Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report.

[esophageal squamous cell carcinoma]

Free jejunal interposition is a useful technique for reconstruction of the cervical esophagus . However , the distal anastomosis between the graft and the remaining thoracic esophagus or a gastric conduit can be technically challenging when located very low in the thoracic aperture . We here describe a modified technique for retrograde stapling of a jejunal graft to a failed gastric conduit using a circular stapler on a delivery system .A 56 year -old patient had been referred for esophageal squamous cell carcinoma at 20 cm from the incisors . On day 8 after thoracoabdominal esophagectomy with gastric pull-up , an anastomotic leakage was diagnosed . A proximal -release stent was successfully placed by gastroscopy and the patient was discharged . Two weeks later , an esophagotracheal fistula occurred proximal to the esophageal stent . Cervical esophagostomy was performed with cranial closure of the gastric conduit , which was left in situ within the right hemithorax . Three months later , reconstruction was performed using a free jejunal interposition . The anvil of a circular stapler (Orvil ®, Covidien ) was placed transabdominally through an endoscopic rendez-vous procedure into the gastric conduit . A free jejunal graft was retrogradely stapled to the proximal end of the conduit . Microvascular anastomoses were performed subsequently . The proximal anastomosis of the conduit was completed manually after reperfusion .This modified technique allows stapling of a jejunal interposition graft located deep in the thoracic aperture and is therefore a useful method that may help to avoid reconstruction by colonic pull-up and thoracotomy .