Development of a technique for jejunal interposition in long-gap esophageal atresia

Primary anastomosis is the treatment of choice in esophageal atresia. There remains a small number of infants in whom establishment of primary esophageal continuity fails or is unrealistic due to a long gap. Esophageal reconstruction then necessitates an interposition/transposition procedure. The most widely used tissues are colon and stomach but each has significant limitations. Jejunum is theoretically the ideal esophageal substitute being of appropriate diameter and having good peristaltic activity. Its use in the past has been limited by the precarious blood supply and restricted length which result from the short mesenteric pedicle. We have attempted to resolve these limitations by using a microvascular anastomosis to augment the blood supply to the proximal jejunum in a series of 5 cases (2 pure atresias, 1 esophageal atresia with proximal fistula, and 2 atresias with distal fistula). In a sixth case (atresia with distal fistula) a free jejunal graft was used. In one case initial surgery was confined to cervical esophagostomy and feeding gastrostomy, in the remaining 5 interposition was necessitated by failure of a primary repair. The age at surgery ranged from 8 to 16 months. The development of the technique and outcome in each patient is described. We conclude that a free jejunal graft is preferable to augmenting the native blood supply and intend to continue with this latter technique.