Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report

Abstract

Background: Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus. However, the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture. We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system.

Case presentation: A 56 year-old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors. On day 8 after thoracoabdominal esophagectomy with gastric pull-up, an anastomotic leakage was diagnosed. A proximal-release stent was successfully placed by gastroscopy and the patient was discharged. Two weeks later, an esophagotracheal fistula occurred proximal to the esophageal stent. Cervical esophagostomy was performed with cranial closure of the gastric conduit, which was left in situ within the right hemithorax. Three months later, reconstruction was performed using a free jejunal interposition. The anvil of a circular stapler (Orvil®, Covidien) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit. A free jejunal graft was retrogradely stapled to the proximal end of the conduit. Microvascular anastomoses were performed subsequently. The proximal anastomosis of the conduit was completed manually after reperfusion.

Conclusions: This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy.

Figure 1

Diagnosis of ESSC, Esophagectomy and Esophagostomy after conduit failure. A) Workup including esophageal fluoroscopy at first presentation of the patient revealed an ESSC at 20-25 cm from the incisors. B) Status post Ivor-Lewis thoraco-abdominal esophagectomy with gastric pull-up and circular end-to-side stapled cervical anastomosis. C) Status post cervical esophagostomy and stump closure of the gastric pull-up conduit, which remained in situ within the right hemithorax.

Figure 2

Position of the gastric pull-up conduit retracted into the right hemithorax before reconstruction.

Figure 3

Reconstruction with free jejunal interposition. A) Gastroscopy and diaphanoscopy of the pull-up gastric interposition after gastroscope insertion via the distal conduit. B) Guide-wire positioning from the cervical incision into the gastric pull-up conduit by endoscopic rendez-vous. C) Attachment of the OrViL® delivery tube to the guide-wire. D) Insertion of the OrViL® circular stapler into the pull-up gastric interposition E) Stapling of the jejunogastrostomy. F) Revascularization and proximal anastomosis of the free jejunal interposition.

Figure 4

Regular EGD transit before discharge of the patient.