Pre-expanded perforator flaps for neo-esophageal reconstruction: A salvage procedure for the treatment of bipolar upper-GI tract exclusion.

Abstract

Background: Total esophageal reconstruction after failure of conventional techniques is a significant surgical challenge, particularly in fragile, multi-operated patients. Traditional options, including gastroplasties, colon transfers, and free jejunal flaps, carry high morbidity, failure rates, or surgical complexity.

Material and methods: We report an innovative four-step strategy for esophageal reconstruction using a presternal skin tube created with tissue expanders and perforator flap techniques. Six patients with prior definitive esophageal exclusion underwent reconstruction between 2009 and 2023. The procedure involved patients with a complex medical history and multiple reconstruction failures, including gatroplasties, coloplasties, and/or ileocoloplasties, and consisted of i) Chest skin expansion with tissue expanders; ii) Tubularization of a perforator flap based on internal mammary vessels; iii) Anastomosis of the distal skin tube with a jejunal "Y" loop; and iv) Proximal anastomosis to the native cervical esophagus.

Results: 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, with patients tolerating liquids, semi-solids, and eventually solid foods after 2-3 months. Imaging and endoscopy confirmed lumen integrity, absence of strictures, and static skin-like epithelium without ulceration.

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