Esophagoplasty

Types of grafts and classification

Various tissues are used to restore the continuity of the digestive tract. Surgeons can use the small intestine, large intestine, or stomach as graft material.

Currently, gastric reconstruction is considered the gold standard. A special tube is fashioned from the greater curvature, preserving the natural direction of muscular contractions (isoperistaltic tube).

Operations are classified according to the route of the graft relative to the chest and mediastinum. Antethoracic (pre-sternal), retrosternal (retro-sternal), and other routes of positioning the new "esophagus" are distinguished.

Small bowel reconstruction (Roux-Hacker-Yudin technique)

This technique is used in severe cases when the native esophagus cannot be saved or utilized. The main indications are:

• Cicatricial strictures of the esophagus refractory to bougienage.
• Conditions following extirpation (total removal) of the thoracic portion of the organ.

The prepared graft can be routed to the neck via several pathways:

1. Antethoracic — subcutaneously anterior to the sternum.
2. Retrosternal — in the fascial space directly behind the sternum.
3. Retrocolic — posterior to the colon.
4. Posterior mediastinal — in the posterior mediastinum (in place of the resected organ).

The classical version of the procedure involves routing a loop of the small intestine, maintaining its blood supply via its vascular pedicle, subcutaneously to the neck, where its end is anastomosed to the cervical esophagus.

Technique of small bowel graft mobilization

For the bowel to engraft in its new location, it must be properly dissected while preserving blood flow. The surgery begins with a midline laparotomy.

The surgeon selects the initial segment of the jejunum, about 10–15 cm distal to the duodenojejunal flexure (Treitz's ligament). This specific area has the optimal conditions for blood supply due to large-caliber arteries and a well-developed network of vascular arcades.

Stages of mobilization:

• The surgeon divides the mesentery strictly through the avascular zones, passing between the II, III, and IV radial arteries.
• The vascular trunks are ligated 2–3 cm below their bifurcation.
• The bowel itself is transected between the I and II radial arteries, forming the cranial stump.
• The created stump is inverted using a purse-string suture.
• The prepared graft is carefully transposed through the created subcutaneous tunnel to the neck.

The stage concludes with the creation of anastomoses. In the neck, the intestinal stump is sutured to the cervical esophagus. In the abdominal cavity, the caudal (lower) end of the graft is anastomosed to the anterior wall of the stomach in an end-to-side fashion.

Modifications and non-standard situations

Every patient's anatomy is unique, and unforeseen difficulties may arise during surgery. Special surgical techniques have been developed to address them.

• Insufficient graft length: If the mobilized jejunum is not long enough to reach the neck, surgeons use the Petrov-Khundadze method. It involves additional extensive mobilization of the ileocecal angle and the root of the mesentery, which significantly "lengthens" the flap.
• Cicatricial gastric shrinkage: Chemical burns of the digestive tract often damage the stomach as well. Suturing the bowel to a scarred organ is impractical. In such cases, the S.S. Yudin modification is used. Its essence is that the cranial stump is not transected a second time, and the continuity of the intestinal tube is restored by creating a U-shaped enteroenterostomy at the very base of the fashioned graft.

Briefly: answers to topical questions

Class and exam questions

What else to study on this topic

• Technique of forming an isoperistaltic tube from the greater curvature of the stomach
• Topography of the vascular arcades of the proximal jejunum
• Technique of ileocecal angle mobilization according to Petrov-Khundadze
• Types and techniques of intestinal anastomoses
• Vascular pedicle complications of the graft

Other topics in the section "Operations on the Chest Wall and Thoracic Organs"

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