Esophageal Reconstruction Using a Pedicled Jejunum with Microvascular Augmentation

Abstract

The pedicled colon segment is widely accepted as a substitute to the gastric tube in esophageal reconstruction of cases where the stomach is not available. The usefulness of reconstruction with a pedicled jejunum has also been reported in recent years. In order to make a long jejunal graft, at least the second and third jejunal vessels have to be severed. However, this leads to a decrease of circulation in the pedicled jejunum. This poor circulation was primarily responsible for the high rates of gangrene and mortality (22.2% and 46.5%, respectively) in the beginnings of jejunal reconstruction. Advances in microsurgery have now enabled surgeons to overcome these disadvantages, as a result, both the rates of gangrene and mortality have decreased to almost zero since the addition of microvascular anastomosis with the jejunal vessels and the internal thoracic vessels. At present, the reconstruction using a pedicled jejunum is a safe operation that provides such advantages as a low incidence of intrinsic disease, more active transport of food, and a lower rate of regurgitation by peristalsis, compared with the reconstruction using the pedicled colon. The disadvantage of the procedure is the relatively high rate of anastomotic leakage (11.1% to 19.2%). Improvements in the surgical procedures to overcome this disadvantage are, therefore, needed before it can be recommended without any reservations.

Esophagectomy and Gastric Pull-through Procedures: Surgical Techniques, Imaging Features, and Potential Complications

“…After esophagectomy, the colon is transected and elevated to the neck through one of three with higher morbidity and mortality compared with a gastric conduit, longer operating times, the creation of additional anastomoses (each with their own rates of leak and stricture formation), and increased postoperative pulmonary complications (18,19).…”

Tissue blood flow to a pedicled jejunal autograft in the dog: A pilot study

“…A pedicled jejunal autograft based on 3 or 4 jejunal arcades has been used successfully to replace portions of the esophagus in people . This technique has been associated with 31% morbidity and 10.5% mortality rates in adult human patients undergoing replacement of the lower esophagus .…”

“…A viable pedicled jejunal autograft, created by ligating up to 3 individual jejunal arteries, has been mostly used for esophageal substitution in humans . In dogs, however, the blood supply of the jejunum has been suggested to be unreliable, and to rely on a short pedicle .…”

Retrograde stapling of a free cervical jejunal interposition graft: a technical innovation and case report

“…Then, the anvil of the OrViL circular stapler was introduced via the conduit and the jejuno-gastrostomy was stapled prior to microvascular reconstruction of the graft vessels. Concerning esophagogastric surgery with jejunal interposition, an ongoing controversy exists, whether esophago-jejunal or pharyngo-jejunal anastomoses should preferably be performed as end-to-side circular stapling or be hand-sewn end-to-end [ 13 , 17 ]. Up until now, no significant differences in anastomotic leakage rates are seen whereas the influence on long-term anastomotic strictures is a matter of debate [ 17 ].…”