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for the colon, whether as a replacement or as a bypass.

Colon esophageal bypass is ideally suited to the two-team approach. Because of the related amounts of dissection required, the cervical team can often delay its incision until the exploratory findings in the abdomen are clearly favorable: (1) an absence of major intra-abdominal metastatic disease, and (2) the presence of a suitable length of colon with a proper arterial blood supply and venous drainage.

Standard endotracheal anesthesia is used, and the patient is placed supine on the operating table with the head turned to the right. Hyperextension of the neck, as achieved with elevation of the shoulders by the so-called thyroid bag, is used. The operative field is prepared from the left mastoid process to the symphysis pubis. A Salem sump nasogastric tube is passed to the point of esophageal obstruction or into the stomach. Intraoperative monitoring is provided by a radial artery line, a central venous pressure line, and continuous electrocardiographic tracing.

A long midline or left paramedian laparotomy incision is used, extending from the xiphoid process to below the umbilicus. Careful exploration is needed to search for hepatic metastases, left gastric artery-celiac axis node metastases, peritoneal or omental implants of tumor, a possible second gastric carcinoma, or other unsuspected intra-abdominal process.

The colon is then mobilized, including its two flexures, from the ascending to the sigmoid colon level. Freeing the colon from the omentum and from the right and left peritoneal reflections is not difficult but must be accomplished carefully. The general surgical background of the thoracic surgeon is a helpful attribute. Points requiring particular care in this dissection are, in order of approach: (1) total detachment of the omentum, leaving it attached to the stomach but preserving the midcolic vessels as the posterior leaf of the omentum is peeled off the transverse mesocolon; (2) taking down the splenic

Figure 24-12 Schematic illustration showing use of the left colon to replace the esophagus. Points A and B are determined by the length of colon necessary to reach the neck. The left colic artery provides the blood supply. The middle colic artery is divided. The colon is placed, always, in isoperistaltic fashion so that the segment near the hepatic flexure is anastomosed to the esophagus in the neck and the end near the sigmoid colon is attached to the antrum of the stomach in the abdomen.

Figure 24-13 The long line with arrows at either end illustrates the extent of colon to be freed for left colon replacement of the esophagus. Blood supply is provided through the inferior mesenteric artery, the left colic artery, and the anastomotic branch connecting the middle colic artery. The middle colic artery has been divided near its origin from the superior mesenteric artery.

TABLE 24-2 -- Indications for Colon Esophageal Bypass


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