Surgery for Esophageal Disease

 A. Arguments to use the stomach 

  - rich blood supply 
  - thick wall 
  - easy to mobilize 

  - posterior mediastinum 
   - preferred location 
  - retrosternal 
   - residual disease 
   - mediastinal inflammation 
   - prior radiation 

  - 10 cm margins 
  - excision of all adjacent tissues 
  - greater omentum, spleen, retroperitoneal lymph nodes, pleura, pericardium and esophageal hiatus 
  - results: 
   11% operative mortality 
   survival: 
    24 % @ 3 years 
    18% @ 5 years 
 
 II. Colon 

 A. Advantages 

  - peristalsis 
  - clears acid 
  - good caliber 
  - used to handling bulk 
 B. Assessment /Preparation 
  - angiogram 
  - colonoscopy or BE if patient older than 40 
  - bowel prep 
 C. Choices 
  - may use left, right or middle 
  - isoperistaltic is probably better 
  - route: sub Q, retrosternal, posterior mediastinal, transpleural 
 
III. Jejunum 
 
 - 22mm on a single vascular pedicle 
 - take 15- 30 cm from the ligament of trietz 
 - transverse cervical artery is good but can use most vessels in the neck 
 - contraindications: 
  - age less than three 
  - patient's stabiltiy 
  - extensive carotid disease 
 - results: 
  - 85-90 % graft survival 
  - 5-20 % operative mortality 
  - 80-90 % with adequate swallowing