CHOICE OF ESOPHAGEAL RECONSTRUCTURE

A 65-year-old man presents with squamous cell carcinoma of the esophagus extending from 34 to 40 cm from the incisors. On EUS there are several hypoechoic ,non homogenous ,sharply delineated paraesophageal lymphnodes within the mediastinum,which are 2cm in diameter.There are no signs of disseminated
disease on this or a...dditional staging studies. Which organ is most commonly used for reconstruction ?

The Correct Answer Is....STOMACH
The type of reconstructive surgery that is recommended for it will depend upon how much esophagus remains after the operation. The surgeon often has to pull the stomach up into the chest. This surgery is called gastric pull up with esophagogastric anastomosis. (Usually a surgeon specialist called a thoracic surgeon performs this type of surgery).

If only a small amount of the esophagus remains then a new esophagus needs to be formed. A new esophagus is usually created by resecting a portion of the colon (large intestine) and using the resected colonic segment as the new esophagus. This is called colon interposition. The colon is considered the organ of choice for patients who require an esophageal substitute and are potential candidates for long survival. This is a major operation with a thirty-day mortality rate of about 13.7%.

Stomach Versus Colon :
If the stomach is intact, most surgeons would use it for esophageal reconstruction. On the contrary,we prefer to use the colon, if available and of suitable quality, particularly if the replacement must last a decade or longer.
A gastric advancement is without doubt the best esophageal replacement.

Jejunal Interposition and Free Graft:
Some authors have advocated the use of jejunum as the esophageal substitute of choice. In our experience, the ability to ingest has been better with a colon than with a jejunal graft. Based on a postoperative questionnaire, patients with colon interpositions were able to eat more and were more likely to experience normal transit and less satiety than those with jejunal interpositions.

These differences probably relate to the greater reservoir capacity of the colon, consistent with its native function. The greater motility in the jejunal graft does little to improve transit and is more likely to cause nausea and bloating. Furthermore, the loss of a segment of colon does not result in more frequent stools.