; Honig, Stephanie E. MD1; Habarth-Morales, Theodore E. BS, 1LT1,3; Amro, Chris MD1; Broach, Robyn B. PhD1; Ibrahim, Kareem MD4; Walker, Michael J. MD4; Carp, Ned Z. MD4; Serletti, Joseph M. MD1; Piccinini, Pedro S. M.D.1. Supercharged Intestinal Interposition for Reconstruction after Complicated Esophagectomy. Plastic & Reconstructive Surgery-Global Open 12(1S1):p 26, January 2024. | DOI: 10.1097/01.GOX.0001005980.78736.4b
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Plastic and Reconstructive Surgery - Global Open, Vol. 12, Iss. 1S1
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