Jejunum pedicled transplantation to replace esophagus

Indication 1. High lesions, need to be anastomosis in the hypopharynx or neck. 2. In the past, a gastrectomy or a colectomy was performed, or a wide range of lesions in the colon itself could not be used to reconstruct the esophagus. Contraindications 1. In the past, jejunal resection was performed. 2. There have been extensive adhesions in the peritoneal cavity due to inflammation or surgery. Preoperative preparation 1. Prepare nutritional conditions according to esophageal cancer thoracotomy. 2. If the patient has a benign lesion and the patient has poor nutrition, he should first perform gastrostomy to improve nutrition. Surgical procedure 1. Need to remove the esophagus, through the right chest anterior lateral, neck and abdominal incision. The left esophagus and abdominal incision were not removed. 2. After the thoracic group was opened, the azygous vein was ligated, the pleural ventricle was cut open, and the esophagus was separated from the upper and lower sides of the tumor. Each belt was pulled outward with a gauze tape to separate the adhesion of the left and the posterior side of the tumor, up to the base of the neck. Down to the esophageal hiatus. The esophageal forceps were cut off from the 2 to 3 cm plane above the diaphragm, and the distal end was sutured with a medium-sized silk thread, and then a layer was embedded. The proximal end was sutured with a silk thread and then protected with a condom. 3. The chest group continued to make a left neck oblique incision, revealing the esophagus. After the cervical esophagus was completely freed by the chest incision, the esophagus could be presented through the neck incision. 4. Abdominal group for mid-abdominal incision, free jejunum mesangium, carefully check the proximal jejunum of 30 ~ 40cm before cutting the blood vessels, find the first jejunal artery of the first vascular arch in the distal side of the duodenal jejunum suspensory ligament and The vein is preserved to ensure blood in the proximal jejunum. The 2nd, 3rd, and 4th jejunal vessels on the primary arch were found and clamped with a vascular clamp for 15 minutes. The blood supply was observed. If the small artery was still close to the intestinal wall, the blood supply was good. The clipped blood vessel was severed and the jejunum was cut 30 cm from the Treitz ligament. Before cutting the intestine, avoid using the intestinal clamp to prevent damage to the tiny blood vessels. Stitch the end. 5. The intestine is lifted to the chest wall to detect its length. Generally, the length of the intestine is not enough to reach the neck, so it must continue to be free. The factors limiting the length of the intestine are the extravascular peritoneal and radial vascular arch on the mesentery. The former plays a "packaging" role in limiting the length of the intestine. Therefore, the peritoneum, lymphoid tissue and nerve fibers surrounding the blood vessel must be Carefully peel off and cut. 6. The peritoneum on the secondary vascular arch can be cut radially at several locations. Cutting the secondary arch at one or two places (the two-way solid arrow in the figure) not only increases the length of the intestine very effectively, but also significantly reduces the degree of distortion of the intestine. Care must be taken before cutting the secondary bow. 7. After obtaining a segment of the intestine of sufficient length, the distal end of the intestine segment is severed. Make a mouth on the transverse mesenteric and gastric ligament. The intestine segment is raised from this incision. The posterior sternal approach was used to open the posterior sternal space from the abdomen and neck; when the subcutaneous tunnel was selected, a 5 cm wide subcutaneous passage was used to connect the incision under the chest. 8. Lift the intestine to the neck. If the color is good, it can be used as esophageal jejunum or hypopharyngeal jejunostomy. The anastomosis is a single-layer intermittent suture. The abdominal group continued to complete jejunostomy, end-to-side jejunal anastomosis and pyloric angioplasty. complication 1. Neck anastomotic leakage: more than 4 to 10 days after surgery, the patient has fever, the neck incision is partially red and tender, and the blistering sound can be heard around the anastomosis. At this time, the incision suture should be removed 4~5 The needle separates the platysma and reveals an anastomosis. The wound sometimes has a foamy secretion that escapes. Oral methylene blue will have a blue liquid leaking out of the wound. 2. Intestinal obstruction: mostly caused by postoperative intestinal adhesion, patients with paroxysmal abdominal pain, bowel sounds hyperthyroidism, abdominal X-ray examination showed multiple gas-liquid surface. Treatment should first try conservative treatment. If it is not effective, open surgery can be considered. 3. Vocal cord paralysis: caused by damage to the recurrent laryngeal nerve when the esophagus is free. 4. Pneumothorax: often caused by damage to the pleura during the posterior sternal space, most of which can be solved by puncture.