FREE JEJUNAL AUTOGRAFT COMBINED WITH EXTENSIVE ESOPHAGOGASTRECTOMY FOR UNSHUNTABLE EXTRAHEPATIC PORTAL-HYPERTENSION

This is the first report of the use of a free jejunal autograft vascul arized by the internal thoracic (internal mammary) artery and vein to restore continuity of the digestive tract after total gastrectomy and distal 65% esophagectomy for recurrent bleeding esophagogastric varice s caused by unshuntable extrahepatic portal hypertension. The procedur e was used in two young adults who, because of numerous previous abdom inal operations, had a severely scarred and contracted intestinal mese ntery that precluded conventional use of the small or large intestine with an intact blood supply to bridge the gap between the upper thorac ic esophagus and the abdominal jejunum. Before referral, the two patie nts had 21 and eight bouts of variceal hemorrhage, respectively, that necessitated a cumulative total of 108 and 74 units of blood transfusi on, necessitated 17 and 12 admissions to the hospital, and failed to r espond to four and five operations and 14 and 18 sessions of endoscopi c sclerotherapy. After extensive esophagogastrectomy combined with a f ree jejunal autograft, both patients have done well during follow-up o f 9 and 3 years, respectively. Both have been in good to excellent hea lth with stable weight, freedom from digestive tract bleeding, normal liver function, and no encephalopathy. These results confirm our recen tly reported conclusions regarding the uniform long-term effectiveness of extensive esophagogastrectomy in the treatment of unshuntable extr ahepatic portal hypertension and suggest that thoracic and general sur geons familiar with microvascular techniques may find the free jejunal autograft to be useful in various circumstances in which it is necess ary to replace all or a substantial part of the thoracic esophagus.