Jejunal Interposition for Esophageal Replacement

Abstract

The evolution of operations on the esophagus date back to Billroth in 1877.l Roux’ in 1907 was the first to describe use of the small bowel for esophageal replacement. The development of these techniques in the early part of the twentieth century paralleled those that used stomach and In 1942, Reinhoff4 successfully replaced the esophagus with a jejunal pedicle graft. Merendino and Dillard’ followed in 1955 with the use of jejunal interposition for peptic stricture of the distal esophagus. As the techniques of microsurgical anastamosis became more readily available, Jurlriewica and colleague^^^^ reported excellent results with free jejunal transfer for cervical esophageal replacement. Jejunal interposition for esophageal replacement can be performed for cervical esophageal replacement but is primarily indicated for lower esophageal replacement. This procedure may be done as a (1) free jejunal graft, (2) an intact loop, (3) a pedicled interposition, or (4) a Roux-en-Y. Free jejunal grafts may be used for hypopharyngeal and upper esophageal replacement. The focus of this article will be lower third esophageal replacement. In general, jejunum is the third choice for esophageal replacement after stomach and colon. The use of jejunum may be undertaken in benign or malignant disease. The jejunum should be considered for esophageal replacement under the following circumstances: (1) distal esophageal disease, (2) stomach not available because of prior surgery or resection, (3) colon not available, (4) patients older than 60 years of age because of the unreliable colonic blood supply (Table 1). Contraindications to the use of jejunum include the overall poor health of the surgical candidate, a history of inflammatory bowel disease, diverticular disease, and neoplasms of the small bowel. Dense adhesions, peritonitis, o r multiple prior intra-abdominal procedures may halt mobilization of the jejunum.