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Eur J Cardiothorac Surg 2005;28:296-300
© 2005 Elsevier Science NL

Original articles

The place of gastro-jejuno-duodenal interposition following limited esophageal resection

^a Department of Surgery, Saint George University Teaching Hospital, Seregélyesi ut 3, H-8000 Székesfehérvár, Hungary
^b Department of Surgery, National Medical Center, Budapest, Hungary
^c Department of Gastroenterology, Medical and Health Science Centre, University of Debrecen, Debrecen, Hungary

Received 22 February 2005; received in revised form 26 April 2005; accepted 28 April 2005.

^* Corresponding author. Tel./fax: +36 22 504 100. (Email: altorjay{at}mail.fmkorhaz.hu).

Abstract

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 esophagal 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.

Key Words: Early Barrett's carcinoma • Peptic stricture • Columnar metaplasia • Limited esophageal resection • Interposition reconstruction