Replacement of the esophagus with jejunum is indicated when the stomach is not suitable because of prior surgery or involvement with disease. Jejunum is then used to replace a portion of the esophagus as a free graft, pedicled graft, or Roux-en-Y replacement Fig. 8.2. Replacement of a distal esophageal peptic stricture should be performed with colon or jejunum in preference to stomach. Interposition of an isoperistaltic segment of intestine is preferable to gastric pull-up, which has a very high incidence of recurrent severe reflux. Roux-en-Y jejunal replacement may be used to replace the stomach and distal esophagus after total gastrectomy including distal esophagectomy. Free jejunal graft is indicated in limited reconstruction of the cervical esophagus. However, total esophageal replacement cannot be accomplished with jejunum alone as the length is insufficient to reach the neck. Important detailed history to exclude patients with disease of the small bowel due to inflammatory bowel disease or previous surgery is crucial in the preoperative preparation. Mechanical bowel preparation is not necessary for jejunal interposition; however, if the jejunum is found to be unacceptable as a conduit or if the blood supply to the jejunum is inadvertently damaged during harvest, rendering it unusable as a conduit, the colon should be readily available and prepared for reconstruction.

After total gastrectomy and distal esophageal resection, Roux-en-Y replacement may be used for reconstruction. Main indications include proximal gastric tumors or esophageal resection into the upper chest. With meticulous preparation, Roux-en-Y configuration will reach the neck, but this is variable; however, it will not reliably reach the cervical esophagus. When it is used after total gastrectomy, jejunum is divided approximately 30 cm beyond the ligament of Treitz. The jejunum is elevated outside the abdomen, and the vascular arcade is transilluminated. The proposed point of division is identified, and the line of division of the mesentery is identified along with the proposed division of several vessels of the mesentery, which will allow transposition of the jejunum up into the chest. The feeding vessel is identified and preserved. The serosal surface of the mesentery is scored, and the vessels to be transected are momentarily clamped and the conduit observed for few minutes for evidence of ischemia or congestion. A window in the transverse mesocolon is created to the left of the middle colic vessels for the jejunum and its mesentery to pass through. In cases of total gastrectomy, the proximal anastomosis is to distal esophagus in the upper abdomen. If distal esophagectomy is performed as for tumors of the cardia that extend to the gastroesophageal junction, the abdominal incision must be brought across the costal margin into the left sixth or seventh interspace.