Jejunal Interposition for Esophageal Replacement After Lye Ingestion in a Pediatric Patient

Abstract

Introduction:

The conduit of choice for esophageal replacement (ER) in children with complex esophageal atresia or caustic injury remains controversial. ¹ The most frequently used conduits include the colonic interposition, gastric pull-up, and the jejunal interposition (JI). ^2,3 The JI is technically challenging and has been associated with high rates of anastomotic stricture and leak. ² There are advantages, however, to the JI, including a better size match to the native esophagus and intrinsic peristalsis that is thought to improve conduit emptying. As a result, they may be less likely to develop significant conduit dilation. ^4,5 Some ERs, particularly after caustic injury, can be uniquely challenging if the pharynx or proximal esophagus is affected; these often require a staged approach in which a neopharynx or proximal conduit is created first, so that another conduit can later be attached to it to complete the reconstruction. We present the case of an 11-year-old boy who ingested lye at 3 years of age. He presented to us with a history of a failed colonic interposition for a staged esophageal reconstruction with a JI. We first performed a tubed anterolateral thigh (ALT) free flap to provide a conduit from his proximal pharynx to an end stoma in his lower neck. After 6 months of recovery, he underwent a pedicled Roux-en-Y JI with microvascular augmentation or “supercharging.” The second stage is the focus of this report.

Materials and Methods:

The operation involved a redo midline laparotomy, sternotomy, and neck dissection. The ALT flap (neoesophagus) was mobilized, and the previous colonic conduit was resected. The internal mammary vessels were prepared for the microvascular anastomosis. The proximal branches of the jejunal mesentery were identified and selectively divided. The jejunum was passed into the anterior mediastinum through a retrocolic-antegrastric-substernal route. An anastomosis was performed between the jejunal vessels and the internal mammary vessels with microsurgical technique. Next the neoesophagojejunal anastomosis was created in an end-to-end single layer approach. Intestinal continuity was completed with an end-to-side jejunojejunostomy in a Roux-en-Y configuration. Intraoperative endoscopy and perfusion assessment (with indocyanine green fluorescence) of the JI conduit were satisfactory.

Results and Conclusions:

The patient recovered well from the operation with no evidence of leak or stricture on his postoperative contrast study. He was discharged home on postoperative day 16 tolerating small amounts of oral intake. Although the native esophagus is the ideal conduit, ER may be required in certain circumstances. ² Given its advantages, the JI remains our first choice for ER but we recognize its highly technical nature for which it is best approached by a multidisciplinary team in a high volume center. This video highlights some of the technical intricacies of our technique.

No competing financial interests exist.

Runtime of video: 9 mins 58 secs