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Double Super-charged Jejunal Interposition for Late Salvage of Long-gap Esophageal Atresia
Ingrid Ganske, MD1, Amir Taghinia, MD2, Joseph Upton, III, MD3, Russell Jennings, MD1, Thomas Hamilton, MD1, Charles Jason Smithers, MD1, Brian Labow, MD, FACS, FAAP2.
1Boston Children's Hospital, Boston, MA, USA, 2Boston Childrens Hospital, Boston, MA, USA, 3Harvard Medical School, Boston, MA, USA.

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. Although no consensus exists as to the optimal reconstructive approach, a recent large meta-analysis of 470 patients from 15 studies reported that CI remains the common primary form of reconstruction (73%), with GPU and JI performed in 21% and 6%, respectively. Short-term mordibity and mortality results are similar for both CI and GPU and include anastamotic leak and graft loss. However, long-term complications differ between these two approaches, with pulmonary complications predominating in GPU, and gastro-intestinal complications more common following CI. Although minimal data are available regarding the frequency of graft failure necessitating late secondary esophageal reconstruction, a need exists for long-term salvage procedures for LGEA patients with late graft dysfunction. Salvage reconstruction for late failure in LGEA is a complex surgical problem fraught technical difficulties and significant risk. When prior colonic or gastric bypass conduits degenerate, JI can be used as a salvage procedure. Although the success rate of JI in the management of LGEA is good, the opposing requirements of adequate conduit length and adequate perfusion make the procedure technically challenging. In salvage situations, when intrabdominal and intrathoracic adhesions and chronic co-morbidities exist, standard approaches may be insufficient. Methods: We report a novel technique in the management of three late treatment failures of LGEA, using JI performed in a pedicled manner and reusing the native blood supply to the primary conduit for two additional arterial and venous anastomoses to two jejunal segmental pedicles, or “double super-charging”. The first case was a 23-year-old male with failed GPU, who underwent a two-stage salvage reconstruction, first mobilizing the gastric conduit, and then creating a Roux-en-Y configuration pedicled jejujum that was supercharged caudally to the gastroepiploic vessels and cranially in the neck. The second case was an 18-year-old female with failed CI, for whom a pedicled JI was performed and supercharged to the internal mammary vessels; the JI was then additionally supercharged to the preserved right colic artery from the preserved prior colonic flap mesentery due to concern for mid-segment vascularity. A third case was a 10-year-old male with failed CI; reconstruction involved pedicled jejunal interposition which was supercharged by anastomosing the third jejunal branch to the remaining middle colic artery from the prior CI, as well as at the first jejunal branch to the left internal mammary vessels.
Results: No flaps were lost in any patients. Average procedure time was 17 hours. Average post-operative ICU admission was 22 days, with extubation occurring on average on post-operative day 13, and hospital discharge on average after 42 days. One patient required delayed chest closure due to swelling. One patient required dilatations and temporary stenting of the esophageal-jejunal anastomosis. All patients were tolerating an oral diet by discharge.
Conclusions: This variation on prior techniques for JI may be useful in salvage situations where long segments of conduit are required.

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