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Double Supercharged Jejunal Interposition for Late Salvage of Long-gap Esophageal Atresia

Ganske, Ingrid M., MD, MPA*; Firriolo, Joseph M., MD*; Nuzzi, Laura C., BA*; Ganor, Oren, MD*; Hamilton, Thomas E., MD; Smithers, C. Jason, MD; Jennings, Russell W., MD; Upton, Joseph III, MD*; Labow, Brian I., MD*; Taghinia, Amir H., MD, MBA, MPH*

doi: 10.1097/SAP.0000000000001520
Microsurgery

Background A variety of surgical techniques exist to manage long-gap esophageal atresia (LGEA), including gastric pull-up (GPU), colonic interposition (CI), jejunal interposition (JI), and distraction lengthening. Salvage reconstruction for late failure of any conduit type is a complex surgical problem fraught with technical difficulty and significant risk. Jejunal interposition can be used as a salvage procedure in the management of LGEA. However, the opposing requirements of conduit length and adequate perfusion make the procedure technically challenging. Chronic comorbidities and abdominal and thoracic adhesions may further complicate these cases.

Methods We report a technique for the management of 3 late treatment failures of LGEA using pedicled JI in conjunction with 2 additional arterial and venous anastomoses, or double supercharging. For 2 patients who presented with failed CI, pedicled JI was performed and supercharged to internal mammary vessels as well as vasculature preserved from the prior colonic flap mesentery. The third patient presented with failed GPU and underwent pedicled JI that was supercharged caudally to the gastroepiploic vessels and cranially to the left common carotid artery.

Results No flaps were lost in any patients. Median operation time was 16.5 hours. Patients were monitored postoperatively in the intensive care unit for a median of 23 days, extubated after 14 days, and discharged at 41 days. Postoperatively, all patients tolerated an oral diet by discharge and continue to enjoy oral intake of all food consistencies without dysphagia or aspiration. Follow-up time spanned 2 to 4 years (average, 3.3 years). One patient required dilatations and temporary stent for stricture, and another required removal of prominent sternal wires; otherwise, no additional procedures were performed.

Conclusions Although technically difficult, double supercharged JI should be considered as a salvage operation to restore esophageal continuity after CI or GPU failure for LGEA, when there are otherwise limited reconstructive options.

From the Departments of *Plastic and Oral Surgery, and

Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.

Received January 29, 2018, and accepted for publication, after revision April 20, 2018.

Conflicts of interest and sources of funding: None of the authors has a financial interest in any of the products, devices, or drugs mentioned in this article.

IRB Statement: This study was approved by the Boston Children's Hospital Committee on Clinical Investigation (protocol number: IRB-P00024103).

Reprints: Amir H. Taghinia, MD, MBA, MPH, Department of Plastic and Oral Surgery, Boston Children's Hospital, 300 Longwood Ave, Boston, MA 02115. E-mail: amir.taghinia@childrens.harvard.edu.

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