Jejunal Pouch Interposition with Fundic-Like Plication After Total Gastrectomy

Purpose We developed a technique of jejunal pouch interposition with a fundic-like jejunal plication (JPI-FP) for reconstruction after total gastrectomy (TG) for gastric cancer. The aim of this study was to investigate the advantages of JPI-FP over Roux-en-Y reconstruction (R-Y).Methods Twenty-two patients who had undergone TG more than 1 year earlier were classified into two groups according to the method of reconstruction used: Group A (n = 7) underwent R-Y, and group B (n = 15) underwent JPI-FP. Group B was subdivided into two groups to examine the usefulness of additional pylorus preservation: group B1 (n = 8), pylorus (−) and group B2 (n = 7), pylorus (+).Results Food intake and body weight were significantly higher in group B than in group A (P < 0.05). Reflux esophagitis was diagnosed in two of the group A patients, but in none of the group B patients. Excessive esophageal bile exposure, determined as the fraction time of esophageal bilirubin absorbance over 0.14 > 50%, was significantly higher in group A than in group B (P < 0.05). There was no significant difference in bile exposure in the jejunal pouch between groups B1 and B2.Conclusions JPI-FP is a superior method of reconstruction after TG to prevent excessive esophageal bile reflux and from a nutritional aspect. The advantage of pylorus preservation remains unconfirmed.     

Evaluation of pylorus-preserving pancreatoduodenectomy with the Imanaga reconstruction by hepatobiliary and gastrointestinal dual scintigraphy.

BACKGROUND: Following pylorus-preserving pancreatoduodenectomy (PPPD), most surgeons use gastrointestinal reconstruction with an end-to-side duodenojejunostomy placed distally to the pancreatojejunostomy and choledochojejunostomy. In contrast, the authors have consistently used PPPD with the Imanaga reconstruction (PPPD-Imanaga) which consists of end-to-end duodeno- jejunostomy, end-to-side pancreatojejunostomy and choledochojejunostomy, performed in that order. In this study, the movement of bile and food after PPPD-Imanaga was evaluated to document the functional advantages of this method. METHODS: Twenty-four patients who had undergone PPPD-Imanaga were subjected to hepatobiliary and gastrointestinal dual scintigraphy. The interval between operation and scintigraphy ranged from 28 days to 67 months. Six of the 24 patients underwent repeated dual scintigraphy for the observation of temporal changes in gastrointestinal function. RESULTS: The incidence of biliogastric reflux and bile stasis in the jejunal loop was markedly decreased at times later than 2 months after operation. Delay of gastric emptying and bile evacuation, sometimes accompanied by stasis in the jejunal loop, affected the mixing status of bile and food at 1 h after the beginning of imaging. A majority of the patients, however, had a satisfactory mixing status at 2 h. CONCLUSION: The Imanaga reconstruction appears to be a recommendable procedure following PPPD, in light of the bile and food movement achieved in the gastrointestinal tract.     

Intestinal microflora and bile acids following biliary tract reconstruction

The purpose of this study was to evaluate the intestinal microflora and the composition of various bile acids in jejunal fluid following B-I and B-II types of biliary reconstruction in dogs. B-1 type reconstruction, in which the biliary tract was directly anastomosed to the food passing tract, was performed in 8 dogs, which received cholecystoduodenostomy (group C-D) and in 8 which received cholecystojejunostomy (group C-J). B-II type reconstruction by Roux-Y cholecystojejunostomy, in which bile flowed into the jejunal limb, was performed in 8 dogs (group R-Y). Incidences of detection of gram-positive, gram-negative and anaerobic bacteria were as follows: 33%, 33% and 6% in the jejunal fluid obtained at initial operation, 67%, 67% and 33% in group C-D, 83%, 67% and 33% in group C-J, and 75%, 88% and 75% in group R-Y. In six dogs in group R-Y, unconjugated or secondary bile acids in the jejunal fluid increased, while these increases were observed in only two dogs in group C-J and in no dogs in C-D. Unconjugated and secondary bile acids were more likely to increase following B-II type reconstruction than following B-I type reconstruction. These findings are thought to be associated with bacterial overgrowth in the jejunal loop. These results suggest that B-II type reconstruction, in which bilio-enterostomy is exposed with infected intestinal fluid and unconjugated and secondary bile acids, is inferior in preventing ascending cholangitis.     

全胃切除术后两种消化道重建术式的前瞻性临床研究阶段报告

目的比较全胃切除术后功能性间置空肠代胃术与Roux—en—Y术两种消化道重建方式的术后远期并发症及生活质量。方法2012年3月至2013年2月间天津医科大学附属肿瘤医院前瞻性入组109例胃癌住院患者,在全胃切除及淋巴结清扫后,术中根据随机数字表法将患者分为R—Y组（采用Roux-en-Y重建术,57例）和FJI组（采用功能性间置空肠代胃重建术,52例）,比较两组患者术后并发症、营养指标及生活质量。结果术后1、3和6个月,FJI组R．S综合征发生率均明显低于R—Y组[13％（6／45）比37％（18／49）,3％（1／30）比42％（14／33）,5％（1／21）比48％（11／23）,均P〈0．01],但在3个月时,FJI组反流和烧心症状的出现率则明显高于R．Y组[53％（16／30）比21％（7／33）,P〈0．01;37％（11／30）比12％（4／33）;P〈0．05]。两组患者术后各项营养指标的差异均无统计学意义（均P〉0．05）。核心问卷EORTCQLQ．c30v3评分显示,两组患者在术后各个随访时间点总体健康状况评分的差异均无统计学意义（均P〉0．05）,但胃癌补充问卷EORTC—QLQ—ST022评分显示,FJI组患者在术后1个月和3个月时,“进食”评分明显优于R—Y组,但在术后3个月时“反流”评分则明显劣于R．Y组（均P〈0．01）。结论功能性间置空肠代胃术保留了食物十二指肠通过和肠道神经传导的完整,是一种较为合理的消化道重建方式。     

Recurrent Heartburn after Laparoscopic Fundoplication is Not Always Recurrent Reflux

Introduction A small cohort of patients present after antireflux surgery complaining of recurrent heartburn. Many of these patients have been empirically recommenced on proton pump inhibitors. Objective The aim of this study was to determine whether patients with symptoms that suggest recurrent reflux had objective evidence of reflux, and to determine predictors of recurrent reflux. Methods We identified all patients from an existing database who had undergone pH monitoring for “recurrent heartburn” after fundoplication. These patients were then cross-referenced to another database, which recorded the outcomes for patients who had undergone a laparoscopic fundoplication. Patients complaining of dysphagia or other problems without heartburn were excluded from analysis. Results Seventy-six patients were identified who met the inclusion criteria. Fifty-six (74%) of these had a normal 24-h pH study. Thirty-five patients (63%) with a normal pH study were on medication for heartburn at the time of referral. Three factors were found to be associated with an abnormal 24-h pH study: a partial fundoplication (P = 0.039), onset of symptoms 6 months or more after surgery (P < 0.001), and a good symptom response when antireflux medication was recommenced (P = 0.015). Conclusions Not all patients complaining of recurrent heartburn after fundoplication have evidence of abnormal reflux. Objective evidence of abnormal esophageal acid exposure should be confirmed before recommencing antireflux medication. Presented at the 10th World Congress of the International Society for Diseases of the Esophagus (ISDE), Adelaide Convention Center, South Australia, Australia, February 24, 2006     

Surgical management of postvagotomy syndrome

The purpose of the present report is to demonstrate the results of conservative surgical treatment in twelve patients with postvagotomy syndrome (PVS). The reconstructive operation performed in each case depended on the preexisting drainage procedure. Out of eight patients who had undergone vagotomy and gastrojejunostomy (GJ) four suffered from bile reflux and vomiting, four from dumping (DU) and four had diarrhea. All underwent closure of GJ and two of them duodenoplasty for coexisting duodenal stenosis. The results were very good (Visick grade I and II) in all patients except for one complete failure. Out of four patients who had undergone vagotomy and pyloroplasty, three had DU, two diarrhea and two bile reflux and vomiting. Pyloric reconstruction was performed in all subjects. Symptoms were relieved in all cases. In one patient radioisotopic control showed mild G/O and D/G reflux. Conservative surgical operations give satisfactory results in the treatment of PVS. Furthermore they have lower morbidity and mortality than radical surgery.     

Hepatobiliary and gastrointestinal imaging after pancreaticoduodenectomy —A comparative study on Billroth I and Billroth II reconstructions

This study was conducted to compare the passage of bile and food through the remnant alimentary tract between 2 and 6 months following pancreaticoduodenectomy in patients undergoing Billroth I (Imanaga) and Billroth II (Child) reconstructions, using dual scintigraphy. In the patients who underwent Child's operation (n=14), hepatobiliary scintigraphy showed a prominent stasis of bile tracer in the proximal jejunal loop and a significant time delay before the bile and food became mixed at the upper jejunum. On the other hand, in the patients who underwent Imanaga's operation (n=9) no bile stasis in the proximal jejunal loop was found and the time taken before the two agents became mixed was similar to that of healthy controls (n=7). The time taken for the two agents to mix at the upper jejunum was 65.8±7.9 min in the patients after Child's operation, 17.3±2.5 min in those after Imanaga's operation, and 18.5±2.8 min in the healthy controls, respectively. Continuous stasis of bile in the proximal loop and severe postcibal asynchronism in patients who undergo Child's operation can therefore cause reflux cholangitis and absorptive disturbances in the long postoperative term. The results of this study suggest that Imanaga's reconstruction is a more physiological procedure than Child's reconstruction following pancreaticoduodenectomy.     

Importance of preoperative and postoperative pH monitoring in patients with esophageal achalasia

Gastroesophageal reflux (GER) can develop in patients with esophageal achalasia either before treatment or following pneumatic dilatation or Heller myotomy. In this study we assessed the value of pre- and postoperative pH monitoring in identifying GER in patients with esophageal achalasia. Ambulatory pH monitoring was performed preoperatively in 40 patients with achalasia (18 untreated patients and 22 patients after pneumatic dilatation), 27 (68%) of whom complained of heartburn in addition to dysphagia (group A), and postoperatively in 18 of 51 patients who underwent a thoracoscopic (n=30) or laparoscopic (n=21) Heller myotomy (group B). The DeMeester reflux score was abnormal in 14 patients in group A, 13 of whom had been treated previously by pneumatic dilatation. Two types of pH tracings were seen: (1) GER in eight patients (7 of whom had undergone dilatation) and (2) pseudo-GER in six patients (all 6 of whom had undergone dilatation). Therefore 7 (32%) of 22 patients had abnormal GER after pneumatic dilatation. Postoperatively (group B) seven patients had abnormal GER (6 after thoracoscopic and 1 after laparoscopic myotomy). Six of the seven patients were asymptomatic. These findings show that (1) approximately one third of patients treated by pneumatic dilatation had GER; (2) symptoms were an unreliable index of the presence of abnormal GER, so pH monitoring must be performed in order to make this diagnosis; and (3) the preoperative detection of GER in patients with achalasia is important because it influences the choice of operation. Presented at the Thirty-Seventh Annual Meeting of The Society for Surgery of the Alimentary Tract, San Francisco, Calif., May 19–22, 1996.     

Reoperation after esophageal replacement in childhood

BACKGROUND: Esophageal replacement is associated with significant morbidity that may lead to operative interventions. This study reviews the management and outcome of children who underwent reoperation after esophageal replacement. METHODS: Eighteen patients who underwent esophageal replacement from 1985 to 1997 were reviewed retrospectively. Ten patients underwent reoperation. Patient management, perioperative morbidity, and the dietary intake at follow-up were recorded for each patient. RESULTS: Of the reoperated patients, 7 had esophageal atresia, 2 had caustic ingestion, and 1 had achalasia. Nine patients received a colon interposition, and 1 received a reverse gastric tube as the initial esophageal replacement. Seven patients required revision of the anastomoses. Three patients required complex esophageal reconstruction: 1 underwent gastric transposition, 1 underwent free jejunal graft, and 1 underwent gastric transposition combined with free jejunal graft. Seven patients were eating well at follow-up. Two patients still required partial gastrostomy tube feeding. One patient died 6 months postoperatively from aspiration pneumonia. CONCLUSIONS: Esophageal replacement continues to be a challenging operation associated with significant complications. Most reoperative procedures were directed toward strictures and persistent fistulae. Complete graft failure can be managed by gastric transposition or free jejunal graft. Despite the perioperative morbidity, most patients have good functional outcome.     

Hepatobiliary and gastrointestinal imaging after pancreaticoduodenectomy--a comparative study on Billroth I and Billroth II reconstructions

This study was conducted to compare the passage of bile and food through the remnant alimentary tract between 2 and 6 months following pancreaticoduodenectomy in patients undergoing Billroth I (Imanaga) and Billroth II (Child) reconstructions, using dual scintigraphy. In the patients who underwent Child's operation (n = 14), hepatobiliary scintigraphy showed a prominent stasis of bile tracer in the proximal jejunal loop and a significant time delay before the bile and food became mixed at the upper jejunum. On the other hand, in the patients who underwent Imanaga's operation (n = 9) no bile stasis in the proximal jejunal loop was found and the time taken before the two agents became mixed was similar to that of healthy controls (n = 7). The time taken for the two agents to mix at the upper jejunum was 65.8 +/- 7.9 min in the patients after Child's operation, 17.3 +/- 2.5 min in those after Imanaga's operation, and 18.5 +/- 2.8 min in the healthy controls, respectively. Continuous stasis of bile in the proximal loop and severe postcibal asynchronism in patients who undergo Child's operation can therefore cause reflux cholangitis and absorptive disturbances in the long postoperative term. The results of this study suggest that Imanaga's reconstruction is a more physiological procedure than Child's reconstruction following pancreaticoduodenectomy.     

Bile acid composition and esophagitis after total gastrectomy

Ten patients who had undergone total or subtotal gastrectomy for carcinoma 1 to 8 years earlier were evaluated in terms of subjective symptoms, endoscopy and the presence of bile in esophagojejunal aspirates obtained by direct aspiration during endoscopy. The concentrations of individual bile acids were determined by means of gas chromatography. Six of the patients had macroscopic esophagitis and all of them also had bile in their aspirate. The remaining four patients with normal esophageal mucosa did not have positive specimens. Neither did the total bile acid concentration nor any of the individual bile acids, regardless of whether they were free or conjugated, correlate with the severity of symptoms or the degree of endoscopic esophagitis. Esophagitis healed in all three patients who underwent conversion of loop esophagojejunostomy to a long Roux-Y reconstruction.     

Altered Esophageal Motility and Gastroesophageal Barrier in Patients with Jejunal Interposition After Distal Esophageal Resection for Early Stage Adenocarcinoma

Introduction Limited resection of the esophagogastric junction has been proven to be safe and oncologically radical in patients with early esophageal cancer. Reconstruction with interposition of isoperistaltic jejunal loop (Merendino procedure) is supposed to prevent gastroesophageal reflux and therefore the recurrence of intestinal metaplasia at the anastomosis. The aim of this study was to assess the frequency of acid and nonacid refluxes after Merendino procedure using multichannel intraluminal impedance-pH (MII-pH) monitoring. Patients and Methods Between 2002 and 2005, 12 patients with esophageal adenocarcinoma underwent limited resection and jejunal interposition. Ten patients agreed to undergo a Gastrointestinal Symptom Rating Scale assessment, upper gastrointestinal (GI) endoscopy, esophageal manometry, and combined 24-h MII-pH monitoring more than 10 months postoperatively. Results Postoperatively, 4 (40%) patients reported belching without heartburn or acid regurgitation, 3 of them having a positive symptom index during 24-h MII-pH monitoring. Upper GI endoscopy revealed no inflammation, metaplasia, or stenosis at the esophagojejunal anastomosis. Esophageal manometry showed ineffective esophageal motility in four of ten patients. Combined 24-h MII-pH monitoring revealed normal distal esophageal acid exposure (% time pH < 4: 0.1% [0–1.5]), normal number of acid reflux episodes (3 [0–11]) but a high number of nonacid reflux episodes (82 [33–184]). Overall, eight patients revealed an abnormal number of nonacid reflux episodes. Conclusion The limited resection with jejunal interposition for early esophageal cancer is efficient in controlling acid but not nonacid reflux. While the clinical relevance of nonacid reflux in the recurrence of Barrett’s esophagus is currently unknown, endoscopic surveillance should be considered in these patients. Poster presented at the Digestive Disease Week, May 21, 2007, Washington DC.     

Manometric Abnormalities and Gastroesophageal Reflux Disease in the Morbidly Obese

Background: Obesity is an epidemic in the USA. Many disorders are associated with obesity including gastroesophageal reflux disease (GERD). However, the prevalence of GERD and esophageal motility disorders in the morbidly obese population is unclear. Methods: During evaluation for bariatric surgery, 61 morbidly obese patients underwent preoperative 24-hr pH and esophageal manometry. A single reviewer evaluated all 24-hr pH and manometric tracings. Johnson-DeMeester score >14.7 was considered diagnostic of GERD. Manometric criteria for motility disorders were from published values. All values are given as mean ± SD. Results: Mean age was 44.4 + 10.3 years. 55 of the patients (90%) were female. Mean BMI was 50.1 ± 7.2 kg/m². 23 patients (38%) complained of GERD symptoms (reflux and/or heartburn). 1 patient (2%) complained of noncardiac chest pain. Mean Johnson-DeMeester score was 19.6 ± 17.8. Mean intragastric and intrabolus pressures were both elevated (8.3 ± 1.6 mmHg and 15 ± 9 mmHg). 33 patients (54%) had abnormal manometric findings: 10 had a mechanically defective LES, 11 had a hypertensive LES, 2 had diffuse esophageal spasm, 3 had nutcracker esopha gus,1 had ineffective esophageal disorder and 14 had nonspecific esophageal motility disorder. Some patients had more than one disorder. 20 patients (33%) had significantly elevated (>180 mmHg) contraction amplitudes at the most distal channel (210.0 ± 28.7 mmHg). Conclusions: Prevalence of manometric abnormalities in the morbidly obese is high. Presence of a nut cracker-like distal esophagus in the morbidly obese is significant and warrants further evaluation.     

Reoperation after failed esophagomyotomy for achalasia

Of 49 patients with achalasia treated surgically between 1975 and 1985, 12 (8 women, 4 men) had undergone transthoracic esophagomyotomy previously. Four had had concomitant upper gastrointestinal surgery. All 12 patients complained of dysphagia; other symptoms included regurgitation, nocturnal aspiration, heartburn, chest pain, vomiting, upper gastrointestinal bleeding and weight loss. The average time from initial operation to onset of symptoms was 9 months. Preoperative investigations and operative findings identified the cause of dysphagia as inadequate or healed esophagomyotomy with persistent or recurrent achalasia (eight patients--two had partially disrupted fundoplications contributing to their dysphagia), hiatus hernia with reflux esophagitis causing esophageal spasm or peptic esophageal stricture (two patients) and incorrect initial diagnosis and treatment (two patients). Treatment, with the aid of intraoperative manometry, included repeat Heller myotomy (five patients), Hill antireflux repair (four patients), takedown of Nissen fundoplication and extension of myotomy (two patients). The average follow-up was 16 months. Eight patients had good results, two required further operation and one underwent multiple dilatations postoperatively. The causes of recurrent dysphagia following surgery for achalasia are diverse and patients require individualized investigation and treatment. Remedial surgery for achalasia can correct postoperative dysphagia but results are less successful than those following an adequate initial operation.     

近端胃癌根治术中消化道重建两种新术式的初步研究

目的:探讨近端胃癌患者手术后消化道重建减少消化液反流发生的方法。方法:设计两种新型吻合方法,即保留贲门结构的食道-残胃吻合术和环状襻式单通道空肠间置术。将两种新术式临床效果与同传统的近端胃切除吻合和全胃切除相比较。结果:4组患者的临床病理资料具有可比性(P>0.05)。各组术后体质量和营养指数在6个月时无明显差异(P>0.05),在24个月时两种新术式组明显优高于传统吻合术组(P<0.05);在术后3年时的生存质量、食管反流的发病率和食管炎的Visick分级方面两种新术式组明显优于传统吻合术组(P<0.01);各组间的1,3,5年生存率差异均无统计学意义(P>0.05)。结论:保留贲门的近端胃癌根治术与环状襻式单通道空肠间置吻合术有望成为胃底贲门癌手术的新术式。     

A MODIFICATION OF ISOLATED ROUX LOOP RECONSTRUCTION AFTER PANCREATICODUODENECTOMY

Background : Different techniques of reconstruction following pancreaticoduodenectomy have been described. A new modification using an isolated Roux-en-Y loop is reported. Methods : The isolated loop is taken up to bile duct rather than pancreas as previously described. Results : Seventeen patients have undergone this procedure. Two pancreatic fistulae developed, both following postoperative abscess formation. There was no operative mortality. Conclusion : This reconstruction provides separation of biliary and pancreatic fluid but adds two further benefits: the wide jejunal lumen allows for an easier pancreaticojejunal anastomosis, particularly when operating on a soft pancreas, and separation of gastric and biliary anastomoses prevents the efflux of bile into stomach.     

Laparoscopic conversion of an omega in a Roux-en-y reconstruction after mini-invasive total gastrectomy for cancer: a technical report

INTRODUCTION: Few cases of laparoscopic total gastrectomy have been published. Reconstruction of the digestive tract was generally accomplished with a Roux-en-y esophagojejunal mechanical anastomosis. Here we report the first 2 cases of laparoscopic conversion of an omega in a Roux-en-y reconstruction due to the occurrence of a severe alkaline esophagitis after mini-invasive total gastrectomy for cancer. MATERIALS AND METHODS: Two male patients presented in 2004. One year prior, at another facility, they had undergone laparoscopic total gastrectomy for cancer, with reconstruction of digestive tract by means of an esophagojejeunostomy with a jejunal loop and Braun's side-to-side enteroanastomosis. They complained of daily symptoms of nausea, regurgitation, heartburn, and early postprandial fullness with reduction of appetite and weight loss of almost 15 kg. Instrumental examination diagnosed alkaline esophagitis. Intervention was performed via laparoscopic approach and the digestive reconstruction was reconfigured in a Roux-en-y type with a proximal limb of almost 60 cm. RESULTS: Operative time was 135 to 180 minutes. No postoperative complications occurred. After 1-year follow-up, symptoms resolution and esophagitis healing have been observed in both patients. CONCLUSIONS: Laparoscopic gastrectomy is gaining wide acceptance. In our opinion, a standardization of the technique is necessary: we believe Roux-en-y should be considered the preferred reconstruction route ensuring the best protection of the esophagus from alkaline reflux.     

Evaluation and surgical correction of esophagitis after partial gastrectomy.

Among 51 patients with refractory symptomatic reflux esophagitis seen during an 18-month period, 8 (16%) had undergone previous partial gastrectomy. Either Billroth II (n = 6) or Billroth I (n = 2) resection had been carried out for peptic ulceration 18 months to 30 years beforehand. Each patients was evaluated by symptom scoring, endoscopy, and 24-hour pH monitoring plus a 16-hour esophageal aspiration study, in which 2-hourly aliquots were measured for acid, pepsin, conjugated and unconjugated bile acids, and trypsin. After conversion to a 45 cm Roux-en-Y gastroenterostomy, symptom scoring and endoscopy were repeated at 6 to 12 months in all eight patients. Pepsin, acid, and unconjugated bile acids were seldom present in esophageal aspirates. Conjugated bile acids in concentrations up to 30 mmol/L and trypsin up to 428 micrograms/ml were found in cases of severe esophagitis, mostly during nocturnal rest. Esophagitis, heartburn, regurgitation, and bilious vomiting were eradicated by Roux-en-Y conversion, but other postgastrectomy symptoms (early satiety, dumping, epigastric pain, and diarrhea) were largely unchanged. Postgastrectomy esophagitis resistant to medical therapy seems likely to be caused by nocturnal exposure to trypsin and conjugated bile acids; it is well controlled by a 45 cm Roux-en-Y conversion.     

A modification of isolated Roux loop reconstruction after pancreaticoduodenectomy.

BACKGROUND: Different techniques of reconstruction following pancreaticoduodenectomy have been described. A new modification using an isolated Roux-en-Y loop is reported. METHODS: The isolated loop is taken up to bile duct rather than pancreas as previously described. RESULTS: Seventeen patients have undergone this procedure. Two pancreatic fistulae developed, both following postoperative abscess formation. There was no operative mortality. CONCLUSION: This reconstruction provides separation of biliary and pancreatic fluid but adds two further benefits: the wide jejunal lumen allows for an easier pancreaticojejunal anastomosis, particularly when operating on a soft pancreas, and separation of gastric and biliary anastomoses prevents the efflux of bile into stomach.     

Replacement of the Cervical and Thoracic Esophagus in Dog Using Free Jejunal Autografts

Free revascularized jejunal grafts based on a single branch of the mesenteric artery and vein were selected and used for replacement of the cervical esophagus in 20 dogs. The graft pedicle was transplanted to the left external jugular vein and the internal carotid artery using end-to-side microvascular anastomoses. The procedure was successful in all the dogs; however, five dogs had fistula formation that healed spontaneously. A similar jejunal autograft was used to replace the thoracic esophagus in 20 dogs. The recipient vessels were the internal thoracic artery and vein. Only four dogs survived. Thirteen dogs could not survive because of infection resulting from leakage of esophageal content from the esophagojejunal anastomoses into the thoracic cavity. Only two dogs had infarcted jejunal grafts. The four surviving dogs could swallow liquid and semisolid food but they never returned to solid food because of difficulties with swallowing. Graft survival was confirmed with endoscopy and arterial angiography. Narrowed jejunal graft lumen was apparent with contrast radiography and endoscopy. The jejunal grafts kept peristalsis and contracted in coordinated fashion with the proximal esophagus. At necropsy, wound healing was evaluated using bursting strength and bursting circular wall tension. Although slight adhesion and fibrosis around the grafts as well as slight inflammatory reaction arround the suture material were observed, the jejunal grafts were grossly and microscopically normal. All esophagojejunal anastomoses healed and the jejunal mucosa looked normal.