Oesophageal Replacement:

Galal Zahran Mohamed Zahran

Reconstruction of the sesophagus after resection or bypass of malignant or benign lesion has been a challenging surgical problem. Avariety of techniques have been advocated. Non has given completely satisfactory results. The stomach, jejunum, colon were all used for reconstruction of oesophagus. The stomach is highly vascular and of adequate length reaching up to the pharynx, easily mobilised with absence of abdominal anastomosis and only single cervical anastomosis. The cervical anastomosis is better than intrathoracic one due to lower incidence of anastomotic fistula in cervical anastomosis. The stomach use has disadvantage of highter incidence of postoperative aspiration pneumonia which adds to mortality and an incidence of serious complications from reflux oesophagitis. Thus its use is not accepted in the patients with benign lesion and the use of colon is advocated. Some surgeons prefere the use of stomach in reconstructionof the oesophagus in patients with malignant disease because this procedure is quickest and simplest, with single anastomosis needed to restore continuity of the gut. The use of the jejunum is unsatisfactory chieflydue to deficient blood supply after mobilization about 25% of the cases, failure resulted from unfavourable disposition of the vessels in the mesentery of the mobilized jejunal loop. The main indication for jejunal interposition is a short reconstruction especially at the cardia. The choice now restrected between the stomach and colon.The potential operative risks appear to be higher in colon interposition is due to the greater length and complexity of the procedure with three anastomosis. The left colon is prefered than right colon because the blood supply to the left colon is rarely prone to anatomic variation. The benign nature of colonic secretion probably explains the low incidence of anastomotic problems and freedom from the risk of postoperative oesophugitis and aspiration from regurgitation. For these advantages the left oolonic interposition is a procedure of choice in the benign lesions.Because of recents in the microvascular anastomosis, a successful free intestinal autograft was reported and deserves renewed attention. The jejunum is prefered because harvesting the autograft is easier and the intraluminal flora are less hazardous. The use of an extracorporeal tube to restore alimentation may be useful in reconstruction of oesophagus. Intubation is considered as being a safer procedure than palliative resection in patients unsuitable for curative treatment.One of the most dangerous complications is leakage from the suture line.Anastomotic leak is the main cause of mortality. Skin tubes, various intestinal conduits, and transposition of the stomach into the thorax thave been used for esophageal replacement in children the colon continues to be the most widely used organ for esophageal replacement in children.