Reestablishing gastrointestinal continuity after esophagectomy can be challenging for patient and surgeon alike. There are no perfect substitutes, since 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 foregoing chapters (Fig. 23-1). To the greatest extent possible, an attempt is made to compare our experiences with the various conduit options with the caveat that there is no level 1 data pertaining to such comparison.

Whenever a reconstruction alternative other than stomach is used, the complexity of the procedure significantly increases. Rather than a single esophagogastric anastomosis, alternative reconstructive efforts will require two to three anastomoses to reestablish continuity. Establishing adequate blood supply to the transposed reconstruction also may be more challenging in contrast to using a well-vascularized gastric conduit. For these reasons, modified whole stomach options are generally considered the first alternative to the native esophagus, despite the relative disadvantages generated by transposing the gastric reservoir into the chest, such as life-long reflux and aspiration risk (Fig. 23-2).

When the stomach is not available, however, alternative conduits for esophageal replacement become necessary. The decision to choose one option over another depends on 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, and a thorough history is an essential part of planning for reconstruction.

The jejunum is an option for either partial or total esophageal replacement (Fig. 23-3). There are several advantages to consider with small bowel reconstruction. It generally remains free of intrinsic disease throughout a patient’s life span and does not undergo senescent lengthening. Compared to the native esophagus, the size-match is excellent. There is a relative abundance of the organ, which permits reconstruction of the whole esophagus with adequate length to maintain nutritional demands. The jejunum also has a reliable blood supply with fairly consistent anatomy that does not routinely require preoperative evaluation. In the past, there were limitations on the length of esophagus that could be reconstructed with the jejunum, but this issue largely has been overcome with microvascular augmentation techniques that can accommodate grafts spanning from the base of the neck to the abdomen.

Indications

Jejunal interpositions can be tailored to any length necessary to replace the resected esophagus. We have found jejunal interpositions to be especially useful for secondary reconstruction attempts after a gastric conduit loss that has resulted in esophageal diversion. Conduit position is also determined in part by the indication requiring reconstruction. Most often placed in the retrosternal position, a supercharged jejunal conduit also may be placed in the posterior mediastinum or less often subcutaneously on the anterior chest. We believe the microvascular anastomosis and subsequent lie of the conduit are best when the conduit is in the substernal position. If local recurrence in the posterior mediastinum is a factor, or the need for radiation exists, the conduit should be placed away from this field.

Surgical Technique

Long-Segment Supercharged Jejunal Conduit

Routine preoperative evaluation is necessary when planning a supercharged jejunal conduit for esophageal replacement. A complete history and physical examination should be performed, and it is important to take note of any previous abdominal, thoracic, or sternal incisions as they may alter the surgical plan and position of the conduit. In the setting of esophageal cancer, complete staging should be performed, including esophagogastroduodenoscopy/endoscopic ultrasound (EGD/EUS) and PET/CT. A CT chest/abdomen with contrast will help rule out metastatic disease, along with abnormalities of the small bowel or major abdominal vessels. Consultation with a plastic surgeon in addition to the thoracic surgeon is necessary when planning a supercharged jejunal conduit. Thorough preoperative patient education and counseling focusing on postoperative expectations, including dietary and lifestyle modifications that will be necessary ­following the procedure should be provided. In contrast to a colon interposition, there is no need for presurgical preparation of the bowel. Naturally, if one is concerned about the viability of the small bowel as a useable conduit, it is not a bad idea to have the colon prepared as another alternative.

Surgical Procedure The patient is positioned supine with a shoulder roll in place and the head turned slightly to the right. The left neck, chest, and abdomen are prepped into the field. The legs may be prepped into the field at the discretion of the plastic surgeon for possible harvest of a saphenous vein graft.

Abdomen An upper midline incision is made and the ligament of Treitz identified along with the proximal jejunum. A complete lysis of adhesions should be performed and any prior feeding jejunostomy or gastrostomy should be taken down and the bowel repaired. Transillumination of the proximal jejunal mesentery will delineate the individual jejunal vessels and their arcades (Fig. 23-4). The first vessel off of the superior mesenteric artery is generally left in place for blood supply to the fourth portion of the duodenum and proximal jejunum. The conduit is then generally based on the second to fourth jejunal vessels, but this can vary depending on the available anatomy. No vessels are divided at the outset of the case. The mesentery is dissected to expose the vessels for the transfer. Attention is then turned toward the route through which the conduit will pass. The posterior mediastinal route will not be described in detail as it is standard procedure for most thoracic surgeons to place a gastric conduit in this location; we do not often place a supercharged jejunum in this location.

Neck A collar incision is made starting at the sternal notch and proceeding upward and lateral along the anterior border of the sternocleidomastoid muscle. Before fully exposing the esophagus, the left hemimanubrium, head of clavicle, and medial aspect of the first rib are removed to increase the space available in the thoracic inlet for the conduit and microvascular anastomosis to the left internal mammary artery. This also alleviates points of bony compression on the conduit which could lead to mesenteric congestion and vascular compromise. Care must be taken when freeing the inferior aspect of the clavicle and first rib so as to not injure the internal thoracic vessels.