Objective. Current standard techniques for surgical reconstruction of the esophagus remain suboptimal. Primary closure of unhealthy esophagus has been associated with a high morbidity rate, primarily due to leak and stricture, and synthetic materials are contraindicated due to the high risk of erosion and infection. Degradable extracellular matrix (ECM) scaffolds have recently shown promising results in both pre-clinical and clinical settings to prevent stricture after extended endomucosal 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. Three patients requiring esophageal reconstruction underwent a patch esophagoplasty using porcine urinary bladder matrix (UBM) ECM scaffold (MatriStem®, ACell Inc, Columbia, MD). In this surgical procedure, the full thickness wall of the esophagus was replaced with UBM-ECM patch that was sutured to the edges of the remaining esophagus, similar to patch angioplasty in vascular procedures. Case 1 was a 58yo woman undergoing reoperation following laparoscopic nissen due to a polypropylene mesh inclusion in the esophagus with surrounding mediastinal abscess. The lower third of the esophagus was disrupted and devitalized and UBM-ECM patch (5x3cm) esophagoplasty was performed. Case 2 was a 22yo man undergoing a cervical esophageal exclusion due to esophageal perforation. During closure of the lateral esophagostomy, a stricture was noticed at the center of the loop. Primary closure was replaced with a 4x2cm ECM patch. The 3rd case was an 8yo boy with history of caustic ingestion at the age of 3. He had received repeated dilations until a perforation with subsequent mediastinitis occurred. A cervical stricturoplasty was performed by opening the cervical esophagus longitudinally through the fibrotic ring. Closure was performed with a 5x3cm UBM-ECM patch.
Results. All patients had a favourable clinical outcome with immediate recovery from the procedure and reinstated oral intake after 7 days. Patient 2 had a micro leak at day 5 that closed spontaneously two days after drainage. Barium swallow control at 3 weeks showed no stricture and adequate esophageal emptying through the surgical segment in all patients. EGD showed complete mucosal remodeling at 2 months with approximately 20% area contraction at the patch level. At one year, the area of the defect was indistinguishable from surrounding healthy tissue. Biopsy on the patch area showed normal squamous epithelium. Patient 3 has a separate intrathoracic stricture that requires further surgery. Clinical outcomes were otherwiswe favorable in all cases.
Conclusions. Historically, stricturoplasty was a complex surgery requiring interposition of pedicled omentum or small bowel. These 3 cases are the first clinical report of reconstruction of the full thickness esophageal wall with biological scaffolds. Site-specific remodeling of ECM scaffolds may have a strong impact in the clinical scenario of esophageal surgery.
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