FIRST SUCCESSFUL TRANSPLANTATION OF SMALL INTESTINAL MUCOSA TO THE CERVICAL ESOPHAGUS AFTER CIRCUMFERENTIAL SCAR EXCISION AND VACUUM SPONGE NEO-VASCULARISATION OF THE TRANSPLANTATION BED

Aims:

A 62 year old man had undergone curative circumferential tubular endoscopic submucosal dissection (ESD) from 20 – 27 cm aborally in july 2015 due to an early squamous cell cancer (SCC). Various measures to prevent stricture formation failed.

Methods:

One year later the patient had to return every 10 days to the hospital for dilatation. Due to again poor surgical alternatives an experimental concept was carried out after prior acute and chronic animal experiments in the pig. As the scar area was likely to be poorly vascularized the scar was first excised in a tubular fashion from the upper esophageal sphincter over 7 centimeters by ESD. Two polyurethan vacuum sponges were used and changed every 3 – 4 days over 20 days in order to stimulate neovascularization of the former scar area at -125 mm Hg. In a second intervention a 30 cm segment of small intestine was harvested surgically and the mucosa specially prepared and transplanted to pre-conditioned cervical esophagus. The specimen was temporarily fixed against the wall using a non-covered nitinol stent.

Results:

Two month after the second procedure several islands of histologically proven vital PAS positive small intestinal mucosa could be observed. In the meantime, small intestinal mucosa has completely spread out in the transplantation area. Clinically the patient has fully recovered from the intervention and works as engineer full time.

Conclusions:

This first case in man shows: Successful small intestinal mucosal transplantation to the esophagus is feasible after tubular ESD excision of a scar. Optimal local vascularization was induced by polyurethane vacuum sponge conditioning of the transplant area similar to plastic surgery. The case that may offer hope for patients with chronic refractory benign esophageal strictures.