Longlimb RouxY Jejunal Reconstruction after Total or Proximal Gastrectomy

A segment of jejunum used for distal esophageal reconstruction is certainly a most useful tool when it combines the benefits of restoring intestinal continuity and prevention of biliary and pancreatic reflux as in a long-limb Roux-Y. Its size is appropriate and peristalsis is retained.70 Because the length of a jejunum interposition is limited by its vascular supply, and although it can reach the neck, in most cases it will rarely reach above the aortic arch. A long-limb Roux-Y reconstruction with jejunum is the preferred conduit after a total gastrectomy and short distal esophageal resection. It is also if a total esophagectomy and total gastrectomy are required, where the interposed colon is anastomosed to the efferent limb (Figure 12.2). The variations in the blood supply to the proximal jejunum can be a challenge especially when a long segment is needed (Figure 12.3).

Transillumination is used routinely to examine the vascular supply. There should be no interruption in the vascular arcade of the segment to be used. It is best to start dissection at least 20 cm from the ligament of Treitz. At this level, vascular branches are longer and more amenable to be pedicled for a long segment. In addition, a minimal length of 20 cm is recommended for the afferent limb to facilitate the construction of the jejunojejunostomy, in order to prevent distortion of the loop and obstruction at the anastomotic site. Once the vessels of

Jejunum Reconstruct Oesophagus

Figure 12.2. In patients requiring total esophagectomy and total gastrectomy, as is required in the patient shown (center), with distal esophageal malignant disease and previous Billroth II procedures,it is preferable to anastomose the interposed colon to a long-limb Roux limb (right) to prevent postoperative oral regurgitation and aspiration of biliary-pancreatic secretions. Such resection and reconstruction can be effected as shown on the left, through a left thoracoabdominal incision and left cervical incision. (Reprinted from Payne.25 Used with permission of Mayo Foundation.)

Figure 12.2. In patients requiring total esophagectomy and total gastrectomy, as is required in the patient shown (center), with distal esophageal malignant disease and previous Billroth II procedures,it is preferable to anastomose the interposed colon to a long-limb Roux limb (right) to prevent postoperative oral regurgitation and aspiration of biliary-pancreatic secretions. Such resection and reconstruction can be effected as shown on the left, through a left thoracoabdominal incision and left cervical incision. (Reprinted from Payne.25 Used with permission of Mayo Foundation.)

Esophagus Reconstruction Surgery

MANAGING FAILED ANTI-REFLUX THERAPY

the main pedicle have been isolated, temporary occlusion with atraumatic vascular bulldog clamps is used on the branches and arcades to be ligated. The presence of pulsation,peristalsis, and color should be observed and maintained before division and ligation of those vessels (Figure 12.4). The jejunum is then transected using a linear-cutting stapler and the ends are oversewn with interrupted 3-0 silk sutures. The distal cut end of jejunum is brought through a small defect in the transverse mesocolon and anastomosed end-to-side to the distal esophagus in one interrupted layer of inverting 3-0 absorbable monofilament polyglyconate (Maxon®) suture. The anastomosis is constructed as close as possible to the end of the efferent limb to avoid a blind pouch situation. The proximal jejunal segment distal to the ligament of Treitz passes behind and to the left of the efferent limb and an end-to-side jejunoje-junostomy is constructed 45 cm distal to the esophageal anastomosis (Figure 12.5). The mesentery is closed to prevent internal herniation.

Esophageal Cuff Gastrectomy

Figure 12.3. Congenital variations in jejunal mesenteric vascular patterns,such as an interruption in the vascular arcade (right), preclude use of portions of the jejunum that would normally be used for esophageal reconstruction (left). (Reprinted from Deschamps.70 Used with permission of Mayo Foundation.)

MANAGEMENT OF ALKALINE REFLUX

Esophageal Reconstruction Surgery

Figure 12.4. After confirmation of viability with trial clamping, division and ligation of the jejunal branches and arcades is accomplished, leaving the main pedicle as the primary blood supply for the efferent loop. Note the uninterrupted arcade and length of the efferent loop, which should be 45 cm. (Reprinted from Deschamps.70 Used with permission of Mayo Foundation.)

Figure 12.4. After confirmation of viability with trial clamping, division and ligation of the jejunal branches and arcades is accomplished, leaving the main pedicle as the primary blood supply for the efferent loop. Note the uninterrupted arcade and length of the efferent loop, which should be 45 cm. (Reprinted from Deschamps.70 Used with permission of Mayo Foundation.)

Esophagectomy Jejunal Interposition

Figure 12.5. Completed long-limb Roux-en-Y reconstruction after total gastrectomy and partial esophagectomy.The efferent loop measures 45 cm in length and passes behind the stomach. The afferent loop measures at least 20 cm and passes behind and to the left of the efferent loop. (Reprinted from Deschamps.70 Used with permission of Mayo Foundation.)

Figure 12.5. Completed long-limb Roux-en-Y reconstruction after total gastrectomy and partial esophagectomy.The efferent loop measures 45 cm in length and passes behind the stomach. The afferent loop measures at least 20 cm and passes behind and to the left of the efferent loop. (Reprinted from Deschamps.70 Used with permission of Mayo Foundation.)

Herbal Remedies For Acid Reflux

Herbal Remedies For Acid Reflux

Gastroesophageal reflux disease is the medical term for what we know as acid reflux. Acid reflux occurs when the stomach releases its liquid back into the esophagus, causing inflammation and damage to the esophageal lining. The regurgitated acid most often consists of a few compoundsbr acid, bile, and pepsin.

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Responses

  • stephen
    How long is Esophagectomy surgery?
    6 years ago
  • Mirrin Kelly
    How long biliary limb?
    6 years ago
  • LEENA
    What is the procedure Rouxy?
    2 years ago

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