Reestablishing gastrointestinal continuity after esophagectomy can be challenging for both the patient and the surgeon. There are no perfect substitutes because 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 previous chapters (Fig. 23-1). Where possible, an attempt is made to compare our experiences with the other conduit options, with the caveat that there are no level 1 data pertaining to such comparison.
Stomach is preferred graft for malignant esophageal replacement. Several configurations have been devised. Depicted here is conduit in which 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 reconstructions will require two to three anastomoses to reestablish continuity. Some reconstructions will also require vascular augmentation, which adds complexity to the procedure compared to using a well-vascularized gastric conduit. For these reasons, based on its native blood supply, tubularized stomach is generally considered the first alternative to replace the esophagus, despite the relative disadvantages, such as lifelong reflux and aspiration risk, generated by transposing the gastric reservoir into the chest (Fig. 23-2).
For most procedures involving esophageal replacement with stomach graft, tube is created along length of greater curvature (between gastric antrum and splenic hilum), and remainder of stomach is discarded (A). B and C. Techniques for reversed and nonreversed gastric tubes, respectively.
When the stomach is not available, alternative conduits for esophageal replacement become necessary. The decision to choose one option over another depends on both 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; thus, a thorough history is an essential part of planning for ...