conduits used for esophageal reconstruction presentation By me in my ward. DR SHAHBAZ KHAN POSTGRADUATE TRAINEE SURGICAL UNIT IV

2. Conduits for Esophageal
Reconstruction
Dr Shahbaz Khan Panhwer
Postgraduate trainee (R1)
Surgical Unit-IV

3. Criteria for Choosing conduits?
• Normal Esophagus ??
• Superior to any potential substitute
• Criteria???
• Living viscus
• Adequacy of its blood supply
• Freedom from intrinsic disease and
• length of resected esophagus that it is capable of
bridging.
• No.of anastomosis/Expertise???

4. So What to Choose?
• Stomach???
• Advantages:
• Reliable Blood supply
• Gastric function
preserved
• Excellent length
• Single anastomosis
• Relatively simple
• Disadvantages:
• Reduced Reservoir
function
• Reflux
• Regurgitation
• Increased risk of
anastomotic leak

5. Colon
• Right sided/Left sided
Colon?
• Advantages:
• Excellent length
• Reservoir function of stomach
• Resistant to reflux
• Disadvantages:
• Blood supply tenuous
• Redundancy
• Most prefer Left
Colon ??
 Diameter smaller
 Less prone to dilate
 More reliable blood supply
 Excellent length

6. Jejunum
• Advantages:
• Peristaltic tube
• No acid/alkaline reflux
• Disadvantages:
• Limited length
• Size
• Vascularity
• Need of
revascularization

7. Anatomy of Colon

8. Colon ( Short segment/Long segment)

9. Right colon interposition

10. Left Colon Interposition

11. Transverse colon interposition

12. Preparation & Workup
• Preoperative
angiogram
• Colonoscopy
• Bowel Preparation

13. Surgical Steps
• Supine,abdomen,chest
&neck draped.
• Midline incision
• Assessment &
Preparation of Long
segment interposition
graft

14. Step-1
• Proper identification of the fusion
line between the colon and the
peritoneum of the posterior
abdominal wall avoids entering the
wrong plane and encountering
bleeding when the colon is being
freed.
• The sigmoid colon is freed from
the retroperitoneum toward the
midline and can also be brought
out of the abdominal wound.

15. Step-02
• The splenic flexure is
similarly mobilized, taking
care not to damage the
spleen, as this incurs
significant additional
morbidity.

16. Step-03
• The transverse colon is
prepared by detaching
the greater omentum
from its antimesenteric
border.
• The omentum is first
detached left of the
midline to enter the
lesser sac; further
separation can then
proceed more readily.

17. Step-03
• Tentatively pick point of division of
right transverse &descending colon,
then measure the length of colon
graft with umbilical tape (5cm below
xiphiod--- angle of jaw)
• Appropriate feeding vessel is
identified via transillumination.
• Temporary vascular isolation is
obtained by placing bulldog clamps
on vessels that will be
divided,observe graft for 5-10min for
signs of ischemia/venous congestion

18. Step-04
• Transverse colon divided with help
of linear stapler just right middle
colic artery.
• Descending Colon is divided just
below bifurcation of left colic into
ascending & descending branches.
• The mesocolon,which has no
other branches between middle &
left colic is incised.

19. Step-05
• To aid delivery
of graft into
neck Penrose
drain/chest
tube is
attached to
the proximal
end of the
conduit.

20. Step-06
• The lower end of the conduit is
anastomosed to a convenient
part of the upper gastrointestinal
tract, whether this be the
stomach, duodenal stump, or
upper jejunum (if gastrectomy
had been performed previously)
• If the stomach is intact, the
conduit is placed in the
retrogastric position.

22. Right Colon
Interposition
• Right colon and the terminal segment
of the ileum are mobilized.
• As mobilization proceeds proximally,
the duodenum is encountered and
care must be taken not to damage the
head of the pancreas; in this region
the main right colic vessel may be
encountered as it courses over the
uncinate process of the pancreas.
• The parietal peritoneum is gradually
transected starting from the iloecolic
region next to the large bowel and
continuing until the right flexure of the
colon,attachment released.

24. Biological trial
of graft
• Trunks of the ileocolic and right
colic vessels are clamped with
vascular clamps, thus leaving the
selected part of the colon
supplied only by the middle colic
vessels.
• If biological trial is positive and no
disturbances in the blood supply
to the isolated fragment of the
colon are observed, mobilization
of the graft may be initiated.

25. Ligation & division
of vessels
• Greater omentum is removed in
the area of the mobilized colon
segment, and next the vascular
trunks, which had been clamped
in vascular clamps, are ligated
and transected.
• Next the transverse colon should
be transected in the middle of its
length.

26. Mobilization of graft
& Anastomosis
• The efferent stump of the transverse
colon is closed with a double-layer
manual suture, or stapled.
• On the other hand, the afferent
stump, which forms the caudal
segment of the mobilized graft, is
closed with a temporary suture until it
is anastomosed with the
stomach/jejunum.
• Transection of the ileum in the caecal
region completes mobilization of the
graft.

27. Jejunal conduits

28. Jejunal Conduits
• 3RD choice as conduit
• Resistant to acid/Bile
• Abundant length
• Pedicled graft ----- Supercharging ??
• FREE Graft with Microvascular anastomosis
• The abdominal cavity is approached from upper
midline incision reaching from the xiphiod
process of the sternum to the umbilicus

29. Surgical steps
• The DJ junction is identified, and the
proximal jejunum is brought out of
the abdomen and placed on a large
gauze pack over the abdominal wall
so that the mesentery is easily
visualized.
• The vascular pattern of the
mesentery is then examined for
completeness of arterial and venous
arcades.
• In patients with a thick mesentery,
transillumination by a strong light
from behind is helpful; in obese
patients, the fat in the mesentery has
to be removed before the arcades
can be delineated

30. • If vascular system appears adequate,
the next step is to evaluate the efficacy
of vascular anastomosis by means of a
biological trial.
 Efficient----natural color & peristalsis
 Inefficient----intense
peristalsis,Cyanosis,marble like
appearance & lack of visible pulsations
• Dissection is begun in the upper
jejunum, at a point approximately
halfway between the edge of the
intestine and the root of the
mesentery, proximal to the branching
of the main Jejunal arteries.

31. Steps
• The jejunum is transected 20 cm
from the DJ flexure and in the
caudal portion beyond the
vascular trunk which forms graft
pedicle.
• The arterial and venous branches
are mobilized separately, then
divided and ligated with fine ties.

32. • When a sufficient length of
mesentery has been prepared for
cervical anastomosis, there is an
excess of jejunum in relation to
the mesenteric length, with
concertina of the intestine.
• Although moderate excess is
harmless, too much redundant
jejunum can result in kinking of
the conduit, which may lead to
obstruction.
• To prevent this complication, a
part of this excessive segment of
jejunum can be resected, and an
end-to-end anastomosis made

33. Abdominal anastomosis
• The conduit is then placed in the retrocolic,
retrogastric position (when appropriate) before
being delivered to the right chest or neck
• Next continuity of the gastrointestinal tract
within the abdominal cavity should be restored
by anastomosing the jejunal stumps remaining
after mobilization of the graft.
• If a gastrectomy has been performed and a
jejunal conduit is used, a Roux-en-Y
configuration of the long jejunal conduit is
satisfactory and an end-to-side
jejunojejunostomy is carried out in the
abdomen.
• Alternatively, the duodenum can be selected as
the site of anastomosis.

34. Indicator graft
• 4-6cm of proximal
jejunum is separated from
graft maintaining
continuity with vascular
arcade.
• Exteriorized as indicator
graft to monitor patency
of vascular anastomosis.
• Ligated & excised on 6th
POD

35. Jejunum Free Graft

36. Identification of segment

37. Division of free graft

38. Anastomosis & Revascularization

39. Complications
• Intraoperative complications
 Hemorrhage
 Injury to tracheobronchial tree
 RLN injury
 Pneumothorax

40. Postoperative complications
• Delayed haemorhage
• Anastomotic leak
• Mediastinitis
• Pulmonary complications
• Arrythmias,MI,Pericardial temponade
• Delayed gastric emptying
• Chylothorax
• Herniation of abdominal visceras through hiatus

41. Functional Complications of
esophageal replacement
• Anastomotic stricture
• Redundancy & impaired emptying
• Obstruction at thoracic inlet or diaphragmatic hiatus
• Reflux esophagitis
• Ulceration of esophageal substitute
• Postvagotomy dumping