Cervical Esophagus Reconstruction

Numerous techniques have been developed to recreate the structure of the esophagus that has been lost to cancer resection or stenosed as a result of radiation or chemical injury.  The cervical esophagus is particularly challenging due to the distance from the intra-abdominal organs and paucity of local tissue for reconstruction.  Microvascular transplants have been performed to allow passage of food and liquid in order to return patients with this devastating problem to a more nutritive state.  Although radial forearm flaps fashioned into a tube have been used, the disadvantages include:

• Hair bearing skin in the esophagus

• Lack of peristalsis

• Limit in length of the flap

Microsurgical transfer of the jejenum allows for a more physiologic reconstruction with 

• Mucosal surface facing the neo-esophagus

• Secretion of mucous in the transplanted segment

• Generous length of the jejenum available

The main disadvantage is the requirement for laparatomy and the need for recovery from laparotomy and bowel resection.

This patient had a laryngectomy and post-operative radiation for a squamous cell carcinoma and suffered from post-radiation esophageal stricture.  In spite of numerous dilatations he experienced a critical stenosis and was unable to pass food or liquid.  Local surgery was unsuccessful in restoring cervical esophageal continuity.  

In order to reconstruct the cervical esophagus a segment of jejenum was traplanted to the neck and repaired to the hyopharynx and upper thoracic esophagus.    The segment of jejenum is seen here in place beside the dissected neck wound.

The blood vessels of the jejenum were repaired to the vessels of the thyrocervical trunk, establishing good flow through the transplanted bowel.  Peristalsis could be seen immediately after circulation was re-established.  A skin graft was used to cover the open neck wound.  The implantable doppler probe was used for monitoring the flap post-operatively.

A gastrograffin swallow was performed at two weeks post-operatively.  In the radiographic image the gastrograffin can be seen passing from the mouth through the transplanted jejenum and into the esophagus in the chest.