The place of gastro-jejuno-duodenal interposition following limited esophageal resection

• Published in: European journal of cardio-thoracic surgery Vol. 28; no. 2; pp. 296 - 300
• Main Authors: Altorjay, Áron, Kiss, János, Paál, Balázs, Tihanyi, Zoltán, Luka, Ferenc, Farsang, Zoltán, Asztalos, Imre, Altorjay, István
• Format: Journal Article
• Language: English
• Published: Amsterdam Elsevier B.V 01.08.2005; Elsevier Science
• Subjects: Adult; Biological and medical sciences; Cardiology. Vascular system; Columnar metaplasia; Duodenogastric Reflux - physiopathology; Duodenum - pathology; Duodenum - surgery; Early Barrett’s carcinoma; Esophageal Neoplasms - pathology; Esophageal Neoplasms - surgery; Esophageal Stenosis - surgery; Esophagectomy - methods; Esophagitis, Peptic - etiology; Esophagogastric Junction - physiopathology; Esophagogastric Junction - surgery; Esophagus - surgery; Female; Gastroesophageal Reflux - physiopathology; Humans; Interposition reconstruction; Jejunum - pathology; Jejunum - surgery; Limited esophageal resection; Male; Medical sciences; Middle Aged; Peptic stricture; Pneumology; Postoperative Complications - etiology; Stomach - pathology; Stomach - surgery; Surgery (general aspects). Transplantations, organ and tissue grafts. Graft diseases; Surgery of the heart; Treatment Outcome; Limited esophageal resection; Early Barrett's carcinoma; Columnar metaplasia; Interposition reconstruction; Peptic stricture; Reconstruction; Stomach; Carcinoma; Duodenum; Stenosis; Surgical resection; Malignant tumor; Phlebology; Esophagus; Treatment; Surgery; Early; Circulatory system; Limit; Cardiology; Interposition
• ISSN: 1010-7940; 1873-734X
• DOI: 10.1016/j.ejcts.2005.04.039

Objective: Although stomach is the best choice for reconstruction after esophagectomy from the viewpoint of safety and ease, an intrathoracic stomach, nevertheless, is a poor long-term substitute. This anatomical configuration abolishes normal antireflux mechanisms and places the acid-excreting stomach subject to biliary reflux, moreover, in an adjacent position to the esophagus within the negative-pressure environment of the thorax. Methods: Between 1995 and 2002, 27 patients with high-grade neoplasia—as early Barrett’s carcinoma—or non-dilatable peptic stricture underwent limited surgical resection of the distal esophagus and esophagogastric junction. In 11 of these cases, the reconstruction was performed with gastro-jejuno-duodenal interposition. The long-term functional results of this specially adapted form of interposition reconstruction have been evaluated. The postoperative follow-up period ranged between 24 and 95 months (mean 68 months). Nine patients (9/11=81.8%) have agreed to undergo endoscopy, radiographic contrast-swallow examination, and 24-h ambulatory esophageal pH and bilirubin monitoring. Results: Three out of nine patients (3/9=33%) demonstrated abnormal levels of esophageal acid exposure during the 24-h study period, whilst none had any evidence of bilirubin exposure in the esophageal remnant. Endoscopy revealed that three patients had reflux esophagitis in the remnant esophagus: Los Angeles A=2, C=1. No stomal or jejunal ulceration at the gastro-jejunal anastomosis could be observed. Histopathologic assessment of the squamous epithelial biopsies demonstrated microscopic evidence of inflammation: minor in two cases, moderate in one and major in one case; however, none of them had evidence of columnar metaplasia in the esophagal remnant at a median of 68 months after surgery. The majority of the patients have been doing well since the operation: 8/9 (88%)=Visick I–II. Conclusions: Gastro-jejuno-duodenal interposition represents an adequate ‘second-best’ method of choice if technical difficulties emerge with jejunal or colon interposition following limited resection of the esophagus performed due to early Barett’s carcinoma or non-dilatable peptic stricture.