J.Jpn. Surg. Soc.. 59(7): 1032-1046, 1958

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TRANSPLANTATION OF THE JEJUNUM FOLLOWING PARTIAL RESECTION OF THE THORACIC ESOPHAGUS. EXPERIMENTAL AND CLINICAL STUDY.

The method of radical operation for carcinoma of the ophagus and cardia has been established. Follow-up reports have become available. Recently, several complaints and metabolic disturbance in the follow-up period have been pointed out. The reason is attributed to the unphysiologic elevated position of the stomach in the thoracic cavity. There is, however, no satisfactory method to eliminate the above mentioned complications. In order to solve this problem, the author studied transplantation of the jejunum following partial resection of the thoracic esophagus. It was found out to be a method suitable for clinical application.
(I) Experimental Study
There are many reports to reconstruct the resected thoracic esophagus with a jejunum. However, the blood supply of the elevated jejunum is liable to be disturbed, which makes its use precarious. Forty-six adult dogs were used to find a method to improve the blood supply of the elevated jejunum and extend its elevation. The following results were obtained:
1) Comparing the bleeding from the edge of mesentery of a freed small intestine which was made by the conventional method and that by resecting unnecessary intestine on the anal side, all cases showed more bleeding by the latter method.
2) The blood flow of the mesentery of a freed jejunum was observed microscopically by Zweifach's method. The author's method showed better blood flow than that by the conventional method. Especially, when the arch of blood vessel of a freed intestine on the oral side is ligated and cut as the last step to prepare the graft, the danger to disturb the blood flow, such as pastoperative thrombosis, will be less.
3) Comparing the survival rate by the conventional method and that by the author's method, the survival rate of a freed intestine by the author's method was higher.
4) Using 5 adult dogs, a segment of small intestine with a pedicle was elevated anterior to the chest wall as high as the neck and and anastomosed with the cervical esophagus. Three out of 5 were successfuly transplanted. The blood flow from the mesentery to the transplanted small intestine was satisfactory 40 days after operation. Histologically, no remarkable changes were seen in the transplanted intestine.
5) The author's method was used on puppies shortly after they were born. The growth of the transplanted small intestine was studied on three survivals. As the grafts grew with the individual, this method may be applied to reconstruct the esophagus in infants.
(II) Clinical Study
Nine cases of carcinoma of the thoracic esophagus who had transplantation of a jejunal graft after partial resection of the thoracic esophagus were studied. The results are follows :
1) Operative results : Two cases who had disorders of the heart, liver and kidney before operation died in the immediate postoperative period. No cases showed necrosis of the grafted intestine or disruption of the anastomosis.
2) None showed any postoperative complaints.
3) By esophagoscopy, reflux esophagitis and ulcer were not observed in the grafted jejunum after operation.
4) Comparing the intak of food and calorie in the postoperative period after using the author's method and the conventional method, the former showed far better results than the latter. Consequently, the increase of body weight after the author's method was better.
5) No case showed abnormal findings on the E.C.G. even after excersie and food intake. Studying the electric axis of the heart, both operation and food intake showed little influence on the cardiac function.
6) Studying the vital capacity, maximal breathing capacity, minute ventilatory volume, pulmonary capacity, rate of ventilation reserve, oxygen removal before and after the operation, the author's method showed little influence on the pulmonary function. The same thing can be said on the separate right and left vital capacity (bronchospirometry) .
7) Liver function tests, i. e., B.S.P., santosol test, serum Takata-Ara reaction, sublimate reaction, urobiliongen in the urine, ratio of A/G, were performed. In the long survival cases, positive reaction of Takata-Ara test and sublimate test was observed and the ratio of A/G was low.
8) All cases of the gastric excretion test showed hypoacidity. All but one revealed free HCL. All cases showed ferment excretion within normal range. Studying the gastric motility curve and x-ray findings, gastric contraction or peristalsis was observed in 4 cases, while dilatation in 2 cases. Section of vagus did not greatly influence the gastric function and postoperative complaints.
9) Digestion and absorption test revealed normal rate of absorption of protein, fat and carbohydrates. Section of vagus, and resection of the intestine did not have any influence upon it.
10) As the patients were little disturbed by the operation, the operative results were favorable, and the postoperative condition was physiological, it is believed that if the surgical indication is carefully selected, the author's procedure is a recomendable one.
(author's abstract)

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