Reinforcement of esophageal anastomoses with an extracellular matrix scaffold in a canine model

Background. The gastric pull-up procedure, a standard intervention after radical esophagectomy, is associated with high morbidity and mortality due to leaks and stricture. A previous preclinical study showed that an extracellular matrix (ECM) scaffold with autologous muscle tissue could be used to repair a complete circumferential defect in the cervical esophagus. The aim of the present study was to determine if healing of end-to-end anastomoses of the esophagus could be improved by reinforcement with an ECM scaffold. Methods. Twelve female mongrel dogs underwent a complete transection of either the cervical esophagus (n = 6) or the gastroesophageal junction (n = 6). A portion of the endomucosa at the anastomotic site was resected and replaced with an ECM scaffold in contact with the subjacent muscle and the muscle was anastomosed. The measured end points included macroscopic and microscopic evaluation and quantification of the esophageal diameter at the anastomotic site. Results. No anastomotic leaks or systemic complications were observed in the ECM-treated animals. Morphologic findings in both groups showed complete mucosal covering of the surgery site. The remodeled esophageal tissue showed angiogenesis and complete epithelialization. Intact, organized layers of muscle tissue were present between the native muscularis externa and the submucosal layer and effectively bridged the transected ends. Conclusions. The ECM scaffold altered the default mechanism of esophageal repair. Scar tissue formation with associated stricture was virtually eliminated, and the esophageal healing response was characterized by the replacement with structurally normal tissue layers. These findings suggest that the high morbidity rate associated with esophagectomy procedures may be reduced by this ECM augmentation procedure at the anastomotic site.