Complex Esophageal Reconstruction: Challenges and Techniques

The objective of this invited expert guide is to discuss options for complex reconstruction for patients presenting with esophageal discontinuity, loss of a gastric conduit, fistula, or other complex esophageal conditions.

On the basis of a series of complex esophageal reconstructions in adults, from multiple institutions, solutions are reviewed and organized by conduit, circumstance, and technique. Patient-specific data are excluded, and the scenarios focus on a summarized presentation of options.

Surgical techniques for esophageal salvage reconstruction and revision are discussed. Esophageal salvage includes stenting, endoscopic vacuum therapy, plication, dilation, assisted emptying, untwisting, endoluminal repair, and operative revision. Esophageal reconstruction includes a variety of routes, timing, and conduits for replacement. Three predominant reconstruction approaches are reviewed, including local or primary options, interposition grafts, and tissue-engineered constructs.

A standard tubularized pedicled gastric conduit is the first choice for esophageal reconstruction. Attempts to salvage leaks and initial esophageal reconstruction conduits should be made before selecting a secondary option. Complex reconstruction can be staged by diversion and later reconstruction when nontraditional conduits are used. The esophagus can be successfully reconstructed from small bowel, colon, myocutaneous, cutaneous, or biomatrix material.