Preexpanded Perforator Flaps for Neoesophageal Reconstruction after Bipolar Upper Gastrointestinal Tract Exclusion

Total esophageal reconstruction after failure of conventional techniques is a significant surgical challenge, particularly in fragile patients who have undergone multiple surgical procedures. Traditional options, including gastroplasties, colon transfers, and free jejunal flaps, are associated with high morbidity rates, failure rates, or surgical complexity.

The authors report an innovative 4-step strategy for esophageal reconstruction using a presternal skin tube created with tissue expanders and perforator flap techniques. Six patients with previous definitive esophageal exclusion underwent reconstruction between 2009 and 2023. The procedure involved patients with complex medical history and multiple reconstruction failures, including gastroplasties, coloplasties, or ileocoloplasties, and consisted of chest skin expansion with tissue expanders, tubularization of a perforator flap based on internal mammary vessels, anastomosis of the distal skin tube with a jejunal Y loop, and proximal anastomosis to the native cervical esophagus.

The entire reconstructive process was completed over 17.5 ± 7.3 months. All patients achieved restoration of digestive tract continuity. Minor complications, including wound dehiscence and fistulas, were observed in all patients, but resolved without major intervention. Functional outcomes were favorable, with a maximum follow-up of 15 years and patients tolerating liquids, semisolids, and solid foods after 2 to 3 months. Imaging and endoscopy confirmed lumen integrity, absence of strictures, and static skin-like epithelium without ulceration.

This staged reconstruction offers a viable and safe alternative for total esophageal replacement in complex, high-risk cases, avoiding additional extensive intrathoracic procedures. The presternal neoesophagus provides acceptable function with manageable complications.

Therapeutic, IV.