Total esophago-gastrectomy followed by composite reconstruction with retrosternal pedicled jejunum and antethoracic-free jejunal autograft: a case report.

ABSTRACT

The patient was a 72-year-old man. He received a detailed gastrointestinal examination because of severe anemia. Early multiple esophageal cancers (affecting 3 sites of the esophagus) and advanced gastric cancer were detected. The patient was scheduled to undergo surgical treatment (esophagectomy and total gastrectomy). This operation would be followed by reconstruction with a pedicled jejunum via the antethoracic route. During the operation, however, the mesentery was found to be thick and short, and the anteroposterior dimension of the patient's body was longer than normal. For these reasons, reconstruction with a pedicled jejunum alone via the antethoracic route was judged to be impossible. We then tried composite reconstruction with a pedicled jejunum and free jejunal autograft via the ante-thoracic route. With this method, the pedicled jejunum was not long enough to allow safe anastomosis of both ends of the intestine. To resolve this difficulty, we raised the pedicled jejunum via the retrosternal route to reduce the needed distance for raising, and the free jejunal autograft before the chest wall was guided to a location behind the sternum at the 3rd intercostal level, followed by anastomosis. In this way, we achieved reconstruction while avoiding tension to the reconstructed intestine. Composite reconstruction using the pedicled jejunum and free jejunal autograft is useful as a means of reconstruction of the esophagus when the stomach affected by disease cannot be used for reconstruction, since this method is expected to reduce the tension to the anastomosed area and ensure good blood supply. Our technique is useful when the intestine to be raised is not long enough for composite reconstruction via the antethoracic route.