title: Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report.
abstract: BACKGROUND
  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.
  
  
  METHODS
  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.
  
  
  CONCLUSIONS
  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.
authors.forename: Christina
authors.initials: C
authors.lastname: Hackl
authors.forename: Felix C
authors.initials: FC
authors.lastname: Popp
authors.forename: Katharina
authors.initials: K
authors.lastname: Ehehalt
authors.forename: Lena-Marie
authors.initials: LM
authors.lastname: Dendl
authors.forename: Volker
authors.initials: V
authors.lastname: Benseler
authors.forename: Philipp
authors.initials: P
authors.lastname: Renner
authors.forename: Martin
authors.initials: M
authors.lastname: Loss
authors.forename: Jurgen
authors.initials: J
authors.lastname: Dolderer
authors.forename: Lukas
authors.initials: L
authors.lastname: Prantl
authors.forename: Thomas
authors.initials: T
authors.lastname: Kühnel
authors.forename: Hans J
authors.initials: HJ
authors.lastname: Schlitt
authors.affiliation: Department of Surgery, University Medical Center Regensburg, Regensburg 93042, Germany. marc.dahlke@ukr.de.
authors.forename: Marc H
authors.initials: MH
authors.lastname: Dahlke
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods; D002294:Carcinoma, Squamous Cell / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000601:surgery*; D000077277:Esophageal Squamous Cell Carcinoma; D016629:Esophagectomy / Q000379:methods*; D004947:Esophagus / Q000601:surgery*; D006801:Humans; D007583:Jejunum / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D017792:Surgical Stapling / Q000379:methods