Chapter 21

Reconstructing a functional esophageal replacement after surgical resection for esophageal malignancy is among the most difficult surgical challenges. Morbidity and mortality rates are high, and the quality of remaining life is profoundly affected by the quality of the functional result obtained. To quote the late Dr. Robert Ginsberg, “Probably no area of reconstructive surgery demands more versatility of approach and technique.”1

The preceding chapters in Part 2 concerning esophageal and proximal stomach malignancy are authored by surgeons selected for their experience and expertise with the most frequently used operations. Each chapter provides detailed and comprehensive information on a specific approach, including indications, perioperative management, operative technique, and complications. This chapter provides information pertinent to the choice of available options. Selection is influenced by the highly variable circumstances associated with the individual patient. The merits and demerits of available options are highlighted and include observations relating to both the organ used and the route employed. Hiebert and Bredenberg have provided an excellent synopsis of this information that warrants review.2 Specific clinical circumstances that influence or direct selection are noted.

There are two primary objectives of the organ-selection process. The first is to restore the elements of normal esophageal function, that is, to maintain the ability to swallow a normal diet comfortably, to retain the ability to burp or vomit when necessary, and to minimize the potential for reflux, regurgitation, and aspiration. The second objective is to select a conduit for replacement that provides minimal morbidity and operative mortality. Needless to say, these obviously desirable objectives are rarely, if ever, totally achieved.

Stomach

Stomach is by far the most popular selection for esophageal replacement after resection of malignant disease (Fig. 21-1). Some form of gastric transposition is usually the simplest and safest option. When mobilized adequately, the stomach almost always can be elevated to the level of the cervical esophagus or pharynx. Maintenance of an adequate blood supply requires preservation of the familiar gastroepiploic vascular arcade. A single anastomosis restores the gastrointestinal continuity.

Figure 21-1.

Stomach is the preferred graft for malignant esophageal replacement. Several configurations have been devised. Depicted here is a conduit in which the whole stomach is used.

Whole Stomach

The term whole stomach indicates that the entire stomach is transposed for the replacement (see Fig. 21-1), in contrast to using the gastric tube, in which the main body of the stomach is retained in its abdominal location. In whole-stomach transposition, the left gastric and short gastric vessels are divided, the pylorus and duodenum are liberated using a Kocher maneuver, and variable lengths of the proximal lesser curvature and lesser omentum are resected along with the esophagus. The greater the length and width of the lesser curvature removed, the more tubular and hence longer is ...

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