Plate 36
###### Figure 32A

The second layer of interrupted 00 silk sutures is completed anteriorly (Figure 29). Next, the peritoneum, which has been initially incised to divide the vagus nerve and mobilize the esophagus, is brought down to cover the anastomosis and anchored with interrupted 00 silk sutures to the jejunum (Figure 30). This ensures a third layer of support that extends all the way anteriorly around the esophageal anastomosis and takes any tension off the delicate line of anastomosis (Figure 31). The catheter can be extended well down the jejunum through the opening in the mesocolon to prevent angulation of the bowel. A number of superficially placed fine sutures are taken to anchor the edge of the mesentery to the posterior parietes to prevent angulation and interference with the blood supply (Figure 31). These sutures should not include pancreatic tissues or vessels in the margin of the jejunal mesentery. The color of the arm of the jejunum should be checked from time to time to make sure the blood supply is adequate. The open end of the proximal jejunum (Figure 32, Y) is then anastomosed at an appropriate point in the jejunum (Figure 32, X) with two layers of 0000 silk, and the opening into the mesentery beneath the anastomosis is closed with interrupted sutures to prevent any possibility of subsequent herniation. Figure 32A is a diagram of the completed Roux-en-Y anastomosis. Some prefer to use a stapling instrument to fashion the esophagojejunal anastomosis. Regardless of the technique used, consideration should be given to reinforcing the angles with interrupted sutures, as well as anastomosing the jejunum to the adjacent diaphragm.

Constant suction is maintained through the nasojejunal tube, which has been threaded through and beyond the anastomosis. During this period alimentation is maintained with intravenous fluids and supplemental vitamins. The patient is ambulated on the first postoperative day, and a gradual increase in activity is encouraged. Early return of peristaltic activity to the bowels may be stimulated by injecting 30 mL of mineral oil through the jejunal tube at regular intervals during the first few postoperative days. When intestinal peristalsis has been established, the suction may be discontinued. A slow administration of feedings low in fat and carbohydrate content will avoid diarrhea. Usually, only water followed by skim milk is given in 30- to 60-mL amounts as tolerated. Oral feedings can be instituted as soon ...

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