The jejunum is a dynamic graft and contributes to bolus transport, whereas the stomach and colon function more as a conduit. The stomach is a poor choice in this circumstance because of the propensity for the reflux of gastric contents into the proximal remaining esophagus following an intrathoracic esophagogastrostomy. It is now well recognized that this occurs, and can lead to incapacitating symptoms and esophageal destruction in some patients. Short segments of colon, on the other hand, lack significant motility and have a propensity for the development of esophagitis proximal to the anastomosis.

Replacement of the cervical portion of the esophagus, while preserving the distal portion, is occasionally indicated in cervical esophageal or head and neck malignancy, and following the ingestion of lye. Free transfer of a portion of jejunum to the neck has become a viable option and is successful in the majority of cases. Revascularization is achieved via use of the internal mammary artery and the internal mammary or innominate vein. Removal of the sternoclavicular joint aids in performing the vascular and distal esophageal anastomosis (Fig. 25-83).

A. The portion of the thoracic inlet to be resected to provide space for a free jejunal graft and access to the internal mammary artery (shaded area). B. Cross-section showing the space available after resection of the sternoclavicular joint and one- half of the manubrium. [Reproduced with permission from Rothberg M, DeMeester TR: Exposure of the cervical esophagus, in Shields TW (ed): General Thoracic Surgery, 3rd ed. Philadelphia: Lea & Febiger, 1989, p 419.]