an anastomotic leak can be a very difficult problem to treat in an inflamed , infected area , especially in a physically compromised patient .
methods of treatment have included primary repair , esophageal resection or diversion , or both , and various types of patches including pleural , mucomuscular , and vicryl mesh .
we report here the use of decellularized human skin for patch repair of an anastomotic esophageal leak .
a 60-year - old male with symptomatic , biopsy proven , esophageal cancer underwent a laparoscopic - assisted distal esophagectomy with right thoracotomy ( ivor lewis esophagectomy ) .
the patient presented from an outside hospital with a history of progressive solid and later liquid dysphagia .
the laparoscopic gastric mobilization was performed via a 10-mm umbilical port , two 10-mm ports in the right lateral abdomen , two 10-mm ports in the left lateral abdomen , and a 5-mm subxiphoid port for liver retraction .
the distal esophagus was also mobilized well into the mediastinum . through a right sixth intercostal minithoracotomy incision ,
the proximal third of the stomach was transected laparoscopically by using a laparoscopic gia stapler .
the proximal stomach was pulled into the chest , and the esophagus was transected about 2 cm proximal to the gross tumor margin and passed to the pathology department for margin evaluation . due to a microscopically positive proximal margin ,
an anastomosis was created in an end - to - side fashion between the distal esophagus and the mobilized distal stomach .
the anastomosis was fashioned in a single - layer technique using 3 0 interrupted full - thickness silk sutures .
a nasogastric ( ng ) tube was left in the stomach ; a feeding jejunostomy tube was placed laparoscopically in the proximal jejunum .
the right chest was closed with a straight 28f and an angled 28f chest tube in place .
on postoperative day # 3 the ng tube was removed , and the patient was started on a clear liquid diet the following day . on pod # 4 , one chest tube was removed and due to minimal output the second chest tube was removed on pod # 8 . on pod # 9 , the patient was found to have a new pleural effusion that was drained .
the following day , pod # 10 , the patient complained of acute onset of back pain .
a ct scan with oral contrast was performed and showed a leak into the right chest .
the leak was not immediately apparent , and a gastroscope was passed into the proximal esophagus and used to evaluate the leak .
the majority of the anastomosis appeared intact , with a small 2-mm dehiscence at the lateral anastomotic edge . due to the friable nature of the surrounding tissue
alloderm was used as a patch onlay over the site of the breakdown . a piece 2x3 cm with a thickness of 0.031 inches to 0.077 inches was fashioned .
it was sewn into place with four 3 0 prolene simple interrupted corner sutures , covering the point of leak .
one more , simple interrupted suture was placed between the corner sutures to reinforce the patch .
the patient was extubated in the recovery room and admitted to the intensive care unit .
on postoperative day ( pod ) # 1 , jejunal tube feeds were initiated . on pod # 3 ,
chest x - rays were obtained daily and showed no effusion . on pod # 6 after his second surgery , the patient underwent a gastrografin swallow that showed no sign of leakage . on the same day , he was started on a liquid diet . on pod # 7 and # 8 ,
five days later , the patient was discharged to a rehabilitation hospital , tolerating a full liquid diet with nightly jejunal tube feeds .
one month after surgery , the patient was readmitted to the hospital due to nausea and vomiting .
he underwent an esophagogastroduodenoscopy , which showed a small ulceration at the anastomosis site , but no sign of stenosis .
currently , the patient is at home , tolerating an oral diet with supplemental tube feedings and receiving ongoing oncological treatment for his esophageal cancer .
one of the most feared complications of esophageal reconstruction surgery is a leak at the anastomotic site .
alanezi et al reported a 7.5% rate of esophageal anastomotic leak , with an associated 35% mortality .
junemann - ramirez et al noted an anastomotic leak rate of 5.1% , with 30- day mortality significantly higher in the leak group vs. nonleak group ( 35.7% vs 4.2% ) .
treatment of esophageal leaks depends on time to diagnosis of the perforation and whether the perforation is walled - off or not .
a walled - off perforation with minimal symptoms and no sepsis may be treated conservatively .
this includes nothing - by - mouth status , antibiotics , and an alternative feeding source .
the reinforcement can be gastric fundus as a partial or total fundoplication , a pleural or muscle flap , or as we are suggesting alloderm mesh . if there is free perforation and early diagnosis , this primary repair and reinforcement is also recommended .
studies report that this technique may also be used for free perforation after a delay of 48 hours to 72 hours .
other techniques used when a diagnosis of perforation has been delayed include resection , cervical esophagostomy , gastrostomy , and jejunostomy .
these include reconstruction of complicated abdominal wound defects , reconstruction of dural defects , pharyngeal reconstruction , vaginal repairs , and multiple plastics applications .
isch et al successfully applied an alloderm patch repair in a canine cervical esophageal leak model . in their study ,
no occurrence of wound infection , sepsis , or anastomotic leak was noted with the use of this material .
furthermore , on evaluation by barium esophagram , no leak , stricture , or diverticulum formation was found .
our hypothesis is that alloderm provides the properties needed for a successful esophageal leak repair .
alloderm provides an acellular matrix for regeneration and healing even in a contaminated field . due to its properties
it also has been shown to minimize the inflammatory reaction associated with prosthetic graft repair .
we have successfully applied alloderm to patch an esophageal intrathoracic leak in a patient with esophageal carcinoma without any resulting leak or stenosis . to our knowledge , this is the first report of successful alloderm use in an esophageal anastomotic leak .
we feel that alloderm is currently the optimal option in complicated esophageal repairs , adding to the surgeon 's armamentarium of repair techniques .
 multiple surgical techniques have been described for repair of esophageal leaks . 
 none of the repairs are optimal , and the morbidity and mortality of an esophageal leak remains high . to our knowledge , this is the first case report of use of alloderm ( lifecell corp , brachburg , nj ) to successfully repair a thoracic anastomotic esophageal leak . 
INTRODUCTION
CASE REPORT
DISCUSSION
CONCLUSION