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 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.
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.
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 the gastric explant. When transposed, it is important to avoid compression of the explant at the level of the diaphragmatic hiatus and at the thoracic inlet in the neck. A pyloroplasty or pyloromyotomy commonly is added, although the indications for this relatively minor addition remain controversial. Long-term functional results are usually satisfactory.3
Failure of the gastric conduit most commonly is due to inadequacy of the blood supply at the upper end of the transposed stomach, which may result in anastomotic leak, dehiscence, and rarely, a potentially devastating necrosis of the upper end of the stomach.
Reflux from the interposed stomach into the residual esophagus or pharynx is a potentially serious problem. In general, the higher the anastomosis (upper thorax or neck), the lower is the incidence of significant reflux.
Long tubular segments of stomach may be fashioned from the greater-curvature side of the stomach (Fig. 21-2A). The blood supply again is derived from the gastroepiploic arcade. The detailed techniques for preparation of both “reversed” and “nonreversed” gastric tubes have been clearly described by Fell and Ximenes-Netto.4 A gastric tube, fashioned with the diameter of the normal esophagus, is the least bulky of the esophageal replacements and passes with minimal compression through the diaphragmatic hiatus, the substernal space or posterior mediastinum, and the thoracic inlet into the neck. The length of tube created varies with the extent of greater curvature selected (between the gastric antrum and the splenic hilum). Provided that the gastroepiploic circulation is preserved, it is always possible to create a tube sufficiently long that it can be elevated to any level in the neck.
For most procedures involving esophageal replacement with a stomach graft, the tube is created along the length of the greater curvature (between the gastric antrum and the splenic hilum), and the remainder of the stomach is discarded (A). B, C. Techniques for reversed and nonreversed gastric tubes, respectively.
The reversed gastric tube (Fig. 21-2B) requires preservation of the left gastroepiploic vessels at the splenic hilum. The marginal arcade is preserved, and the more robust right gastroepiploic vessels are divided at the antral end of the stomach. The nonreversed gastric tube is carried on the right gastroepiploic artery, with division of the gastric end of the tube at or close to the splenic hilum (Fig. 21-2C).
The communication between right and left gastroepiploic vessels appears variable and is sometimes flimsy or missing from the marginal arcade (usually toward the splenic end). It would appear, however, that there is almost always a satisfactory circulation, maintained through collateral vessels, in the gastrocolic and gastrosplenic omenta, provided that the left gastric circulation remains intact. Technically, the simplest of these reconstructions is a reversed gastric tube without dissection or ...