Supercharged Jejunal Interposition: A Reliable Esophageal Replacement in Pediatric Patients

Evaluation of Ischemic Time and Complications in Free Jejunum Transfer

BACKGROUND

In free jejunum transfer, knowing the ischemic tolerance time of the jejunum is crucial. It helps determine the need for reharvesting if an unexpected situation prolongs the ischemic time. The current ischemic tolerance time in humans is unknown. We investigated the relationship between ischemic time and postoperative complications in head and neck cancer patients who underwent free jejunum transfer.

METHODS

The study included 76 patients with available medical records out of 103 patients who underwent free jejunum transfer between 2009 and 2023. The association between the surgical procedure, including ischemic time, and patient's background, and flap engraftment, stenosis of the intestinal anastomosis, the swallowing function, and other complications was investigated.

RESULTS

The ischemic time for jejunal flaps ranged from 1 h 24 min to 6 h, with a mean of 197 ± 55.5 min. In 72 patients, the jejunum was successfully engrafted, but vascular occlusion occurred in another four patients. In three of these patients, jejunal necrosis occurred, and there was no specific trend in ischemic time. Stenosis of the intestinal anastomosis occurred in 17 cases (22%), with ischemic time (≥3 h) and age (≥75 years) being significant factors for stenosis (ischemic time: 30% vs. 10%, p = 0.048, age: 50% vs. 15%, p < 0.01). No significant correlations were observed with other complications or the swallowing function.

CONCLUSION

There was no specific trend between ischemic time and jejunal survival rate, indicating that an ischemic time within 6 h may not have affected engraftment. Although we have recently performed intestinal anastomosis prior to vascular anastomosis, the choice of surgical technique should be adapted to the patient's age and background.

The History and Legacy of the Foker Process for the Treatment of Long Gap Esophageal Atresia

Historically, children afflicted with long gap esophageal atresia (LGEA) had few options, either esophageal replacement or a life of gastrostomy feeds. In 1997, John Foker from Minnesota revolutionized the treatment of LGEA. His new procedure focused on "traction-induced growth" when the proximal and distal esophageal segments were too far apart for primary repair. Foker's approach involved placement of pledgeted sutures on both esophageal pouches connected to an externalized traction system which could be serially tightened, allowing for tension-induced esophageal growth and a delayed primary repair. Despite its potential, the Foker process was received with criticism and disbelief, and to this day, controversy remains regarding its mechanism of action - esophageal growth versus stretch. Nonetheless, early adopters such as Rusty Jennings of Boston embraced Foker's central principle that "one's own esophagus is best" and was instrumental to the implementation and rise in popularity of the Foker process. The downstream effects of this emphasis on esophageal preservation would uncover the need for a focused yet multidisciplinary approach to the many challenges that EA children face beyond "just the esophagus", leading to the first Esophageal and Airway Treatment Center for children. Consequently, the development of new techniques for the multidimensional care of the LGEA child evolved such as the posterior tracheopexy for associated tracheomalacia, the supercharged jejunal interposition, as well as minimally invasive internalized esophageal traction systems. We recognize the work of Foker and Jennings as key catalysts of an era of esophageal preservation and multidisciplinary care of children with EA.

Contemporary outcomes of the Foker process and evolution of treatment algorithms for long-gap esophageal atresia

BACKGROUND

Esophageal growth using the Foker process (FP) for long-gap esophageal atresia (LGEA) has evolved over time.

METHODS

Contemporary LGEA patients treated from 2014-2020 were compared to historical controls (2005 to <2014).

RESULTS

102 contemporary LGEA patients (type A 50%, B 18%, C 32%; 36% prior anastomotic attempt; 20 with esophagostomy) underwent either primary repair (n=23), jejunal interposition (JI; n = 14), or Foker process (FP; n = 65; 49 primary [p], 16 rescue [r]). The contemporary p-FP cohort experienced significantly fewer leaks on traction (4% vs 22%), bone fractures (2% vs 22%), anastomotic leak (12% vs 37%), and Foker failure (FP→JI; 0% vs 15%), when compared to historical p-FP patients (n = 27), all p ≤ 0.01. Patients who underwent a completely (n = 11) or partially (n = 11) minimally invasive FP experienced fewer median days paralyzed (0 vs 8 vs 17) and intubated (9 vs 15 vs 25) compared to open FP patients, respectively (all p ≤ 0.03), with equivalent leak rates (18% vs 9% vs 26%, p = 0.47). At one-year post-FP, most patients (62%) are predominantly orally fed.

CONCLUSION

With continued experience and technical refinements, the Foker process has evolved with improved outcomes, less morbidity and maximal esophageal preservation.

Experience in reconstruction of esophagus, epiglottis, and upper trachea due to caustic injuries in pediatric patients and establishment of algorithm

BACKGROUND

Unintentional swallowing of corrosive agents cause problems in the pediatric population. Swallowing dysfunction can be seen after injuring the pharynx and/or epiglottis which leads to the obstruction of esophagus. An algorithm was established taking into account the injury to the epiglottis and restoring gastrointestinal continuity with isolated or combine free and or supercharged jejunum flap, or supercharged colon transposition flap.

METHODS

Seventeen patients between the ages of 3 and 16 (mean age: 7.7) were treated between 1985 and 2019. Three different procedures were performed based on endoscopic findings; for patients with no or minimal damage to epiglottis, pedicled colon transposition was done in 12 cases. For patients with epiglottic scarring or edema, a two-stage reconstruction was performed. In the first stage, free jejunum flap was implemented to the pharynx to facilitate food passage, followed by a pedicled jejunum in two cases, or a pedicled colon transposition in two cases to provide gastrointestinal continuity. For one patient with severe epiglottic scarring, a free jejunal flap was used as a diversion conduit in the first stage, followed by supercharged colon transposition to restore gastrointestinal continuity.

RESULTS

Supercharged intestinal flaps were harvested with 3-4 cm of extra intestinal tissue than the measured thoracic portion in each individual in order to reach the hypopharyngeal region. The size of the free jejunal flaps were 10 cm. Oral feeding was initiated on the eighth postoperative day. Partial loss of the anterior wall of the jejunal flap was seen in one case, in which a free anterolateral thigh-vastus lateralis musculocutaneous flap was used for reconstruction. The mean follow-up time was 5.1 years and there was no stricture in the final outcome.

CONCLUSION

A competent epiglottis is essential for proper swallowing reflex. Meticulous microsurgical dissection and performing supercharged intestinal flaps provide a complication-free end result.

Evolution, lessons learned, and contemporary outcomes of esophageal replacement with jejunum for children

BACKGROUND

The jejunal interposition is our preferred esophageal replacement route when the native esophagus cannot be reconstructed. We report the evolution of our approach and outcomes.

METHODS

The study was a single-center retrospective review of children undergoing jejunal interposition for esophageal replacement. Outcomes were compared between historical (2010-2015) and contemporary cohorts (2016-2019).

RESULTS

Fifty-five patients, 58% male, median age 4 years (interquartile range 2.4-8.3), with history of esophageal atresia (87%), caustic (9%) or peptic (4%) injury, underwent a jejunal interposition (historical cohort n = 14; contemporary cohort n = 41). Duration of intubation (11 vs 6 days; P = .01), intensive care unit (22 vs 13 days; P = .03), and hospital stay (50 vs 27 days; P = .004) were shorter in the contemporary cohort. Anastomotic leaks (7% vs 5%; P = .78), anastomotic stricture resection (7% vs 10%; P = .74), and need for reoperation (57% vs 46%; P = .48) were similar between cohorts. Most reoperations were elective conduit revisions. Microvascular augmentation, used in 70% of cases, was associated with 0% anastomotic leaks vs 18% without augmentation; P = .007. With median follow-up of 1.9 years (interquartile range 1.1, 3.8), 78% of patients are predominantly orally fed. Those with preoperative oral intake were more likely to achieve consistent postoperative oral intake (87.5% vs 64%; P = .04).

CONCLUSION

We have made continuous improvements in our management of patients undergoing a jejunal interposition. Of these, microvascular augmentation was associated with no anastomotic leaks. Despite its complexity and potential need for conduit revision, the jejunal interposition remains our preferred esophageal replacement, given its excellent long-term functional outcomes in these complex children who have often undergone multiple procedures before the jejunal interposition.