P1.021. Esophageal Reconstruction in an Adult with Failed Colonic Interposition and Recurrent Aspiration

Abstract

Abstract Topic Benign Disease: Esophageal Surgery Case Submission We present a 23-year-old male with a history of tracheoesophageal fistula repaired in childhood with multiple revisions including a esophagostomy and ultimately a colonic interposition. He continued to have recurrent aspiration pneumonia and is now referred for evaluation for suspected conduit dysfunction. His surgical history is significant for extensive childhood operations, including left lower lobectomy, multiple EGDs with serial dilations for stricture, and partial colon resection for growth-related complications. His medical history includes asthma, repaired congenital heart disease (septal defect), and short bowel syndrome. He currently has both gastrostomy and jejunostomy tubes in place. Despite this complexity, he had maintained reasonable functional status into early adulthood. Interestingly, his symptoms were relatively subtle. He denied significant dysphagia, regurgitation, or chest pain and reported adequate oral intake, though he did note intermittent sensations of aspiration. He remained on room air at rest. Upper gastrointestinal contrast study demonstrated delayed transit through the colonic interposition, incomplete gastric distention, and retrograde reflux of contrast into the distal conduit. Moderate proximal duodenal dilation was present without complete obstruction. There was also significant colonic conduit dilation occupying the entire left hemithorax. Taken together, the imaging suggested functional obstruction and poor conduit emptying with secondary reflux and chronic aspiration. In this setting, the primary issue is not dysphagia alone, but progressive pulmonary compromise from chronic aspiration in a patient with already limited respiratory reserve. The combination of delayed conduit emptying, reflux into a markedly dilated colonic interposition, and recurrent pneumonias raises concern for functional failure of the reconstruction. At the same time, his relatively preserved oral intake and minimal subjective dysphagia complicate the decision-making process. Given the degree of conduit dilation and structural dysfunction, revision of the colon conduit was felt unlikely to provide durable benefit. After multidisciplinary discussion the decision was to proceed with esophagectomy with removal of the failed colon conduit and reconstruction with substernal gastric pull-up. This case raises important questions regarding optimal management of late colonic interposition failure in adults with repaired esophageal atresia. Specifically, regarding indications for conduit salvage versus replacement, technical considerations in reoperative esophageal surgery/conduit revision with altered anatomy and prior lung resection, and strategies to minimize perioperative pulmonary complications in this high-risk population.