A Novel Endoscopic Esophageal Reconstruction Technique

Silvana Perretta, MD, James Wall, MD, Bernard Dallemagne, MD, Jacques Marescaux, MD FRCS FACS. IRCAD Department of Digestive and Endocrine Surgery, University of Strasbourg

Objective: Esophageal reconstruction presents a significant clinical challenge in patients ranging form neonates with long-gap esophageal atresia to adults after esophageal resection. Both gastric and colonic replacement conduits carry significant morbidity. As emerging organ sparring techniques are established for early stage esophageal tumors, less morbid reconstruction techniques are warranted. Having developed expertise in esphageal mural tunneling for the purposes of endoscopic Heller’s myotomy, here we show a novel endoscopic approach for esophageal lengthening and reconstruction in a porcine model.Methods: A model of esophageal defect was created in a pig (30-35Kg) under general anesthesia by thorascopically transecting the esophagus above the gastro-oesophageal junction. The reconstruction technique involved bilateral submucosal endoscopic lengthening myotomies (BSELM) with a magnetic compression anastomosis (MAGNAMOSIS™) using endoscopically delivered magnetic rings. The first ring is delivered transorally to the proximal esophageal segment. The second ring is placed through a minimal invasive gastrotomy and delivered retrograde with endoscopic assistance. The MAGNAMOSIS™ rings automatically align and join when placed within a few centimeters of one another. The gradual necrosis between the rings forms a compression anastomosis over a period of days. Results: The technique was feasible in the pig model. The BSELM approach lengthened the esophagus 1cm for every 2cm length of myotomy. The myotomy targeted only the inner circular fibers of the esophagus with preservation of the longitudinal layer to protect against long-term dilation and pouching.Conclusions: Emerging endoscopic capabilities are enabling complex endoluminal esophageal procedures. BSELM is a novel and technically feasible approach to esophageal lengthening and reconstruction. Further survival studies are needed to establish the safety and efficacy of this technique.