Reestablishing gastrointestinal continuity after esophagectomy can be challenging for patient and surgeon alike. There are no perfect substitutes, since every reconstructive alternative is inferior to the native, normal esophagus. Ultimately, the goals for reconstruction include the maintenance of continuity, ability to swallow followed by adequate transit of food through the replacement conduit, provision of some barrier to reflux and aspiration, and independence from nutritional sources other than a normal oral diet. Simultaneously, every surgeon has the obligation to minimize morbidity, mortality, and long-term alterations in quality of life to the greatest extent possible. At odds to these objectives are the indications for removing the native organ and the extent to which it must be sacrificed. Clearly, situations that require complete removal of the esophagus up to the base of the tongue necessitate different reconstructive efforts compared to junctional tumors where a portion of the thoracic esophagus can remain intact. Esophageal surgeons must be adept and versatile at many different replacement options. This chapter focuses on the description of reconstructive options, emphasizing conduits other than stomach as described in foregoing chapters (Fig. 23-1). To the greatest extent possible, an attempt is made to compare our experiences with the various conduit options with the caveat that there is no level 1 data pertaining to such comparison.
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.
Whenever a reconstruction alternative other than stomach is used, the complexity of the procedure significantly increases. Rather than a single esophagogastric anastomosis, alternative reconstructive efforts will require two to three anastomoses to reestablish continuity. Establishing adequate blood supply to the transposed reconstruction also may be more challenging in contrast to using a well-vascularized gastric conduit. For these reasons, modified whole stomach options are generally considered the first alternative to the native esophagus, despite the relative disadvantages generated by transposing the gastric reservoir into the chest, such as life-long reflux and aspiration risk (Fig. 23-2).
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 and C. Techniques for reversed and nonreserved gastric tubes, respectively.
When the stomach is not available, however, alternative conduits for esophageal replacement become necessary. The decision to choose one option over another depends on patient and surgeon factors. The more common preferences include the colon or jejunum in variations of length and vascular supply. Prior abdominal operations or preexisting pathology may limit the use of either organ, and ...