Intraoperative Solutions for the Gastric Conduit that Will Not Reach



Fig. 8.1
We prefer the posterior mediastinal (in situ) route as this is the shortest route between the stomach and esophagus



In cases where the left colon is involved with extensive diverticular disease or atherosclerotic occlusion of the inferior mesenteric artery, and splenic vein thrombosis with thrombosis of the inferior mesenteric vein, it is unusable as a conduit. The right colon is an acceptable conduit and is used as an alternative conduit that will reach the esophagus in the neck.

The right colon is inspected and its retroperitoneal attachments are dissected and lysed. The mesentery of the right colon is transilluminated and the ileocolic, right colic, marginal, and middle colic arteries identified. Clamps are placed on the ileocolic and right colic arteries, and the right colon is inspected for adequate perfusion through the marginal artery. The right colon is then harvested, leaving the marginal artery intact. An appendectomy is performed. Appropriate lengths of right colon are divided with a GIA 75-mm stapler, and the colocolonic anastomosis is performed in a single layered interrupted fashion. The proximal end is drawn up into the neck carefully to prevent trauma or injury to the harvested colon. The proximal anastomosis is then completed created via a single-layer end of esophagus to the side of the colon along the taenia. Finally we construct the cologastric anastomosis with either an EEA staplers or a side-to-side stapled technique.



Jejunum as an Alternative Conduit


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.

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Fig. 8.2
Jejunum is then used to replace a portion of the esophagus as a free graft, pedicled graft, or Roux-en-Y replacement

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.
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Jun 28, 2016 | Posted by in GASTOINESTINAL SURGERY | Comments Off on Intraoperative Solutions for the Gastric Conduit that Will Not Reach
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