Functional integration of an autologous engineered esophagus in a large-animal model

nature biotechnology Article https://doi.org/10.1038/s41587-026-03043-1 Functional integration of an autologous engineered esophagus in a large-animal model Received: 2 February 2025 A list of authors and their affiliations appears at the end of the paper Accepted: 4 February 2026 Published online: xx xx xxxx Check for updates Tissue engineering of the esophagus has been limited by stent dependance and poor muscle regeneration. Here we report an integrated strategy to engineer a 2.5-cm esophageal segment by microinjecting autologous pericyte-like myogenic precursors and fibroblasts in a decellularized porcine scaffold to repair circumferential defects in 10-kg minipigs (n = 8), modeling pediatric use. Bioreactor maturation induced a proangiogenic phenotype, with in vivo support from biodegradable intraluminal stents and a vascularizing pleural wrap. This coordinated approach yielded safe and effective esophageal conduits; oral feeding supported normal growth, morbidity resembled that of clinical esophageal replacement and was endoscopically manageable, and 63% (5/8) survived to the 6-month endpoint. Comprehensive multimodal analyses demonstrated progressive recapitulation of native architecture, with increasing neuromuscular regeneration and vascularization, correlating with functional recovery, absence of symptomatic stricture and the presence of secondary peristalsis by 6 months. These results demonstrate that the combination of complementary regenerative, conditioning and surgical strategies enables a functionally integrated, contractile esophageal graft with ongoing structural maturation without immunosuppression. Hollow organ tissue engineering (TE) has great potential to improve outcomes for persons with organ failure. This is now a clinical reality; successful clinical applications of TE substitutes include the urethra1, vagina2, arteries3 and trachea, with the latter engineered by our group using decellularized donor-derived trachea seeded with the individual’s own cells4. Pediatric and adult esophageal pathologies, congenital or acquired, can lead to notable tissue deficits, often requiring esophageal reconstruction. These conditions include esophageal carcinoma, refractory esophageal stricture secondary to caustic, reflux or radiation injury and esophageal atresia (EA). EA is a congenital condition affecting 1 in 3,500 newborns, whereby intrathoracic esophageal continuity is interrupted to a variable degree5,6. Expedient operative neonatal correction by primary anastomosis allows for restoration of esophageal continuity and, therefore, feeding. However, in approximately 10% cases, a ‘long gap’ of the esophagus (LGEA) makes primary anastomosis challenging. LGEA is associated with prolonged hospital stays, substantial morbidity and lower quality of life compared to simpler subtypes7. Transplantation is not an option because of a complex vascular supply e-mail: ; Nature Biotechnology and lack of size-appropriate grafts. Currently, continuity is corrected by (1) delayed primary repair after months of gastrostomy feeding; (2) esophageal replacement by transposition of existing organs into the esophagus (stomach, colon and jejunum); or (3) internal or external traction techniques8. However, all these options have recognized shortcomings; various case series report that 30–53% of infants with LGEA have insufficient esophagus for delayed primary repair9,10, with a higher reported risk of anastomotic stricture, leak, gastroesophageal reflux and reoperation rate compared to primary repair. Replacements result in lost or reduced function of the substitute organ and are also associated with substantial morbidity, including graft necrosis, reflux, dysmotility, anastomotic leak, redundancy and long-term malignancy depending on the organ of choice. Traction techniques are known to be associated with recurrent strictures and surgical failure7. As such, there is an unmet clinical need11. TE solutions for partial thickness (that is, mucosal) and focal esophageal defects have been successfully translated clinically12. Circumferential esophageal repair, however, remains challenging Article because of the need for sufficient muscle regeneration to coordinate peristalsis. TE approaches have included the use of acellular or cellularized, natural or synthetic scaffolds in large-animal models with variable success, resulting in recurrent strictures and limited tissue regeneration, particularly when using acellular scaffolds11–19. Although some studies reported prolonged animal survival, to our knowledge, none have demonstrated graft peristalsis, stent independence or sustained growth. These parameters are essential for clinical translation, particularly in a pediatric setting13–19. Patch esophagoplasty models suggest that cell seeding of scaffolds results in better tissue regeneration with respect to unseeded scaffolds20–23. Interestingly, many studies also describe prompt graft reepithelization in vivo, irrespective of seeding strategy15,24,25. TE offers the possibility to provide a personalized, size-matched, circumferential esophageal graft to ensure continuity without sacrifice or damage to an existing organ26–28. However, to our knowledge, success of circumferential TE esophageal scaffolds has not been demonstrated in growing animal models as would be required for pediatric use or shown evidence of consistent muscle contraction or stent independence, key features of esophageal function29. We previously demonstrated successful TE of repopulated, biocompatible, multilayered TE grafts in vitro. This was achieved by seeding decellularized rat esophageal scaffolds with human mesoangioblasts (MABs), murine fibroblasts (FBs) and murine neural crest cells, followed by implantation in the omentum of immunocompromised mice30. In addition, we previously demonstrated feasibility of xenotransplantation of decellularized porcine scaffolds in a rabbit model31. In the present work, we investigated an optimized approach to engineer autologous esophageal constructs of a pediatric scale. We produced and transplanted fully circumferential autologous TE esophageal grafts in minipigs, modeled upon the anticipated requirement for pediatric use in LGEA and produced within a clinically relevant timeframe (Fig. 1a). Grafts were generated by microinjecting autologous MABs and FBs into decellularized porcine esophageal scaffolds, followed by bioreactor culture. We demonstrated the feasibility, safety and efficacy of this approach by thoracic transplantation in a growing large-animal model without immunosuppression. We show graft integration, remodeling and recapitulation of native tissue architecture over time using a multimodal approach in conjunction with functional outcomes such as survival, patency and contractility. https://doi.org/10.1038/s41587-026-03043-1 Information and Extended Data Fig. 1e–i) and microinjected (1 × 105 cells per µl, 30 µl per injection every 3 mm, 120 microinjecti (...truncated)