title: Back-up procedures following complicated gastric pull-up procedure for esophageal reconstruction: Salvage with intestinal flaps.
abstract: BACKGROUND
  Gastric pull-up (GPU) is the most common procedure for restoring the continuity of the alimentary tract. Yet, complications because of anastomotic problems are reported to be as high as 25% after this procedure. Managing the neck with anastomotic leakage or stricture following failed GPU and/or radiotherapy is formidable. We report our method, basic algorithm and results with the complicated GPU procedure management with intestinal transfers .
  
  
  METHODS
  Nineteen cases referred to our department with complicated esophageal reconstruction following GPU procedure were included in this report. Of the19 patients, 18 had undergone GPU procedure for reconstruction after cancer resection (mean age 55 years) and one for idiopathic esophagitis (mean age 45years). Fifteen patients presented with severe stricture formation and 4 patients with leakage from the anastomotic site. Average time between the GPU and salvage procedures was 7.3 months for patients with stricture formation and 15.5 days for patients with leakage. Pedicled colon interposition (n = 8) was used when the upper end of the gastric tube was located below the sternoclavicular junction. A free jejunal flap (n = 11) was utilized when defects were located at the neck (above the sternoclavicular junction).
  
  
  RESULTS
  In all patients salvage procedures with intestinal flap transfer were successful with complete flap survival. Post-operative period was uneventful except of two patients with pedicled colon interposition who presented minor leakage post-operatively (10.5%). This was treated with conservative means, leading to spontaneous healing. The average follow-up for the patients with tumor resection was 11.8 months (range: 6 to 30) after the salvage procedure. All patients resumed smooth oral intake eventually. There were 16 patients who could feed with solid diet, whereas three patients were able to tolerate only soft diet.
  
  
  CONCLUSIONS
  Intestinal tissues can be safely and successfully transferred as salvage procedures, with meticulous technique, careful patient selection and individual flap design. While gastric pull-up remains a good procedure for esophageal reconstruction, the methods described in this report are useful as back-up armaments in complicated cases. © 2015 Wiley Periodicals, Inc. Microsurgery 36:567-572, 2016.
authors.affiliation: Department of Plastic and Reconstructive Surgery, Marmara University School of Medicine, Istanbul, Turkey.|Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.
authors.forename: Bulent
authors.initials: B
authors.lastname: Sacak
authors.affiliation: Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.|Department of Plastic and Reconstructive Surgery, St Thomas' Hospital, London, UK.
authors.forename: Georgios
authors.initials: G
authors.lastname: Orfaniotis
authors.affiliation: Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.
authors.forename: Fabio
authors.initials: F
authors.lastname: Nicoli
authors.affiliation: Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.
authors.forename: En-Wei
authors.initials: EW
authors.lastname: Liu
authors.affiliation: Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan.
authors.forename: Pedro
authors.initials: P
authors.lastname: Ciudad
authors.affiliation: Department of Plastic Surgery, Chang-Gung Memorial Hospital, Taipei, Taiwan.
authors.forename: Shih-Heng
authors.initials: SH
authors.lastname: Chen
authors.affiliation: Department of Plastic and Reconstructive Surgery, China Medical University Hospital, Taichung, Taiwan. d19722@mail.cmuh.org.tw.
authors.forename: Hung-Chi
authors.initials: HC
authors.lastname: Chen
mesh_terms: D000328:Adult; D000368:Aged; D000465:Algorithms; D057868:Anastomotic Leak / Q000601:surgery*; D003106:Colon / Q000601:surgery*; D003661:Decision Support Techniques; D004940:Esophageal Stenosis / Q000209:etiology / Q000601:surgery*; D004944:Esophagoplasty / Q000379:methods*; D005500:Follow-Up Studies; D006801:Humans; D007583:Jejunum / Q000637:transplantation*; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D016879:Salvage Therapy / Q000379:methods; D013270:Stomach / Q000601:surgery*; D013524:Surgical Flaps / Q000601:surgery* / Q000637:transplantation; D016896:Treatment Outcome