Colonic Graft Research Articles

Ways to solve the issues of surgical treatment of stomach cancer

Surgical method is the only effective method of stomach cancer treatment. On the basis of dividing the stomach into angiological segments, lymphogenic metastasis was studied, classification of gastric cancer and extraligamentous lymph nodes localizations was created. Based on the performed surgeries working classification of extended lymphodissection was suggested. The data on the formation of esophageal-intestinal anastomosis, identification of the origin of key complications after gastrectomy are given. By introducing single-raw esophago-jejunal anastomosis it was possible to almost completely eliminate complications leading to death which together account for up to 90% of the complications: suture failure, pancreatitis and pancreatic necrosis. The volume of the resected stomach was revised without worsening long-term treatment results. During gastrosplenectomies for ablastic block dissection of lymph nodes the author proposes standard binding of the splenic vessels - proximal to the left gastroepiploic artery arising from the splenic artery. The remaining part of the pancreas after gastrosplenectomy with pancreas resection is proposed to be stitched using atraumatic sutures, which avoids formation of pancreatic fistula. In the clinic we developed esophagogastrosplenectomy from laparoscopic mediastinal access with isoperistaltic right colon graft for esophageal reconstruction with anastomosis located in the neck, antethoracic esophageal reconstruction with graft from the large curvature of the stomach, as well as created original drainages of our own design, which allowed excluding peritonitis without inconsistency of the sutures and abscesses of the abdominal cavity. The author concludes that gastrectomy and subtotal distal gastric resection according to his original methods are an effective tool in the surgical treatment of gastric cancer.

Original treatment for ischaemic stenosis of colon interposition: Report of two cases

IntroductionThe treatment of ischaemic stenosis of colon interposition for oesophageal replacement remains poorly defined. Case reportWe report two cases of patients operated for ischaemic stenosis of the cervical extremity of the colon interposition for caustic stenosis of the oesophagus. Treatment consisted of resection of the stenosis with creation of a new cervical anastomosis after complete release of the colon graft via a neck and upper midline incision in one patient and a new ileocolic graft exclusively replacing the stenotic segment of the oesophagoplasty in the second patient. DiscussionThese two cases illustrate the complex treatment modalities required for this complication. ConclusionThe treatment of choice of ischaemic stenosis of colon interposition is resection with creation of a new anastomosis, but repeat graft may sometimes be the only available treatment option.

Reconstruction after esophagectomy for esophageal cancer patients with a history of gastrectomy.

Pedicled jejunal flap and colon graft interposition are choices for esophageal reconstruction in patients with a history of gastrectomy or those who have undergone synchronous esophagogastrectomy. However, the optimal conduit in this situation is still being debated. We reviewed the literature concerning esophageal reconstruction using a conduit other than the stomach. Approximately 10% of esophagectomized patients undergo esophageal reconstruction using pedicled jejunum or colon interposition in Japan. The jejunal graft and colon graft are selected evenly, although the percentage of jejunal graft use is gradually increasing. Microvascular supercharge was performed in most of the reports of pedicled jejunal graft reconstruction, whereas vascular enhancement was not popularly used in the reports of colon graft interposition. Although the incidences of graft loss and anastomotic leakage were comparable between grafts, mortality rates seem to be higher in patients who undergo colon graft reconstruction than in those who undergo reconstruction with a jejunal graft. Prospective comparisons of short-term outcomes as well as long-term quality of life are needed to identify the best method of reconstruction.

In vivo regeneration of bladder muscular wall using decellularized colon matrix: an experimental study.

Finding a proper scaffold for augmentation is a serious challenge in bladder tissue engineering. We hereby aimed to determine the histological aspects of a decellularized colon graft for bladder augmentation in healthy rats. Rat colon tissues were decellularized using perfusion-based method. After partial cystectomy, bladders were grafted with a patch of decellularized colon. Bladder specimens were investigated in 12 rats at 1, 3, and 9months postoperatively for further histological changes and immunohistochemistry analyses were also performed. One month after implantation, partial seeding of new cells was observed. After 3months continuity of transitional epithelium of natural bladder on the decellularized grafted colon tissue was confirmed with histological and immunohistochemical examinations. All augmented bladders demonstrated a spherical shape without stone formation, necrosis or graft rejection. The presence of urothelium with similar morphology to the natural urothelium and visible blood vessels were found within 3months of operation. All immunohistochemical markers (except markers of colonic stem cells) were expressed in biopsies obtained 3months after surgery demonstrating a progressive vascular and smooth muscle cell infiltration into the graft after implantation. This study suggests that decellularized colon may provide a viable material for bladder augmentation in rats to pave the road for future applications of this natural collagen scaffold.

Colon Reconstruction and Esophageal Reconstructive Surgery

Esophageal reconstruction using colon graft was investigated in this review. Since the first use of the colon for esophageal reconstruction by Kelling and Vulliet, the colon reconstruction became a reliable surgical option to reconstruct partially or totally the esophagus. Over the time, the efficacy of colon graft has been thoroughly evaluated and definitively attested by competent surgeons during the past three decades. The mortality has been significantly improved however the early morbidity is still slightly higher compared to gastric reconstruction. Despite the increased operative time and number of anastomoses, the advantages of a colon graft become apparent including its relatively straight mesentery, its status as an enough long graft to be pulled up to the neck, its low incidence of disease, its resistance gastroesophageal reflux and its long-term good functional results. Compared to right colon, the left colon has less variation in blood supply and a smaller lumen diameter which matches perfectly with esophageal lumen. Colon reconstruction in an isoperistaltic fashion is the standard in order to prevent regurgitation and improve food transit. The posterior mediastinum and the substernal route are the most commonly route used in esophageal reconstruction. However in case of substernal colon reconstruction, as recommended by authors, the thoracic inlet should be enlarged by the partial remove of the manubrium and the left clavicle to ensure there is no compression on the transposed graft at the level of the thoracic inlet. The selection of appropriate colon graft should be based on the adequacy of blood supply and the length of reconstruction. Thereafter microvessel anastomosis should be added in cases where graft ischemia might occur.

Blood Transfusion and Cervical Anastomotic Leakage in Esophageal Reconstructive Surgery

Introduction: Esophageal reconstruction is associated with significant blood loss and blood transfusion rates. Blood transfusion is a quick method of correction of anemia and rapid restoration of intravascular volume. However, concerns exist about the side effects of blood transfusion on the anastomotic complications. This prospective study aimed to report the impact of intraoperative blood transfusion on cervical anastomotic leak rate in esophageal reconstructive surgery Patients and methods: From 2006 to 2014, 85 the left isoperistaltic colon grafts based on the left colonic vessels were performed. There were 71 females and 14 males. The mean age of patients was 25 years. The mean preoperative haemoglobin (Hb) was 11.24 ± 9.23 g/dl. Operative blood loss 500 ml was used as threshold for ABT. The oesophagocolique anastomotic integrity was assessed by barium study. Impact of intraoperative allogeneic blood transfusion on the cervical anastomosis rate was studied. Statistical analyses were performed using Student’s t-test or the chi-square test. The multivariate analysis was performed by SPSS 11.0 for Windows (SPSS, Chicago, IL, USA). Results: The median operative duration was 3 hours. The median hospital stay was 14 days. The mortality rate was 2.4%. Graft necrosis occurred in two patients. Fifty patients received intra-operative allogeneic blood transfusion. Twenty seven patients were developed a cervical leak. There were 23 females and 4 males. Leak was occurred in 22 patients who received intraoperative ABT. The complete spontaneous healing of leak was obtained in all patients after a median delay of 7 days. The result of the univariate and multivariate analysis revealed that the intra-operative allogeneic blood transfusion was a predictive factor of cervical leak. Conclusion: The correction of preoperative anemia, meticulous surgical dissection, good haemostasis and the respect of the guidelines of blood transfusion may reduce intraoperative blood transfusion and related surgical site infection.

15-year Personal Experience of Esophageal Reconstruction by Left Colic Arterydependent Colic Graft for Caustic Stricture: Surgical Technique and Postoperative Results

INTRODUCTION Stricture formation of oesophagus is inevitable in some cases of caustic ingestion. Oesophageal reconstruction using colon aims to restore both gut continuity and swallowing function. The aim of this retrospective study is to report a 15-year personal experience of surgical management of esophageal caustic stricture by using substernal left colic interposition. MATERIALS AND METHODS From 1999 to 2014, 105 patients with esophageal caustic stenosis were managed surgically. There were 90 women and 15 men. Patients aged from 15 to 70 years. Emergency esophago-gastrectomy was performed in 4 patients. Early gastric stenosis was treated before reconstructive surgery by gastro-jejunostomy in 12 patients. Nutritional disorders were corrected before surgery .The thoracic inlet was enlarged in36 patients. The functional results were evaluated in all patients. RESULTS Postoperative death occurred in 3 patients . The complication rate was 26.6%. The transplant necrosis was occurred in 2 patients .Cervical anastomotic leakage occurred in 15 patients .Early reoperation was performed in 4 patients. Cervical anastomosis stricture occurred in 8 patients. The redundancy was occurred in 2 patients .The swallowing function was considered good in 94 patients ( 89.5%) . Conclusion The early endoscopic evaluation provides accurate diagnosis and permit to define an appropriate therapeutic strategy . The goal of esophageal reconstructive surgery is to restore digestive continuity and good swallowing function .The left colon graft based on left colic vessels and interposed by substernal route is the technique of choice to reconstruct the scarred esophagus with good results. Key words esophageal stricture, left colon graft , results

The selection of procedures for the treatment of panurethral stricture secondary to lichen sclerosus and the histological evidence of urethral involvement

Objective To explore the procedure selection and outcomes of treatment for the patients with severe panurethral strictures secondary to lichen sclerosus (LS) and evaluated the bulbar urethral specimens histologically. Methods Seventy-eight patients with severe panurethral strictures of LS underwent one-stage urethroplasty using different mucosal grafts between January 2003 and December 2014. The mean age was 48 years (range 38-72). The mean stricture length was 14.3±2.6 cm (range 11.0-22.0). Midline perineal incisions or circumcoronal and midline perineal incisions were used and two procedures were chosen as follow: ①the strictured urethras were dissected from the corpora cavernosa only along the left side and the stricture urethras were opened by a dorsal longitudinal incision which extended about 1.5 cm into the proximal healthy urethras. The strictured urethras were augmented using oral mucosal grafts(1.5 to 2.0 cm in width and an appropriate in length) (n=50); ② for the patients whose urethras were very narrow or obliterated, the urethras were reconstructed using colonic mucosal graft(3 cm in width and an appropriate in length)after the severe strictured urethras were excised (n=28). Biopsies were taken separately from the urethral meatus and bulbar urethral specimens. Results All of the 78 patients were followed up for 6-110 months (mean of 48.3 months). Sixty-nine patients (88.5%) urinated well, with the mean urinary peak flow rate of 23.4 ml/s (range 15.2-47.0 ml/s), and urethrography showed that each had a patent urethra with adequate lumen. Complications associated with urethra occurred in 9 patients (11.5%). Three patients developed urinary fistula secondary to infection, which required surgical correction; 6 patients developed meatal stenosis 3-11 months postoperatively, and all voided well after meatoplasty. The incidence of LS-positive biopsies was 100.0% in the glans and 88.5% in the meatus. In the bulbar urethral mucosa, the histological alteration in all biopsies was squamous metaplasia of the hyperplasia, and no histological evidence of typical LS was documented. However, homogenization of the collagen with diffuse lymphocyte infiltration was observed in the bulbar urethral specimens of 2 patients, and squamous metaplasia of the hyperplasia with serious orthokeratosis that was similar to its cutaneous counterpart was found in another 2 patients. Conclusions Our study suggests that urethroplasty with oral mucosal grafts is effective to treat panurethral stricture associated with LS. Urethroplasty with a colonic mucosal graft is suitable for repairing very severe strictured or obliterated urethra. No histological evidence of typical LS is observed in the bulbar urethral specimens. Key words: Urethral stricture; Lichen sclerosus; Colonic mucosa; Urethral reconstruction

Malignancy arising in a 41-year-old colonic interposition graft

The colon can be used for esophageal reconstruction after an esophagectomy. The development of a malignancy in the colonic interposition graft is rare, with less than 15 cases reported in the literature. We present a case of a 60-year-old male with high-grade dysplasia of the colonic interposition graft used for reconstruction of the esophagus, which developed 41 years after the esophageal reconstruction. The long-term complication of the development of a malignancy must be considered when using the colon for reconstruction especially when the esophageal reconstruction is performed for a benign cause.

Strategies for the treatment of aorto-oesophageal fistula†

Presenting a surgical strategy for aorto-oesophageal fistula (AEF). From October 1999 to August 2013, 16 patients with AEF were treated at Kobe University Hospital. The mean age was 65.5 ± 10.2 years, and the male/female ratio was 13/3. Eight patients had non-dissecting thoracic aneurysm, 3 had chronic aortic dissection, 5 had oesophageal cancer and 1 had fish bone penetration. Five patients were in shock. Four patients had previous thoracic endovascular aortic repair (TEVAR) in the descending aorta and 1 had hemi-arch replacement. As treatment for AEF, 8 patients underwent TEVAR, 2 had a bridge TEVAR to open surgery, 2 had extra-anatomical bypass (EAB) and 5 had in situ reconstruction of the descending aorta. The oesophagus was resected in 8 patients, and an omental flap was installed in 7 patients. For the 4 most recent cases, simultaneous resection of the aorta and oesophagus, in situ reconstruction of the descending aorta using rifampicin-soaked Dacron graft and omental flap installation were performed. Hospital mortality was noted in 4 patients (25.0%; persistent sepsis n = 3 and pneumonia n = 1). However, since 2007, only 1 of 5 patients died (pneumonia). All patients with oesophageal cancer died during follow-up. Two patients underwent oesophageal reconstruction using a pedicled colon graft and one is on the waiting list for oesophageal reconstruction. Bridging TEVAR is a useful adjunct in treating AEF patients with shock. One-stage surgery consisting of resection of the aneurysm and oesophagus, in situ reconstruction of the descending aorta and omental flap installation provided a better outcome in the AEF surgical strategy compared with conservative treatment.

Colonic Esophageal Reconstruction by Substernal Approach for Caustic Stricture: What is the Impact of the Enlargement of the Thoracic Inlet on Cervical Anastomotic Complications?

Background: The two most commonly employed options for esophageal reconstruction are the posterior mediastinal route and the substernal route. Therefore, the biggest disadvantage of the retrosternal approach is the potential risk for compression of the graft at the site of the thoracic inlet. The purpose of this study is to report our results by analysing the impact of the enlargement of the thoracic inlet by removing the left half of manubrium and internal third of clavicle on the cervical anastomotic leakage. Methods: From 2005 to 2013, 82 left colonic interpositions for oesophageal caustic stricture were performed at our institution. There were 70 women and 12 men. Ten patients had a hypopharyngeal stricture that required also reconstructive surgery. Dilation was done in 56 patients. Results: An esophagocolic anastomosis was performed in 72 patients. A gastroenteroanastomosis was performed before reconstruction in 10 patients. A pharyngoplasty was associated in 10 patients. The thoracic inlet was enlarged in 35 patients .The colonic graft was anastomosed to the posterior surface of the stomach in 69 patients. The mortality rate was 2.43 %. Graft necrosis occurred in two patients. Cervical leakage was occurred in 25 patients. Eight patients developed a cervical structure. Statistical analysis revealed that the non-enlargement of the thoracic inlet was a predictive factor of cervical leak (OR; 3.63, CI; 1.06 -12.40, P= 0.039 ) .therefore the enlargement is associate with lower rate of cervical leak. The functional results were good. Conclusion: The non-enlargement of the thoracic inlet is a predisposing factor of cervical leak in substernal colonic interposition. Therefore the enlargement seems reduce the cervical leakage

Colon Interposition via the Retrosternal Approach without Enlargement of the Thoracic Inlet for the Management of Esophageal Stricture

The accidental or intentional ingestion of a caustic substance is common in Eastern Europe, South America, and Asia and corrosive strictures appear in up to 85% of cases. Prognosis is influenced by the type, concentration, and amount of the caustic material ingested. Esophageal replacement is managed using colon, small bowel, stomach, gastric tubes, segments of skin, or a myocutaneous flap. In particular, colon interposition is a useful treatment option when esophageal replacement is necessary. The retrosternal passage of a colon graft usually requires enlargement of the thoracic inlet to minimize potential compression of the colon graft or its blood supply. In fact, many surgeons consider that this maneuver is essential to obviate any compression of the upper aspect of the colon graft above the thoracic inlet. However, we have achieved good results for colon interposition for esophageal reconstruction without enlargement of the thoracic inlet. In this retrospective study, we reviewed the records of patients that underwent esophageal replacement using colon and a retrosternal approach without enlargement of the thoracic inlet.

Decelluarization and Reseeding of Porcine Colon with Human CaCo-2 Cells for Whole-Scale Organ Engineering Applications

A new approach to whole-scale organ engineering is the seeding of stem cells upon a decellularized scaffold of a desired organ. Current efforts seek to use this method for whole-scale organ engineering. Here, we report a novel decellularizationrecellularization approach to engineering a human colonic graft with human enterocytes and xenogeneic scaffold. Porcine colon tissue was decellularized with protein-solubilizing agents and recellularized by incubation with Caco-2. Immunohistochemistry, DNA staining, and SEM were used to study the effects upon the scaffold. Exposure to 2%SDS-0.5%Triton solution for four hours resulted in the best decellularization and preservation of microstructure, while tissues treated with 2%SDS-0.5%Triton and 0.05%Trypsin/EDTA supported the best recellularization. Our method provides a potential strategy for streamlined regeneration of a viable colonic lumen from xenogeneic and allogeneic sources while maintaining colon microstructure and potential for recellularization.

An extremely rare case of pancreatic metastasis of esophageal squamous cell carcinoma

We report a rare case of a 68-year-old male with metachronous pancreatic metastasis that was resected 2 years after salvage esophagectomy for local recurrence of esophageal squamous cell carcinoma (ESCC). Two years and 8 mo ago, he had undergone definitive chemoradiotherapy for the lower thoracic ESCC and achieved a complete response. Chemoradiotherapy used the protocol of the Japan Clinical Oncology Group trial 9906. Approximately 8 mo later, he developed a local recurrence of the ESCC and underwent thoracoscopic salvage esophagectomy followed by reconstruction with a conduit colon graft via a subcutaneous route. Recently, a tumor of the pancreatic body was found on routine follow-up computed tomography (CT). The tumor diameter was 15 mm on CT, and the maximum standardized uptake value of the lesion was 5.49 at 18F-2-fluoro-2-deoxy-D-glucose positron-emission tomography, strongly suggesting pancreatic cancer. In addition, all tumor markers were within the reference intervals. Therefore, distal pancreatectomy was performed with the resultant histological diagnosis being confirmed as pancreatic metastasis of the ESCC. He was treated with adjuvant chemotherapy, and there has been no evidence of recurrence 9 mo after the surgery. Resection of pancreatic metastasis offers a good prognosis and should be considered for solitary ESCC metastasis.

Ileocolon Interposition Graft Following Surgery for Gastro-esophageal Junction Adenocarcinoma

The stomach remains the most preferred esophageal substitute following esophagectomy for cancer [1]. However in circumstances where the stomach is not available due to involvement by the cancer, such as in our patient, or due to prior surgery, a few other options are still available. While the jejunum is suitable to reconstruct total gastrectomy and distal esophagectomy at or below the level of pulmonary hilum, its use when more of esophagus is resected is complicated by the need for micro vascular reconstructive surgery [2]. In such a scenario, the colonic conduit is the preferred substitute because of its consistent blood supply, long length and acid resistance [2]. Traditionally, the left colonic graft is more often used, but there is an increasing trend towards using right sided colonic or ileo-colonic conduits. We present a report wherein an ileo-colon interposition graft based on middle colic artery was used to reconstruct the Gastro-Intestinal tract following subtotal esophagectomy and total gastrectomy.

Curative resection of gastric tube cancer by hand-assisted thoracoscopic surgery

We report a 78-year-old male who underwent successful resection of a gastric tube cancer by hand-assisted thoracoscopic surgery. The patient was initially placed in the supine position, and the abdominal portion of the gastric tube was mobilized via upper midline laparotomy. A pedicled colonic graft supplied by the left colic artery was prepared. The patient was then moved to the left decubitus position, and five ports were placed in the right chest wall. The surgeon stood in front of the patient, and inserted his left hand into the right pleural cavity through the laparotomy incision. After the whole gastric tube was successfully mobilized, the patient was returned to the supine position. The gastric tube was reconstructed with the pedicled colonic graft via the subcutaneous route. The surgical resection margins were free of cancer. The patient currently survives more than 16 months after surgery.

1584 Applicability of Sigmoid Colon Graft for Vaginal Replacement (Colovaginoplasty) at young age

ObjectiveTo evaluate the applicability, feasibility, complications, short and long term results of vaginoplasty by using sigmoid colon graft with the use of stapler for resuming colonic continuity in children with...

Left colonic graft in esophageal reconstruction for caustic stricture: mortality and morbidity

The adequacy of the blood supply to the left colon graft and its ability to transport food effectively from pharynx to stomach made it an esophageal substitute of choice, particularly in esophageal caustic stricture. From 1999 to 2009, 60 patients underwent colon interposition for esophageal caustic stricture (n= 57) and cancer (n= 3). An isoperistaltic colonic graft based on the left colonic artery could be used in all of these patients. The substernal route was used exclusively, and upper thoracic inlet was opened when necessary. The isoperistaltic left colonic graft interposed by substernal route represents the surgical procedure of choice in all operations performed for esophageal substitution during the study period. The operative mortality rate was 3.3%. A cervical fistula occurred in 10 patients (16.6%) and cervical anastomotic stricture in five patients (8.3%). Dilation was required in all the stricture of the esophageal colonic anastomosis with good response. The isoperistaltic left colic transplant supplied by the left colic pedicle is an excellent long-term replacement organ for the esophageal caustic stenosis. When performed by experienced surgeons, the left isoperistaltic esophagocoloplasty is a satisfactory surgical method for esophageal reconstruction with acceptable early morbidity and good long-term functional results.

Invited Commentary

Invited Commentary

La transplantation intestinale : Indications et stratégie

Intestinal transplantation is a valid therapeutic option for adults and children with irreversible intestinal failure, and not only for short bowel syndrome. The use of tacrolimus, monoclonal antibodies and antiviral therapy has improved both graft and patient survival. The lesser severity of graft rejection in combined liver-small bowel transplantation, as well as the safety of associated colon grafting, are now well established. Long-term intestinal graft function may be totally restored, allowing maintenance in adults and normal growth in children after weaning from parenteral nutrition. ITx is indicated only for selected patients with irreversible intestinal failure in whom long-term PN is no longer a safe option. The medico-surgical therapeutic strategy must be discussed early in order to ensure that ITx is performed at the right time in optimal conditions.