Cervical esophagogastric anastomosis via a retrosternal gastric conduit for adult type A long-gap esophageal atresia after 18 years of gastrostomy: A case report

Cervical esophagogastric anastomosis via a retrosternal gastric conduit for adult type A long-gap esophageal atresia after 18 years of gastrostomy: A case report | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Cervical esophagogastric anastomosis via a retrosternal gastric conduit for adult type A long-gap esophageal atresia after 18 years of gastrostomy: A case report Masahiro Kohmoto, Takeshi Yamashita, Satoru Goto, Akira Saito, and 8 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8366849/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Background Adult reconstruction for type A long-gap esophageal atresia (LGEA) after prolonged gastrostomy dependence is rare. We report an adult patient who had been reliant on gastrostomy since birth and regained durable oral intake after planned reconstruction, emphasizing the preoperative exclusion of tracheoesophageal fistula (TEF), individualized route selection, and tailored cervical anastomosis. Case presentation : An 18-year-old woman with type A LGEA underwent neonatal thoracotomy without definitive repair, followed by gastrostomy. At 2 years of age, cervical esophagostomy was performed for recurrent aspiration. Preoperative computed tomography showed a markedly dilated proximal cervical esophagus with esophagostomy at the left neck and absence of intramediastinal esophagus. No tracheoesophageal fistula (TEF) was identified. Anticipating posterior mediastinal adhesions and difficulty in elevating the gastric conduit through the posterior mediastinum, we planned cervical esophagogastric anastomosis using a gastric conduit through the retrosternal route. An anastomotic leak and left pneumothorax occurred postoperatively but resolved with conservative management. Left recurrent laryngeal nerve palsy occurred without aspiration. She commenced oral intake on postoperative day (POD) 12 and was discharged on POD 21; her body weight increased by 3 kg after 3 months. Conclusion Durable oral feeding is feasible after long-term gastrostomy in adult type A LGEA when TEF is absent and the reconstruction route and anastomotic technique are individualized for reach and perfusion. The retrosternal route is reasonable when posterior mediastinal adhesions or conduit reach are concerns; candidacy should be determined individually. Long-gap esophageal atresia Type A esophageal atresia Adult Retrosternal route Cervical esophagogastric anastomosis Case Report Figures Figure 1 Figure 2 Figure 3 Background Esophageal atresia (EA) is a congenital interruption of esophageal continuity, occurring in approximately 1 in 3,000 live births 1 , 2 . Primary neonatal repair is the standard of care and generally yields favorable outcomes 3 , 4 . In contrast, long-gap EA (LGEA)—wherein the proximal and distal segments are separated to a degree that precludes tension-free primary anastomosis—often necessitates staged strategies and, in selected cases, esophageal replacement 5 – 7 . Most reconstructions are completed in infancy or early childhood, and adult reconstruction after years of enteral feeding is exceptionally uncommon 7 . Three practical considerations support contemporary LGEA management: (i) confirming the anatomy and excluding the possibility of residual fistulae based on airway evaluation 8 ; (ii) selecting the conduit transfer route-posterior mediastinal or retrosternal-according to prior thoracic surgery, adhesions, and anticipated conduit reach 9 – 13 ; and (iii) optimizing anastomotic perfusion and minimizing tension, using strategies such as traction-based lengthening (Foker), circular myotomy (Livaditis), and spiral myotomy (Kimura), described in pertinent studies on EA 6,7,9,12,14–16 . We herein report durable restoration of oral feeding in an adult with type A LGEA after 18 years of gastrostomy dependence and describe the key enabling decision. Case presentation An 18-year-old woman (height: 131.4 cm; weight: 30.4 kg; body mass index: 17.6 kg/m 2 ) presented for definitive reconstruction of type A LGEA. In the neonatal period, thoracotomy was performed in her home country with the intent to repair the atresia; definitive reconstruction was not completed, and a gastrostomy was created. At 2 years of age, a left cervical esophagostomy was performed for recurrent aspiration. No referral letters or operative notes were available; the medical history was reliant on family report and current imaging. The patient’s menstrual cycles were regular, with no clinical features of endocrine dysfunction. The serum albumin level was 4.5 g/dL preoperatively. No relevant family history or social risk factors were identified. The patient was not on any regular medications. Because of limitations within the healthcare system in her home country, definitive surgical treatment was not available. Moreover, socioeconomic circumstances hindered overseas referral; ultimately, she traveled to Japan and underwent reconstruction. Contrast-enhanced computed tomography (CT) demonstrated a dilated esophagus, left cervical esophagostomy, and absence of the intramediastinal esophagus (Fig. 1a–c). Water-soluble contrast esophagography showed a J-shaped proximal pouch with egress via the cervical esophagostomy (Fig. 2a). Retrograde endoscopy via the gastrostomy identified a distal esophageal blind stump approximately 3 cm above the cardia (Fig. 2b–d). Preoperative magnetic resonance imaging (MRI) did not identify a tracheoesophageal fistula (TEF). The internal diameter of the proximal esophagus was 70 mm on CT and MRI. The esophagostomy orifice was located at the apex of the proximal pouch (end-on) rather than the sidewall. Given the high likelihood of posterior mediastinal adhesions after prior thoracotomy and the anticipated difficulty in conduit transfer through the posterior mediastinum, a retrosternal route to the cervical anastomosis was planned. Surgical technique Under general anesthesia with endotracheal intubation, the patient was placed in the supine position with slight neck extension. Based on the findings of MRI and the clinical course, the likelihood of a residual TEF was considered extremely low; bronchoscopy after anesthesia induction was performed as a confirmatory safeguard, which did not find evidence of TEF. The operation was commenced laparoscopically with a 5-cm mini-laparotomy. Dense adhesions between the prior gastrostomy site and the left lateral hepatic segment were released (Fig. 3a). Along the greater curvature, the omentum was divided approximately 3 cm from the right gastroepiploic arcade, and the short gastric vessels were divided sequentially to mobilize the fundus. The left gastric artery and vein were divided. A remnant distal blind esophageal stump approximately 3 cm proximal to the cardia was identified at the hiatus (Fig. 3b,c). A subtotal gastric conduit was fashioned using a linear stapler, preserving the right gastric and right gastroepiploic arteries as vascular inflow (Fig. 3d). The cervical esophagostomy was excised through a left oblique cervical incision. The orifice was located lateral to the sternocleidomastoid muscle. Dissection proceeded along the esophageal wall, mobilizing the proximal esophagus off the trachea. Severe adhesions involving the external and internal jugular veins and the common carotid artery were evident. A retrosternal tunnel was created laparoscopically, and the gastric conduit was delivered to the neck. End-to-end cervical esophagogastric anastomosis was performed by manual suturing. Finally, a feeding jejunostomy (8-Fr tube) was created. Postoperative course A left pneumothorax was detected just after surgery, and a chest tube was inserted, which was removed on postoperative day (POD) 2 because of rapid improvement. On POD 1, bronchoscopic suction was required to mitigate difficulty with sputum clearance due to left vocal cord paralysis. A cervical anastomotic leak presented as a neck abscess and was managed conservatively by opening and local drainage of the cervical wound. Enteral nutrition was maintained via the feeding jejunostomy until oral intake was established and stable. The patient started oral intake on POD 12 and was discharged on POD 21. After 3 months, oral feeding remained stable, and her body weight had increased by 3 kg; the jejunostomy tube was subsequently removed. No aspiration occurred despite left recurrent laryngeal nerve (RLN) palsy. Dietary advancement was followed with good tolerability. Planned follow-up included nutritional monitoring and surveillance for anastomotic stricture or reflux-related symptoms, with endoscopic assessment, as clinically indicated. Discussion and Conclusion Adult reconstruction after prolonged enteral feeding in type A LGEA is exceptional 5–7 . In our case, three interlinked decisions facilitated success. First, airway confirmation excluded a residual TEF⁸. Preoperative imaging strongly suggested type A LGEA, and bronchoscopy at induction confirmed the absence of TEF without procedural burden. Second, route selection was individualized. Cervical anastomosis may be performed using either the posterior mediastinal or retrosternal route 9–13 . Because prior thoracotomy increased the likelihood of adhesions and posed compromised conduit passage, the retrosternal route was favored—consistent with accepted alternatives in esophageal reconstruction¹³. Third, the cervical anastomosis strategy was tailored. Although some meta-analyses suggest that stapled anastomoses may reduce anastomotic leak rates relative to hand-sewn techniques 17 , the EA-specific geometry in this case—a dilated cervical esophagus following adhesiolysis with attention to cervical reach and conduit perfusion along the retrosternal route—favored a hand-sewn end-to-end approach to allow precise caliber matching and tension distribution. A cervical anastomotic leak occurred but was controlled with local drainage, and oral intake was ultimately maintained. Long-standing cervical esophagostomy produces significant neck scarring, where difficult adhesiolysis around major cervical vessels and the esophagus is expected¹⁸. Intraoperative nerve monitoring (NIM) has been shown to reduce RLN palsy or facilitate earlier recognition in thyroid surgery and esophagectomy¹⁹ , ²⁰. Although NIM was available but not used in this case, selective use may be beneficial when severe scarring is anticipated. Clinical implications Even after prolonged gastrostomy dependence, swallowing can be preserved in adults with confirmed type A anatomy; moreover, a feasible transfer route can be achieved through reconstruction within standard oncologic principles, provided that the technique is individualized to pouch geometry and conduit reach. Patient perspective From the patient’s perspective, regaining oral feeding after several years of gastrostomy improved daily comfort and enabled broader social participation. In conclusion, durable oral feeding is feasible after long-term gastrostomy in adult type A LGEA when the possibility of TEF is excluded, and the route and anastomosis are individualized for reach and perfusion. The retrosternal route is a viable option when posterior mediastinal adhesions or conduit reach are concerns, but candidacy should be determined on a patient-specific basis. Abbreviations EA: esophageal atresia LGEA: long-gap esophageal atresia TEF: tracheoesophageal fistula POD: postoperative day RLN: recurrent laryngeal nerve NIM: intraoperative nerve monitoring CT: computed tomography MRI: magnetic resonance imaging Declarations Acknowledgements We thank the multidisciplinary team involved in the perioperative care of this patient at Showa Medical University Hospital. We also thank Editage (www.editage.com) for English language editing. The authors are solely responsible for the content and writing of this article. Authors’ contributions MK and TY conceptualized and designed the study. MK, TY, AS, KM, TA, SA, and NN collected the clinical data and contributed to perioperative management. MK wrote the manuscript. SG, KO, YW, MM, and TA supervised the study. All authors have reviewed and approved the final manuscript and agree to be accountable for all aspects of this research. Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors. Availability of data and materials All data supporting the findings of this case are included within the article. Additional information is available from the corresponding author upon reasonable request. Ethics approval and consent to participate Ethical approval was waived for this case report, as per our institutional policy for single-patient case reporting. Written informed consent for participation and publication of this report was obtained from the patient. Consent for publication Written informed consent was obtained from the patient for publication of this case report and any accompanying images. Competing interests The authors declare that they have no competing interests. References Nassar N, Leoncini E, Amar E, Arteaga-Vázquez J, Bakker MK, Bower C, et al. Prevalence of esophageal atresia among 18 international birth defects surveillance programs. Birth Defects Res A Clin Mol Teratol. 2012;94:893-9. Pedersen RN, Calzolari E, Husby S, Garne E; EUROCAT Working group. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions. Arch Dis Child. 2012;97:227-32. Bourg A, Gottrand F, Parmentier B, Thomas J, Lehn A, Piolat C, et al. Outcome of long gap esophageal atresia at 6 years: a prospective case-control cohort study. J Pediatr Surg. 2023;58:747-55. Dunkley ME, Zalewska KM, Shi E, Stalewski H. Management of esophageal atresia and tracheoesophageal fistula in North Queensland. Int Surg. 2014;99:276-9. Spitz L, Kiely EM, Drake DP, Pierro A. Long-gap oesophageal atresia. Pediatr Surg Int. 1996;11:462-5. Sharma N, Srinivas M. Laryngotracheobronchoscopy prior to esophageal atresia and tracheoesophageal fistula repair: its use and importance. J Pediatr Surg. 2014;49:367-9. Séguier-Lipszyc E, Bonnard A, Aizenfisz S, Enezian G, Maintenant J, Aigrain Y, et al. The management of long gap esophageal atresia. J Pediatr Surg. 2005;40:1542-6. Liu J, Yang Y, Zheng C, Dong R, Zheng S. Surgical outcomes of different approaches to esophageal replacement in long-gap esophageal atresia: a systematic review. Medicine (Baltimore). 2017;96:e6942. Foker JE, Linden BC, Boyle EM, Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg. 1997;226:533-41. Livaditis A, Rådberg L, Odensjö G. Esophageal end-to-end anastomosis: reduction of anastomotic tension by circular myotomy. Scand J Thorac Cardiovasc Surg. 1972;6:206-14. Kimura K, Nishijima E, Tsugawa C, Matsumoto Y. A new approach for the salvage of unsuccessful esophageal atresia repair: a spiral myotomy and delayed definitive operation. J Pediatr Surg. 1987;22:981-3. Hirschl RB, Yardeni D, Oldham K, Sherman N, Siplovich L, Gross E, et al. Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia. Ann Surg. 2002;236:531-41. Bax NM, van der Zee DC. Jejunal pedicle grafts for reconstruction of the esophagus in children. J Pediatr Surg. 2007;42:363-9. Burgos L, Barrena S, Andrés AM, Martínez L, Hernández F, Olivares P, et al. Colonic interposition for esophageal replacement in children remains a good choice: 33-year median follow-up of 65 patients. J Pediatr Surg. 2010;45:341-5. Cowles RA, Coran AG. Gastric transposition in infants and children. Pediatr Surg Int. 2010;26:1129-34. Liu QX, Min JX, Deng XF, Dai JG. Is hand sewing comparable with stapling for anastomotic leakage after esophagectomy? A meta-analysis. World J Gastroenterol. 2014;20:17218-26. Urschel JD, Urschel DM, Miller JD, Bennett WF, Young JE. A meta-analysis of randomized controlled trials of route of reconstruction after esophagectomy for cancer. Am J Surg. 2001;182:470-5. Yamagata Y, Yoshida N, Uchiyama A, Takagi T, Baba S, Naito Y, et al. Surgical approach to cervical esophagogastric anastomosis. Ann Thorac Cardiovasc Surg. 2013;19:241-6. Barczyński M, Konturek A, Pragacz K, Papier A, Stopa M, Nowak W. Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study. World J Surg. 2014;38:599-606. Yuda M, Nishikawa K, Ishikawa Y, Takahashi K, Kurogochi T, Tanaka Y, et al. Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy. Surg Endosc. 2022;36:3957-64. Additional Declarations No competing interests reported. Cite Share Download PDF Status: Under Review Version 1 posted Editorial decision: Revision requested 04 Feb, 2026 Reviews received at journal 24 Jan, 2026 Reviews received at journal 19 Jan, 2026 Reviewers agreed at journal 18 Jan, 2026 Reviewers agreed at journal 16 Jan, 2026 Reviewers invited by journal 16 Jan, 2026 Editor invited by journal 22 Dec, 2025 Editor assigned by journal 20 Dec, 2025 Submission checks completed at journal 20 Dec, 2025 First submitted to journal 15 Dec, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8366849","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":577080767,"identity":"ff687ee2-6c59-45a8-abc3-d1294f5a6cc0","order_by":0,"name":"Masahiro Kohmoto","email":"","orcid":"","institution":"Showa Medical University","correspondingAuthor":false,"prefix":"","firstName":"Masahiro","middleName":"","lastName":"Kohmoto","suffix":""},{"id":577080768,"identity":"fb169e38-7359-434c-b454-8a922ce5cde0","order_by":1,"name":"Takeshi Yamashita","email":"","orcid":"","institution":"Showa Medical 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1","display":"","copyAsset":false,"role":"figure","size":56399,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative computed tomography (CT) findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(a) Dilated cervical esophagus (white arrow)\u003cbr\u003e\n(b) Esophagostomy in the left neck (white arrow)\u003cbr\u003e\n(c) Absence of the esophagus in the mediastinum\u003c/p\u003e","description":"","filename":"1.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8366849/v1/104d8f13f04240023ffb416e.jpg"},{"id":100761216,"identity":"92129309-f1c4-4cc7-abe3-fdb8f469071a","added_by":"auto","created_at":"2026-01-21 07:37:30","extension":"jpg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":51411,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePreoperative contrast radiographs and endoscopic findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(a) Contrast radiograph using amidotrizoic acid showing a J-shaped cervical esophageal pouch and contrast leakage from the cervical fistula\u003cbr\u003e\n (b) Contrast radiograph obtained during retrograde endoscopy showing a blind-ending esophageal stump approximately 3 cm from the cardiac sphincter\u003cbr\u003e\n (c, d) Endoscopic views of the blind-ending esophageal stump\u003c/p\u003e","description":"","filename":"2.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8366849/v1/3a3861a9a5aaaf590e615b88.jpg"},{"id":100761241,"identity":"3b14bcc4-38e5-4f99-a4ea-d586b958d3bf","added_by":"auto","created_at":"2026-01-21 07:38:03","extension":"jpg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":115804,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOperative findings\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e(a) Dense adhesions between the gastrostomy site of the stomach and the left lateral segment of the liver\u003cbr\u003e\n(b, c) A blind-ending remnant abdominal esophagus is seen approximately 3 cm from the esophageal hiatus\u003cbr\u003e\n(d) A subtotal gastric conduit is created using a linear stapler.\u003c/p\u003e","description":"","filename":"3.jpg","url":"https://assets-eu.researchsquare.com/files/rs-8366849/v1/f07eb169a92a6eaff3574285.jpg"},{"id":100762139,"identity":"c217c16a-0744-4933-8792-fdd645b25be3","added_by":"auto","created_at":"2026-01-21 07:53:23","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":785651,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8366849/v1/154dd137-fefa-43dc-83b6-4123a93be66b.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Cervical esophagogastric anastomosis via a retrosternal gastric conduit for adult type A long-gap esophageal atresia after 18 years of gastrostomy: A case report","fulltext":[{"header":"Background","content":"\u003cp\u003eEsophageal atresia (EA) is a congenital interruption of esophageal continuity, occurring in approximately 1 in 3,000 live births\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e,\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Primary neonatal repair is the standard of care and generally yields favorable outcomes\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e,\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e. In contrast, long-gap EA (LGEA)\u0026mdash;wherein the proximal and distal segments are separated to a degree that precludes tension-free primary anastomosis\u0026mdash;often necessitates staged strategies and, in selected cases, esophageal replacement\u003csup\u003e\u003cspan additionalcitationids=\"CR6\" citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Most reconstructions are completed in infancy or early childhood, and adult reconstruction after years of enteral feeding is exceptionally uncommon\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e \u003cp\u003eThree practical considerations support contemporary LGEA management: (i) confirming the anatomy and excluding the possibility of residual fistulae based on airway evaluation\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e; (ii) selecting the conduit transfer route-posterior mediastinal or retrosternal-according to prior thoracic surgery, adhesions, and anticipated conduit reach\u003csup\u003e\u003cspan additionalcitationids=\"CR10 CR11 CR12\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u003c/sup\u003e; and (iii) optimizing anastomotic perfusion and minimizing tension, using strategies such as traction-based lengthening (Foker), circular myotomy (Livaditis), and spiral myotomy (Kimura), described in pertinent studies on EA\u003csup\u003e6,7,9,12,14\u0026ndash;16\u003c/sup\u003e. We herein report durable restoration of oral feeding in an adult with type A LGEA after 18 years of gastrostomy dependence and describe the key enabling decision.\u003c/p\u003e"},{"header":"Case presentation","content":"\u003cp\u003eAn 18-year-old woman (height: 131.4 cm; weight: 30.4 kg; body mass index: 17.6 kg/m\u003csup\u003e2\u003c/sup\u003e) presented for definitive reconstruction of type A LGEA. In the neonatal period, thoracotomy was performed in her home country with the intent to repair the atresia; definitive reconstruction was not completed, and a gastrostomy was created. At 2 years of age, a left cervical esophagostomy was performed for recurrent aspiration. No referral letters or operative notes were available; the medical history was reliant on family report and current imaging. The patient’s menstrual cycles were regular, with no clinical features of endocrine dysfunction. The serum albumin level was 4.5 g/dL preoperatively. No relevant family history or social risk factors were identified. The patient was not on any regular medications. Because of limitations within the healthcare system in her home country, definitive surgical treatment was not available. Moreover, socioeconomic circumstances hindered overseas referral; ultimately, she traveled to Japan and underwent reconstruction. Contrast-enhanced computed tomography (CT) demonstrated a dilated esophagus, left cervical esophagostomy, and absence of the intramediastinal esophagus (Fig.\u0026nbsp;1a–c). Water-soluble contrast esophagography showed a J-shaped proximal pouch with egress via the cervical esophagostomy (Fig.\u0026nbsp;2a). Retrograde endoscopy via the gastrostomy identified a distal esophageal blind stump approximately 3 cm above the cardia (Fig.\u0026nbsp;2b–d).\u003c/p\u003e\n\u003cp\u003ePreoperative magnetic resonance imaging (MRI) did not identify a tracheoesophageal fistula (TEF). The internal diameter of the proximal esophagus was 70 mm on CT and MRI. The esophagostomy orifice was located at the apex of the proximal pouch (end-on) rather than the sidewall. Given the high likelihood of posterior mediastinal adhesions after prior thoracotomy and the anticipated difficulty in conduit transfer through the posterior mediastinum, a retrosternal route to the cervical anastomosis was planned.\u003c/p\u003e\n\u003cdiv id=\"Sec3\"\u003e\n \u003ch2\u003eSurgical technique\u003c/h2\u003e\n \u003cp\u003eUnder general anesthesia with endotracheal intubation, the patient was placed in the supine position with slight neck extension. Based on the findings of MRI and the clinical course, the likelihood of a residual TEF was considered extremely low; bronchoscopy after anesthesia induction was performed as a confirmatory safeguard, which did not find evidence of TEF.\u003c/p\u003e\n \u003cp\u003eThe operation was commenced laparoscopically with a 5-cm mini-laparotomy. Dense adhesions between the prior gastrostomy site and the left lateral hepatic segment were released (Fig.\u0026nbsp;3a). Along the greater curvature, the omentum was divided approximately 3 cm from the right gastroepiploic arcade, and the short gastric vessels were divided sequentially to mobilize the fundus. The left gastric artery and vein were divided. A remnant distal blind esophageal stump approximately 3 cm proximal to the cardia was identified at the hiatus (Fig.\u0026nbsp;3b,c). A subtotal gastric conduit was fashioned using a linear stapler, preserving the right gastric and right gastroepiploic arteries as vascular inflow (Fig.\u0026nbsp;3d). \u003c/p\u003e\n \u003cp\u003eThe cervical esophagostomy was excised through a left oblique cervical incision. The orifice was located lateral to the sternocleidomastoid muscle. Dissection proceeded along the esophageal wall, mobilizing the proximal esophagus off the trachea. Severe adhesions involving the external and internal jugular veins and the common carotid artery were evident. A retrosternal tunnel was created laparoscopically, and the gastric conduit was delivered to the neck. End-to-end cervical esophagogastric anastomosis was performed by manual suturing. Finally, a feeding jejunostomy (8-Fr tube) was created.\u003c/p\u003e\n\u003c/div\u003e\n\u003ch3\u003ePostoperative course\u003c/h3\u003e\n\u003cp\u003eA left pneumothorax was detected just after surgery, and a chest tube was inserted, which was removed on postoperative day (POD) 2 because of rapid improvement. On POD 1, bronchoscopic suction was required to mitigate difficulty with sputum clearance due to left vocal cord paralysis. A cervical anastomotic leak presented as a neck abscess and was managed conservatively by opening and local drainage of the cervical wound. Enteral nutrition was maintained via the feeding jejunostomy until oral intake was established and stable. The patient started oral intake on POD 12 and was discharged on POD 21. After 3 months, oral feeding remained stable, and her body weight had increased by 3 kg; the jejunostomy tube was subsequently removed. No aspiration occurred despite left recurrent laryngeal nerve (RLN) palsy. Dietary advancement was followed with good tolerability. Planned follow-up included nutritional monitoring and surveillance for anastomotic stricture or reflux-related symptoms, with endoscopic assessment, as clinically indicated.\u003c/p\u003e\n\n\n\n\n\n\n\n"},{"header":"Discussion and Conclusion","content":"\u003cp\u003eAdult reconstruction after prolonged enteral feeding in type A LGEA is exceptional\u003csup\u003e5–7\u003c/sup\u003e. In our case, three interlinked decisions facilitated success. First, airway confirmation excluded a residual TEF⁸. Preoperative imaging strongly suggested type A LGEA, and bronchoscopy at induction confirmed the absence of TEF without procedural burden. Second, route selection was individualized. Cervical anastomosis may be performed using either the posterior mediastinal or retrosternal route\u003csup\u003e9–13\u003c/sup\u003e. Because prior thoracotomy increased the likelihood of adhesions and posed compromised conduit passage, the retrosternal route was favored—consistent with accepted alternatives in esophageal reconstruction¹³. Third, the cervical anastomosis strategy was tailored. Although some meta-analyses suggest that stapled anastomoses may reduce anastomotic leak rates relative to hand-sewn techniques\u003csup\u003e17\u003c/sup\u003e, the EA-specific geometry in this case—a dilated cervical esophagus following adhesiolysis with attention to cervical reach and conduit perfusion along the retrosternal route—favored a hand-sewn end-to-end approach to allow precise caliber matching and tension distribution. A cervical anastomotic leak occurred but was controlled with local drainage, and oral intake was ultimately maintained.\u003c/p\u003e\u003cp\u003eLong-standing cervical esophagostomy produces significant neck scarring, where difficult adhesiolysis around major cervical vessels and the esophagus is expected¹⁸. Intraoperative nerve monitoring (NIM) has been shown to reduce RLN palsy or facilitate earlier recognition in thyroid surgery and esophagectomy¹⁹\u003csup\u003e,\u003c/sup\u003e²⁰. Although NIM was available but not used in this case, selective use may be beneficial when severe scarring is anticipated.\u003c/p\u003e\u003ch3\u003eClinical implications\u003c/h3\u003e\u003cp\u003eEven after prolonged gastrostomy dependence, swallowing can be preserved in adults with confirmed type A anatomy; moreover, a feasible transfer route can be achieved through reconstruction within standard oncologic principles, provided that the technique is individualized to pouch geometry and conduit reach.\u003c/p\u003e\u003ch3\u003ePatient perspective\u003c/h3\u003e\u003cp\u003eFrom the patient’s perspective, regaining oral feeding after several years of gastrostomy improved daily comfort and enabled broader social participation.\u003c/p\u003e\u003cp\u003eIn conclusion, durable oral feeding is feasible after long-term gastrostomy in adult type A LGEA when the possibility of TEF is excluded, and the route and anastomosis are individualized for reach and perfusion. The retrosternal route is a viable option when posterior mediastinal adhesions or conduit reach are concerns, but candidacy should be determined on a patient-specific basis.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eEA: esophageal atresia\u003cbr\u003e\u0026nbsp;LGEA: long-gap esophageal atresia\u003cbr\u003e\u0026nbsp;TEF: tracheoesophageal fistula\u003cbr\u003e\u0026nbsp;POD: postoperative day\u003cbr\u003e\u0026nbsp;RLN: recurrent laryngeal nerve\u003cbr\u003e\u0026nbsp;NIM: intraoperative nerve monitoring\u003cbr\u003e\u0026nbsp;CT: computed tomography\u003cbr\u003e\u0026nbsp;MRI: magnetic resonance imaging\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWe thank the multidisciplinary team involved in the perioperative care of this patient at Showa Medical University Hospital. We also thank Editage (www.editage.com) for English language editing. The authors are solely responsible for the content and writing of this article.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eMK and TY conceptualized and designed the study. MK, TY, AS, KM, TA, SA, and NN collected the clinical data and contributed to perioperative management. MK wrote the manuscript. SG, KO, YW, MM, and TA supervised the study. All authors have reviewed and approved the final manuscript and agree to be accountable for all aspects of this research.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAll data supporting the findings of this case are included within the article. Additional information is available from the corresponding author upon reasonable request.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eEthical approval was waived for this case report, as per our institutional policy for single-patient case reporting. Written informed consent for participation and publication of this report was obtained from the patient.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eWritten informed consent was obtained from the patient for publication of this case report and any accompanying images.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eNassar N, Leoncini E, Amar E, Arteaga-V\u0026aacute;zquez J, Bakker MK, Bower C, et al. Prevalence of esophageal atresia among 18 international birth defects surveillance programs. Birth Defects Res A Clin Mol Teratol. 2012;94:893-9. \u003c/li\u003e\n\u003cli\u003ePedersen RN, Calzolari E, Husby S, Garne E; EUROCAT Working group. Oesophageal atresia: prevalence, prenatal diagnosis and associated anomalies in 23 European regions. Arch Dis Child. 2012;97:227-32. \u003c/li\u003e\n\u003cli\u003eBourg A, Gottrand F, Parmentier B, Thomas J, Lehn A, Piolat C, et al. Outcome of long gap esophageal atresia at 6 years: a prospective case-control cohort study. J Pediatr Surg. 2023;58:747-55. \u003c/li\u003e\n\u003cli\u003eDunkley ME, Zalewska KM, Shi E, Stalewski H. Management of esophageal atresia and tracheoesophageal fistula in North Queensland. Int Surg. 2014;99:276-9. \u003c/li\u003e\n\u003cli\u003eSpitz L, Kiely EM, Drake DP, Pierro A. Long-gap oesophageal atresia. Pediatr Surg Int. 1996;11:462-5. \u003c/li\u003e\n\u003cli\u003eSharma N, Srinivas M. Laryngotracheobronchoscopy prior to esophageal atresia and tracheoesophageal fistula repair: its use and importance. J Pediatr Surg. 2014;49:367-9. \u003c/li\u003e\n\u003cli\u003eS\u0026eacute;guier-Lipszyc E, Bonnard A, Aizenfisz S, Enezian G, Maintenant J, Aigrain Y, et al. The management of long gap esophageal atresia. J Pediatr Surg. 2005;40:1542-6. \u003c/li\u003e\n\u003cli\u003eLiu J, Yang Y, Zheng C, Dong R, Zheng S. Surgical outcomes of different approaches to esophageal replacement in long-gap esophageal atresia: a systematic review. Medicine (Baltimore). 2017;96:e6942. \u003c/li\u003e\n\u003cli\u003eFoker JE, Linden BC, Boyle EM, Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg. 1997;226:533-41. \u003c/li\u003e\n\u003cli\u003eLivaditis A, R\u0026aring;dberg L, Odensj\u0026ouml; G. Esophageal end-to-end anastomosis: reduction of anastomotic tension by circular myotomy. Scand J Thorac Cardiovasc Surg. 1972;6:206-14. \u003c/li\u003e\n\u003cli\u003eKimura K, Nishijima E, Tsugawa C, Matsumoto Y. A new approach for the salvage of unsuccessful esophageal atresia repair: a spiral myotomy and delayed definitive operation. J Pediatr Surg. 1987;22:981-3. \u003c/li\u003e\n\u003cli\u003eHirschl RB, Yardeni D, Oldham K, Sherman N, Siplovich L, Gross E, et al. Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia. Ann Surg. 2002;236:531-41. \u003c/li\u003e\n\u003cli\u003eBax NM, van der Zee DC. Jejunal pedicle grafts for reconstruction of the esophagus in children. J Pediatr Surg. 2007;42:363-9. \u003c/li\u003e\n\u003cli\u003eBurgos L, Barrena S, Andr\u0026eacute;s AM, Mart\u0026iacute;nez L, Hern\u0026aacute;ndez F, Olivares P, et al. Colonic interposition for esophageal replacement in children remains a good choice: 33-year median follow-up of 65 patients. J Pediatr Surg. 2010;45:341-5. \u003c/li\u003e\n\u003cli\u003eCowles RA, Coran AG. Gastric transposition in infants and children. Pediatr Surg Int. 2010;26:1129-34. \u003c/li\u003e\n\u003cli\u003eLiu QX, Min JX, Deng XF, Dai JG. Is hand sewing comparable with stapling for anastomotic leakage after esophagectomy? A meta-analysis. World J Gastroenterol. 2014;20:17218-26. \u003c/li\u003e\n\u003cli\u003eUrschel JD, Urschel DM, Miller JD, Bennett WF, Young JE. A meta-analysis of randomized controlled trials of route of reconstruction after esophagectomy for cancer. Am J Surg. 2001;182:470-5. \u003c/li\u003e\n\u003cli\u003eYamagata Y, Yoshida N, Uchiyama A, Takagi T, Baba S, Naito Y, et al. Surgical approach to cervical esophagogastric anastomosis. Ann Thorac Cardiovasc Surg. 2013;19:241-6. \u003c/li\u003e\n\u003cli\u003eBarczyński M, Konturek A, Pragacz K, Papier A, Stopa M, Nowak W. Intraoperative nerve monitoring can reduce prevalence of recurrent laryngeal nerve injury in thyroid reoperations: results of a retrospective cohort study. World J Surg. 2014;38:599-606. \u003c/li\u003e\n\u003cli\u003eYuda M, Nishikawa K, Ishikawa Y, Takahashi K, Kurogochi T, Tanaka Y, et al. Intraoperative nerve monitoring during esophagectomy reduces the risk of recurrent laryngeal nerve palsy. Surg Endosc. 2022;36:3957-64. \u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Long-gap esophageal atresia, Type A esophageal atresia, Adult, Retrosternal route, Cervical esophagogastric anastomosis, Case Report","lastPublishedDoi":"10.21203/rs.3.rs-8366849/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8366849/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eAdult reconstruction for type A long-gap esophageal atresia (LGEA) after prolonged gastrostomy dependence is rare. We report an adult patient who had been reliant on gastrostomy since birth and regained durable oral intake after planned reconstruction, emphasizing the preoperative exclusion of tracheoesophageal fistula (TEF), individualized route selection, and tailored cervical anastomosis.\u003c/p\u003e\u003ch2\u003eCase presentation\u003c/h2\u003e \u003cp\u003e: An 18-year-old woman with type A LGEA underwent neonatal thoracotomy without definitive repair, followed by gastrostomy. At 2 years of age, cervical esophagostomy was performed for recurrent aspiration. Preoperative computed tomography showed a markedly dilated proximal cervical esophagus with esophagostomy at the left neck and absence of intramediastinal esophagus. No tracheoesophageal fistula (TEF) was identified. Anticipating posterior mediastinal adhesions and difficulty in elevating the gastric conduit through the posterior mediastinum, we planned cervical esophagogastric anastomosis using a gastric conduit through the retrosternal route. An anastomotic leak and left pneumothorax occurred postoperatively but resolved with conservative management. Left recurrent laryngeal nerve palsy occurred without aspiration. She commenced oral intake on postoperative day (POD) 12 and was discharged on POD 21; her body weight increased by 3 kg after 3 months.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eDurable oral feeding is feasible after long-term gastrostomy in adult type A LGEA when TEF is absent and the reconstruction route and anastomotic technique are individualized for reach and perfusion. The retrosternal route is reasonable when posterior mediastinal adhesions or conduit reach are concerns; candidacy should be determined individually.\u003c/p\u003e","manuscriptTitle":"Cervical esophagogastric anastomosis via a retrosternal gastric conduit for adult type A long-gap esophageal atresia after 18 years of gastrostomy: A case report","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-01-21 07:16:02","doi":"10.21203/rs.3.rs-8366849/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-02-04T07:35:46+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-24T08:49:34+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-01-19T21:00:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"309504426936758583459275278001610715825","date":"2026-01-18T11:33:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"190256135933857626356509545720457805890","date":"2026-01-16T15:14:08+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-01-16T11:05:49+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-12-22T06:06:38+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-12-20T07:32:15+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-12-20T07:30:52+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Surgery","date":"2025-12-15T13:18:53+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bsur","sideBox":"Learn more about [BMC Surgery](http://bmcsurg.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bsur/default.aspx","title":"BMC Surgery","twitterHandle":"@BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"0db396ea-afd3-4acc-874b-b096dfe3c35f","owner":[],"postedDate":"January 21st, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-06T14:11:36+00:00","versionOfRecord":[],"versionCreatedAt":"2026-01-21 07:16:02","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8366849","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8366849","identity":"rs-8366849","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}