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

[Modern esophageal surgery and late functional results as equations with several unknowns--Hungarian Academy of Sciences Doctoral Thesis]

Using the same surgical method and anatomically ideal primary healing, the functional results could even be different later. Trying to identify various factors being responsible for the above differences, 637 patient's data, who underwent previous oesophago-gastric surgery between 1985-2005, were analyzed. Biochemical, histological and electrophysiological examinations had been evaluated. Developing hypertrophy-like metabolic changes and enteric ganglionitis as morphological alternations of LES muscles induced by GERD may be reasons for complaints after antireflux surgery. The marking of Z-line with endoscopic clips followed by an immediately upright contrast study and substractional evaluation is appropriate for detecting true short esophagus. Open surgical procedures are justified even in the new millennium in cases when the patient already underwent previous upper abdominal operations - due to an increased risk of injury because of adhesions - in cases of primarily recurrent paraesophageal hernias after an unsuccessful open and/or laparoscopic reconstruction, as well as in cases of reflux with complications. When adenocarcinomas of the gastro-oesophageal junction are examined preoperatively, the ratio of the performed catabolic - AMAN, CB, and DPP I - enzymatic activity of the tissue sample from the tumour and adjacent intact mucosa within 2 cm of the tumour may have a prognostic value even in the preoperative examination period, and neo-adjuvant treatment should be considered in these group of patients. The patients' post-operative complaints and symptoms change during the post-operative period and correlate with the parameters of the myoelectric and contractile activities of the "Akiyama stomach". Tachygastria seems to be the major pathogenetic factor involved in the contractile dysfunction. 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 oesophagus performed due to early Barrett's carcinoma or non-dilatable peptic stricture.

The esophageal remnant after gastric interposition

Gastric interposition is usually considered the reconstruction of choice following esophageal resection. However, a number of reports show that esophagectomy followed by a gastric transplant is associated with poor quality of life and significant reflux esophagitis in the esophageal remnant. The aim of this work is to review the factors affecting the mucosa of the esophageal remnant when using the stomach. A Medline was conducted. Additional references and search pathways were sourced from the references of reviewed articles. Reflux disease is considered an unavoidable consequence of esophageal resection followed by gastric interposition. Mucosal damage from acid and bile exposure in the esophageal remnant affects approximatively 50% of these patients. There is usually no correlation between symptoms and the presence of mucosal damage in the remaining esophagus. Endoscopy and endoscopic biopsies are the only reliable methods to document the status of the mucosa. When present, reflux esophagitis shows a progression from inflammation to erosions and to the development of columnar lined metaplasia. Esophageal and gastric function, gastric drainage operation, level of the anastomosis, route of reconstruction, and patients' position after the operation have all been shown to influence the severity and extent of damage in the esophageal remnant. Prevention and treatment of esophagitis in the remaining esophagus are discussed. When the stomach is used as a substitute to reconstruct the esophagus whether for malignant or benign conditions, an in vivo model of reflux diseases is created. Studies using this model may help clarify molecular and cellular events that lead to irreversible insult on the esophageal mucosa. Improvement to the reconstruction itself must be sought to favor better results with the gastric transplant.