Orloff M J, Daily P O, Orloff L A, Orloff M S
Department of Surgery, University of California, Medical Center, San Diego 92103-8999.
J Thorac Cardiovasc Surg. 1994 Aug;108(2):346-53.
This is the first report of the use of a free jejunal autograft vascularized 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 varices caused by unshuntable extrahepatic portal hypertension. The procedure was used in two young adults who, because of numerous previous abdominal operations, had a severely scarred and contracted intestinal mesentery that precluded conventional use of the small or large intestine with an intact blood supply to bridge the gap between the upper thoracic esophagus and the abdominal jejunum. Before referral, the two patients had 21 and eight bouts of variceal hemorrhage, respectively, that necessitated a cumulative total of 108 and 74 units of blood transfusion, necessitated 17 and 12 admissions to the hospital, and failed to respond to four and five operations and 14 and 18 sessions of endoscopic sclerotherapy. After extensive esophagogastrectomy combined with a free jejunal autograft, both patients have done well during follow-up of 9 and 3 years, respectively. Both have been in good to excellent health with stable weight, freedom from digestive tract bleeding, normal liver function, and no encephalopathy. These results confirm our recently reported conclusions regarding the uniform long-term effectiveness of extensive esophagogastrectomy in the treatment of unshuntable extrahepatic portal hypertension and suggest that thoracic and general surgeons familiar with microvascular techniques may find the free jejunal autograft to be useful in various circumstances in which it is necessary to replace all or a substantial part of the thoracic esophagus.
这是首例关于使用由胸廓内（乳内）动脉和静脉血管化的游离空肠自体移植来恢复全胃切除和远端65%食管切除术后消化道连续性的报告，该手术针对不可分流的肝外门静脉高压引起的复发性食管胃静脉曲张出血。该手术应用于两名年轻成年人，由于此前多次腹部手术，他们的肠系膜严重瘢痕化和挛缩，排除了常规使用具有完整血供的小肠或大肠来桥接上段胸段食管与腹部空肠之间间隙的可能性。在转诊之前，这两名患者分别发生了21次和8次静脉曲张出血，累计输血108单位和74单位，分别住院17次和12次，并且对4次和5次手术以及14次和18次内镜硬化治疗均无反应。在进行广泛的食管胃切除联合游离空肠自体移植术后，两名患者分别在9年和3年的随访期间情况良好。两人健康状况良好至极佳，体重稳定，无消化道出血，肝功能正常，无脑病。这些结果证实了我们最近报告的关于广泛食管胃切除术在治疗不可分流的肝外门静脉高压方面一致的长期有效性的结论，并表明熟悉微血管技术的胸外科和普通外科医生可能会发现游离空肠自体移植在各种需要替换全部或大部分胸段食管的情况下有用。
