Free jejunal flap esophagoplasty for ischemic colon conduit replacement
Colon interposition is mainly used as a second-line treatment, when the stomach has to be resected, or when the stomach is deliberately kept intact for benign diseases in patients with long-life expectancy. Colon provides extended conduit length, reliable blood supply and low incidence of reflux. However, the early and late postoperative ischemic complication rate is 5–15%. The most serious but rare complication is the acute conduit necrosis. More severe cases of necrosis require conduit take down with proximal esophageal diversion and placement of an enteral feeding tube. Reconstruction can be planned for later if possible. An uncommon complication is the colonic stricture due to chronic ischemia, which can be treated with conservative methods such as dilation and stenting. Surgery may be indicated since the impaired deglutition can compromise the quality of life. Supercharged or free jejunal interposition is a suitable alternative conduit for esophageal replacement in patients with otherwise limited delayed reconstructive options. Good functional outcomes can be achieved despite the formidable technical challenges in this group of patients. In three such cases, we could successfully use a free jejunal flap for reconstruction; in two cases after colon conduit necrosis and in one case due to a late ischemic stricture. In each case the replacement type was different, using substernal, presternal and sternotomy routes. The arterial blood supply was provided by the internal mammary artery. Saphenous graft was used to interconnect to external jugular or innominate vein to reestablish the venous drainage. All three patients survived without further complications.