The place of gastro-jejuno-duodenal interposition following limited esophageal resection.
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 esophageal 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.
Altorjay
Aron
A
Department of Surgery, Saint George University Teaching Hospital, Seregélyesi ut 3, H-8000 Székesfehérvár, Hungary. altorjay@mail.fmkorhaz.hu
Kiss
János
J
Paál
Balázs
B
Tihanyi
Zoltán
Z
Luka
Ferenc
F
Farsang
Zoltán
Z
Asztalos
Imre
I
Altorjay
István
I
D000328:Adult; D004383:Duodenogastric Reflux / Q000503:physiopathology; D004386:Duodenum / Q000473:pathology / Q000601:surgery*; D004938:Esophageal Neoplasms / Q000473:pathology / Q000601:surgery*; D004940:Esophageal Stenosis / Q000601:surgery*; D016629:Esophagectomy / Q000379:methods; D004942:Esophagitis, Peptic / Q000209:etiology; D004943:Esophagogastric Junction / Q000503:physiopathology / Q000601:surgery; D004947:Esophagus / Q000601:surgery; D005260:Female; D005764:Gastroesophageal Reflux / Q000503:physiopathology; D006801:Humans; D007583:Jejunum / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D013270:Stomach / Q000473:pathology / Q000601:surgery*; D016896:Treatment Outcome