Colonicjejunal Esophageal Replacement

Once it is established that esophageal resection is indicated, an organ for esophageal replacement becomes necessary. Although the stomach is the usual organ for esophageal replacement, the colon or jejunum also can be used. The stomach, in general, is sturdier and has more reliable blood supply. Care must be taken that the replacement organ is usable and that it is pathologically free of disease. Endoscopy, arteriography and contrast radiography are useful to determine this. Not all of these are necessary, for example when using the stomach as the conduit organ. However, endoscopy should always be performed to rule out ulceration or malignancies.

For colonic bypass, colonoscopy should be performed preoperatively, as well as angiography to evaluate the colonic vessels. A barium enema should be performed last (since it obscures the angiogram dye). Bowel preparation preopera-tively is mandatory.

The colon bypass will now be explained in detail. The patient is supine and an upper midline incision performed. The omentum is detached from the transverse colon. The peritoneal reflection on the left is taken down. The middle colic artery and vein are ligated near the origin at the superior mesenteric vessels. The transverse colon is transected proximally using the GIA stapler. The mesentery of the sigmoid is transilluminated to identify the left colic artery, which will be included with the replaced colonic segment. The colon segment to be used is transsected at the sigmoid region and this segment is now attached only to its supplying artery and vein. It is passed posterior to the stomach through a rent in the gastrohepatic omentum and this allows the most direct alignment of the artery and vein. The esophagus is bluntly removed through the abdominal approach as well as the cervical approach as described previously. The esophagus is removed and the colonic segment brought up transhiatally into the left neck where an esophagocolonic anastomosis is performed in the neck and distally a colon-to-gastric anastomosis is performed. A pyloroplasty is performed to prevent gastric retention. A colocolotomy is then performed to anastomose the proximal transsected colon to the distal transsected colon to re-establish gastrointestinal continuity.

Another organ that is much more rarely used is a free jejunal graft. In this situation, a segment of jejunum is dissected with its vascular pedicle and bowel continuity is re-established with an end-to-end anastomosis. The free jejunal segment is then brought up into the neck and the superior thyroid lingual or facial arteries are anastomosed to the jejunal artery and vein. In addition, the transverse cervical artery at the base of the neck may be used. The free jejunal graft is best used for a localized resection. For example, in the case of cervical esophageal resection where only this portion of the esophagus is resected, an anastomosis can be performed, from the pharynx to the jejunum and then another anastomosis at the base of the neck.

Baby Sleeping

Baby Sleeping

Everything You Need To Know About Baby Sleeping. Your baby is going to be sleeping a lot. During the first few months, your baby will sleep for most of theday. You may not get any real interaction, or reactions other than sleep and crying.

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