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The security of the esophageal purse string should be evaluated before the handle and cartridge are approximated (Figure 6). After verifying that the combined thickness of the esophagus and jejunum is within the safe range of the staples, the circular stapler (EEA) instrument is fired. Superficial interrupted sutures about the anastomosis are added after the instrument has been opened, gently rotated, and withdrawn. The nasogastric tube is passed beyond the anastomosis.

The open end of the jejunal limb is prepared for a stapled closure (Figure 7). Once again, the noncutting linear stapler (TA 60) should be applied to serosa and at an angle to ensure an adequate blood supply to the antimesenteric border. Some prefer to place several sutures to anchor the arm of the jejunum posteriorly. This removes tension from the suture line and ensures against possible rotation.

The reestablishment of the gastrointestinal tract continuity beyond the ligament of Treitz can be accomplished in many ways. The afferent limb is connected to the Roux-en-Y jejunal loop approximately 25 cm from the ligament of Treitz and about 40 cm from the esophagojejunal anastomosis. A side-to-side anastomosis is performed, using a cutting linear stapler (GIA 60) introduced into the antimesenteric sides of the jejunum (Figure 8). This anastomosis can be accomplished like the enteroenterostomy of a Roux-en-Y. The mucosal stab wounds are then closed with a noncutting linear stapler (TA 60) (Figure 9).

The construction of a pouch below the esophagojejunal anastomosis does not seem to have a significantly beneficial effect on long-term nutrition.

The two jejunal limb mesenteries are approximated to eliminate potential internal hernia. The adequacy of the blood supply of each limb is verified, especially at the critical point near the anastomosis.

The blood volume is sustained, along with fluid and electrolyte balance. Early ambulation is encouraged. Clear liquids are given in limited amounts after 24 hours. Oral feedings are begun once the integrity of the anastomosis is established with a fluoroscopic water-soluble contrast study. The patient is instructed in the value of six small feedings per day initially and is gradually advanced to three regular meals. The patient and family require reassurance that problems concerning eating should be minimal. The weight should slowly increase, unless a diagnosis of extensive malignancy has been verified. Vitamin B12 injections must be given monthly along with a monthly dietary survey and nutritional evaluation. These monthly visits with reassurance can be helpful to the patient in returning the caloric intake toward normal during the first ...

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