Patch Esophagoplasty: Esophageal Reconstruction Using Biologic Scaffolds

Background. Standard techniques for surgical reconstruction of the esophagus remain suboptimal. Primary closure of diseased or injured esophagus has been associated with high morbidity, primarily due to leak and stricture, and synthetic materials are contraindicated due to the high risk of erosion and infection. Degradable bioscaffolds composed of extracellular matrix (ECM) have recently shown promising results in both preclinical and clinical settings to prevent stricture after extended endoscopic mucosal resection. We propose a novel surgical technique that utilizes an ECM scaffold as a reconstructive patch to augment the esophageal diameter during primary repair. Methods. Four patients requiring esophageal reconstruction underwent a patch esophagoplasty using an ECM scaffold composed of porcine urinary bladder ECM. The full thickness wall of the esophagus was replaced with an ECM patch that was sutured to the edges of the remaining esophagus, similar to the patch angioplasty performed in vascular procedures. Results. All patients had a favorable clinical outcome with immediate recovery from the procedure and reinstated oral intake after 7 days. One patient had a micro leak at day 5 that closed spontaneously 2 days after drainage. Follow-up studies including barium swallow and esophagogastroduodenoscopy (EGD) showed adequate esophageal emptying through the surgical segment in all patients. The EGD showed complete mucosal remodeling at 2 months, with approximately 20% area contraction at the patch level. The area of the defect was indistinguishable from surrounding healthy tissue. Biopsy of the patch area showed normal squamous epithelium. One of the patients had a separate intrathoracic stricture that required further surgery. Clinical outcomes were otherwise favorable in all cases. Conclusions. An alternative for the treatment of esophageal stenosis is presented which uses a biological scaffold and an innovative surgical procedure. Additional work, including prospective studies and long-term follow-up, is required to fully evaluate the potential of this bioscaffold-based regenerative medicine approach for esophageal reconstruction. (C) 2014 by The Society of Thoracic Surgeons