Retrosternal pedicled jejunum interposition: an alternative for reconstruction after total esophago-gastrectomy.

Objective: If the colon cannot be used for reconstruction after total esophago-gastrectomy, alternatives have to be sought.

Methods: From 1990 to 2001, retrosternal jejunum loop interposition was performed in 35 patients (male/female: 29:6; mean age 59.2, range 16-83 years) due to cancer in 32 cases and to esophageal perforation in three cases. In all patients reconstruction with stomach or colon, respectively, was impossible on behalf of the underlying histology, of previous resection of the stomach and impedient colonic diseases. A jejunal segment with abundant arcades was chosen, preserving a strong, distal arteriovenous mesenteric pedicle, while 2-3 proximal mesenteric vessels were severed. The loop was pulled up retrosternally, establishing a cervical end-to-side esophagojejunostomy. A Roux-en-Y anastomosis was done in a convenient position.

Results: Two patients died perioperatively due to mediastinitis and consecutive multiorgan failure (one Boerhaave's syndrome, one suicidal ingestion of acid). In one case the oral part of the loop developed venous congestion and was replaced by a free jejunal transplant. The perioperative course of 32 patients was uneventful. Seventeen patients are up and well (1-8.5 years). Sixteen patients died of metastatic disease. The functional results are satisfactory. In about 50% of patients recurrent dilatations became necessary due to anastomotic scars. However, none of the patients complained about severe dysphagia.

Conclusion: In cases of impedient colonic diseases, the pedicled, retrosternal jejunal loop with cervical anastomosis is an alternative for reconstruction after total esophagogastrectomy.