Colon Interposition For Esophageal Replacement Research Articles

Colon interposition in the management of post-corrosive strictures

: Stricture of the esophagus is the most frequent late sequelae of the ingestion of caustic agents. It is disabling, lead to chronic pain and malnutrition. Endoscopic dilatation still remains the first-line management but cannot be effective in all patients. When surgery is indicated, only selected patients can be submitted to an esophago-gastroplasty. Colon interposition for esophageal replacement is more frequently performed for treatment of caustic burns, but many questions still remain about colonic tract to be used (right or left), route of transposition and timing of the operation. Surgeon’s experience is the most important factor to choose the right colonic tract as esophageal substitute. Age, psychiatric disorders, massive ingestion, emergency tracheotomy, extended visceral resections, short delays in reconstruction, and pharyngeal involvement worsen surgical outcomes, therefore surgery should be performed in high-volume centers. Follow-up of these patients should not tend only to verify the patency of the transit and weight maintenance, but it should identify any lesion of the graft and any metabolic alteration referring to an altered permeability of the transposed colic segment. In this review, we present the main step of preoperative, intraoperative and postoperative pathway of esophageal reconstruction for caustic strictures with a colonic graft, critically exposed according to our experience.

610. NOVEL HYBRID TECHNIQUES FOR DELAYED RECONSTRUCTION OF THE CERVICAL PART OF A LEFT COLON INTERPOSITION: A CASE REPORT

Abstract Conduit necrosis following colon interposition for esophageal replacement is a devastating complication with a high morbidity and mortality rates. Survivors often face a challenging journey of complex reconstructive procedures. A multi-disciplinary approach is paramount to tailor the management according to the patient's anatomy, nutritional and psychological status, conduit alternatives and routes. This case report provides a series of novel reconstructive techniques, each of which could be helpful for esophageal surgeons facing such difficult situation. A 36 years old female, with a history of corrosive ingestion at the age of 5 years, who was subjected to series of regular dilatation since then, presented with a tight stricture not passing a wire. She underwent a subcutaneous isoperistaltic left colon interposition. The postoperative course was complicated with necrosis of the cervical part of the graft with infection of the subcutaneous tunnel. Resection was done with esophagostomy and colostomy in the neck. The patient survived the acute stage, feeding was established through the colostomy opening in the neck. Delayed reconstruction was planned 6 months later. The skin between the two openings in the neck was considered posterior wall of the conduit, and transaxillary pedicled thoracodorsal artery perforator flap (TDAP) was used to reconstruct the anterior wall (1,2). Partial flap loss occurred (3). Debridment and gastrostomy were done. The result was two gaps on both ends of the flap (3). The food regurgitated upwards from the gastrostomy. An antireflux stent was placed inside the flap to bridge the defects and allow oral intake (4). The TDAP-colon side was closed using a local flap from TDAP and skin graft (5,6). The esophageal side was closed primary and covered by a supraclavicular flap (7-12). Management of graft failure should focus on controlling sepsis and nutrition. Attempts should be made to preserve any surviving part of the conduit as long as it doesn’t add to sepsis. A combination of Myocutaneous flaps could be used to replace the cervical part of the conduit as TDAP and supraclavicular flaps. Stent could be used successfully to bridge a failure in a skin flap. Finally, a dedicated team is paramount for a successful outcome.

How to ensure immediate and long-term good blood supply by the careful dissection of the marginal artery and supercharge with neck vessels in esophageal reconstruction with the colon segment interposition: 35 years of experience

Colon interposition for total esophageal replacement cases represents one of the most challenging procedures in surgery. A retrospective study has been conducted and suggestions are proposed according to the analysis of 268 patients who underwent colon interposition for esophageal replacement. Complication rates and the duration of hospital stay were retrospectively analyzed. A total of 268 patients were operated between 1984 and 2018. In group 1, 164 patients underwent colon interposition without supercharging with neck vessels and in group 2, 104 patients underwent colon interposition with supercharging. Data regarding flap loss, anastomotic leakage, the duration of hospital stay, and stricture formation in the long-term were statistically analyzed and compared between two groups. The success rate of reconstruction was 98,1% (161 of 164 patients) and 99% (103 of 104 patients) for group 1 and 2, respectively. Early complication (anastomotic leakage) rate was 4,9% in group 1 and 1% in group 2. The differences between two groups regarding flap loss and anastomotic leakage rates were not statistically significant (p = 0,495 and p = 0,077, respectively). The hospital stay was 26,3 days for patients without supercharging (group1) and 20,5 days for patients with supercharging (group 2). In group 1, 6,7% (11/164) of patients had narrowing at the junction of the pharynx and colon; however, in group 2, proximal anastomotic stricture formation was observed in only 1% (1/104) of the patients. The stricture rate was significantly lower in group 2 when compared to group 1 (p = 0,021). The careful dissection of the marginal artery and supercharging with neck vessels provide lower complication rates in colon interposition for esophageal reconstruction.

Thoracoscopic assisted colon interposition for long-gap esophageal atresia: a novel technique

The purpose of this work is to present preliminary results of a novel technique of thoracoscopically assisted colon interposition for esophageal replacement in long-gap esophageal atresia (LGEA). Management of LGEA remains a challenge. When primary repair is not possible, esophagocoloplasty is our first choice for esophageal replacement; we usually place the colon retrosternally, but we treated two patients with LGEA who had previously undergone a sternotomy. Therefore, we decided to place the graft via an intrathoracic route, but the passage of the colic graft into the thorax was performed video-assisted thoracoscopic. The follow-up of the two patients is now 4 years. They are both currently in good general conditions and their feeding behavior is comparable to the other infants of equal in age. We have not got any complications related to the technique, in particular any problems associated with the thoracoscopically assisted colonic replacement. We found that short-term survival was accomplished with apparently equivalent outcomes of thoracoscopically assisted colon interposition for LGEA.

The Use of Fluorescence Imaging in Colon Interposition for Esophageal Replacement: A Technical Note.

Every field of surgery has seen an explosion of new technologies aimed at improving surgical technique and reducing complications. The use of near-infrared (NIR) fluorescence to assess perfusion has been described in several surgical disciplines. NIR provides the surgeon with real-time perfusion assessment of a target organ or anastomosis and can be invaluable in aiding decision-making during the index operation. In the following article we discuss the use of fluorescence-guided perfusion assessment during colonic interposition for esophageal replacement. To our knowledge this is the first description of the use of fluorescence-guided perfusion assessment during colonic interposition.

Colon Interposition for Corrosive Esophageal Stricture: Single Institution Experience with 119 Cases.

The colon is an alternative graft organ for esophageal reconstruction. The present study reviewed our experience with the colon interposition for esophageal replacement following corrosive ingestion, to evaluate the outcomes of colon interposition based on our surgical experience. The clinical data of 119 patients who underwent colon interposition for esophageal replacement from January 2005 to March 2017 were retrospectively analyzed. The routes of the colon interposition were retrosternal in 119 (100%). The median operative time was 390 min (range: 290-610 min) and the median blood loss was 615 mL (range: 270-2500 mL). Of these 119 patients, the cervical anastomosis was performed at the hypopharynx (n=20, 16.8%), the larynx (n=3, 2.5%), and the cervical esophagus (n=96, 80.7%). Five patients experienced cervical anastomotic leakage (4 cases for esophagus-colon, and one for hypopharynx-colon). One patient experienced wound infection of the abdominal wall. Three patients had injury of recurrent laryngeal nerve and hoarseness. Three patients had stress ulcer with bleeding and treated with octreotide. Two patients suffered from incomplete intestinal obstruction. The postoperative follow-up was made for 12 months in all patients and all of them were alive. In conclusion, The colon is well-suited for esophageal reconstruction. The selection of the colon graft should be flexible and be based on the inspection of blood supply and the length needed. We must therefore make every effort to reduce the number of postoperative complications, and improve the quality of life for patients.

Результаты повторной толстокишечной пластики пищевода при хирургическом лечении карцином пищевода и пищеводно-желудочного перехода

Результаты повторной толстокишечной пластики пищевода при хирургическом лечении карцином пищевода и пищеводно-желудочного перехода

Total esophageal substitution for combined hypopharyngeal and esophageal strictures after corrosive injury in children

Background/purposeThe treatment of children with esophageal strictures and involvement of the hypopharynx caused by caustic substance ingestion continues to be challenging. The aims of the present study are to describe the peculiarities of the technique of complete esophageal substitution for the treatment of children with severe caustic strictures (pharyngocoloplasties) and to compare the results to those of classical esophagocoloplasty with thoracic and abdominal esophageal substitution in another group of children. MethodsA total of 258 children underwent colon interposition for esophageal replacement. Among these patients, 19 had complex esophageal caustic strictures involving the high level of the esophagus and hypopharynx without response to endoscopic dilatations. This group was compared with another group who required partial esophagocoloplasty with intact hypopharynx and high esophagus (239 patients). For the pharyngocoloplasty procedure, the transverse and great parts of the right colon were the segments selected for interposition and were maintained by a double vascular pedicle based on the left colic vessels and the marginal paracolic arcade via the sigmoid vessels. ResultsIn the pharyngocoloplasty group, 9 patients (47.4%) presented with cervical anastomosis stenosis with episodes of aspiration pneumonia, although good responses to endoscopic dilatation treatments were observed. All patients survived. In the esophagocoloplasty group, the main complications were cervical leaking (18.0%) and stenosis (16.7%). Statistical comparisons revealed that the pharyngocoloplasty patients exhibited a lower incidence of cervical leakage and increased incidences of cervical stenosis and aspiration pneumonia, although all patients could swallow normally. ConclusionPharyngocoloplasty with complete esophageal substitution is a safe and effective procedure for the treatment of esophageal caustic strictures with severe stenoses reaching the hypopharynx that are refractory to previous endoscopic treatment. Level of evidenceII

RECONSTITUCIÓN DE TRÁNSITO ESOFÁGICO CON INTERPOSICIÓN DE COLON DERECHO

esophageal reconstruction using right colon interposition background: Esophageal replacement therapy is indicated for benign and malignant esophageal lesions and can be performed using stomach, jejunum or colon. aim: To report the experience using right colon interposition for esophageal replacement. material and methods: Review of medical records of 41 patients aged 17 to 73 years (29 males), subjected to right colon interposition in the last 20 years. Indications, complications, mortality and long term results were recorded. results: Forty nine percent of patients had a malignant esophageal lesion. Esophagectomy was performed using a transhiatal route or thoracotomy in 44 and 30% of patients, respectively. Retroesternal ascension was the most common route used in 88% of patients. The most common surgical complication was cervical fistula in 29% of patients, followed by fistula of the anastomosis between colon and jejunum in 7% of patients. Pneumonia was the most common medical complication. Postoperative mortality was 7%. conclusions: The mortality in this series of patients is similar to that reported elsewhere.

Laparoscopically assisted esophagectomy and colon interposition for esophageal replacement in children: preliminary results of a novel technique

Background Colonic interposition is one of the surgical options in children when esophageal replacement is necessary, especially when the stomach is not suitable as a conduit. Conventional open surgery and blind mediastinal dissections present reasonable morbidity, which can be reduced by videosurgery. The authors present novel techniques and the preliminary results of the first series of laparoscopically assisted esophagectomies and colonic interpositions (LECIN) in children. Methods Five children aged 19 months to 4 years underwent LECIN. Indications were complicated esophageal atresia and severe caustic esophagitis. The patients were operated on laparoscopically using 3 ports, including the gastrostomy site. Transhiatal esophagectomy was carried out, followed by pyloroplasty and mobilization of the transverse colon maintaining a double blood supply from the left pedicle. The stomach at the gastrostomy site was freed and closed in 3 cases. The colon was exteriorized through this 2- to 3-cm site or through the umbilicus, and the conduit was fashioned extracorporeally, including the colocolic and gastrocolic anastomosis. The colon was pulled up along the retromediastinal tunnel for the coloesophageal anastomosis through a cervical incision. Results Operative times ranged from 3 to 4.3 hours; there were no conversions and no complications related to laparoscopy. There were no cardiorespiratory problems, and 4 were extubated immediately after operation. Feedings could be started by day 3 to 4. Postoperative complications included atelectasis (1), pneumonia (1), and cervical stenosis because of persistent fibrotic esophagus, requiring cervical revision (1). One needed dilatations for mild dysphagia. After a follow-up period of 10 to 29 months, all patients are asymptomatic, gaining weight, and feeding well. Conclusions These preliminary data suggest that LECIN is feasible and can be safely performed with very low morbidity in children. Further studies with larger series and follow-up are expected.

Colon interposition for esophageal replacement: a single-center experience.

Gastric tube interposition has become the method of choice for esophageal replacement after esophagectomy. Colon interposition, on the other hand, is widely considered to be a method of last resort, associated with high morbidity and mortality. The present study reviews our experience with colon interposition for esophageal replacement. Nineteen consecutive patients undergoing colon interposition for esophageal replacement between 1 January 1994 and 31 July 2001 were reviewed. Outcome was compared with international publications on colon interposition as well as with our results following gastric tube interposition (fundus rotation gastroplasty). Fourteen men and five women with a median age of 68 years (range 44-78) underwent colon interposition for benign ( n=9) and malignant ( n=10) lesions. Eighteen patients underwent trans-hiatal esophagectomy with cervical anastomosis, and one patient underwent thoraco-abdominal esophagectomy with intrathoracic anastomosis. Surgical morbidity was 36.8% (7/19). Anastomotic insufficiency and fatal mediastinal bleeding occurred in one patient each (5.3%). No cases of graft necrosis were observed, and no re-operations were necessary. In-hospital mortality was 15.8% (3/19), twice due to surgical complications (abdominal sepsis, mediastinal bleeding) and once due to pulmonary and cardiac failure. As a late complication, four patients (21.1%) developed anastomotic strictures that necessitated repeated endoscopic dilatation. Gastric tube interposition remains the method of choice for esophageal replacement. Colon interposition, however, is a valuable alternative with a good long-term function. Early mortality, however, remains a matter of serious concern.

Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon.

To describe the technique and results of an alternative colon interposition procedure in which the ascending and transverse colon is used as graft, but that still relies on the left colonic artery for blood supply. The standard procedure to obtain a left colon interposition graft requires ligation of the middle colic artery and mobilization of the left and right flexure. This approach carries a risk because preparation of the left flexure may damage arterial or venous collaterals located at this site that are crucial for graft perfusion. The authors modified the standard technique so that mobilization of the left flexure is no longer necessary. To obtain a colon interposition graft that is long enough, the ascending colon was included into the graft by ligating the middle and the right colic artery. The left colic artery remained the blood-supplying vessel. From January 1997 to June 1998, 15 patients underwent modified colon interposition with a cervical anastomosis (12 esophagectomies, 3 esophagogastrectomies). In all cases, intraoperative blood supply from the left colic artery to the proximal ascending colon was sufficient. After surgery, four major complications occurred (27%). Endoscopy demonstrated a vital graft in all patients. In one patient a leakage of the cervical anastomosis was observed. One patient died of herpes pneumonia. Postoperative artificial ventilation was required for an average of 2.8 +/- 4.6 days, the average intensive care unit stay was 6.9+/-4.5 days, and the average total hospital stay was 24.1 +/- 15.1 days. An intact left colic artery, including its collaterals at the splenic flexure, supplies sufficient blood to the proximal ascending colon after central ligation of the middle and right colic artery. Even without mobilization of the left flexure, a sufficient graft length can be obtained. Preliminary complication rates with the use of this technique for colon interposition are in the range of those found for the standard colon interposition technique. These modifications may represent an alternative to established procedures for creating a colon interposition graft.

Esophageal replacement by interposition of pedicled ascending colon flap supplied by the inferior mesenteric artery

Colon interposition for esophageal replacement is indicated in patients with benign esophageal disease, in patients who require an esophago gastrectomy for a potential cure and in patients in whom the stomach is no longer available for replacement because of preceding surgery. In 30 patients we performed colon interposition grafts for esophageal replacement using a modified technique. This technique includes ligation of the middle and right colic artery, thereby creating an interposition graft of the whole ascending colon which receives blood exclusively from the left colic artery. The main advantage of this procedure is the length of the interposition graft. Preparation of the left colic flexure is no longer required. Nineteen patients had an esophagectomy, 11 patients an esophago-gastrectomy. Minor complications in this unselected patient group occurred six times (20%), and major complications were observed in seven patients (23.3%). Frequency of anastomotic leakage amounted to 13.3%, hospital mortality to 10%. Frequency of postoperative complications and hospital mortality of patients in whom a modified colon interposition was done is comparable with published data of unselected patient groups, which had either a standard colon interposition graft for esophageal replacement or a gastric pull-through procedure.

Colon Interposition for Esophageal Replacement: Current Indications and Long-Term Function

Background. In contrast to the use of the stomach as an esophageal substitute, the use of the colon is becoming uncommon. Methods. From 1985 to 1995, 60 patients underwent colon interposition for esophageal cancer (n = 37), benign stricture (n = 13), iatrogenic fistula (n = 5), achalasia (n = 3), or necrosis of a previous substitute (n = 2). A long isoperistaltic conduit based on the left colonic artery could be used in 52 patients (86.7%). The surgical route used was through the esophageal bed in 38 patients (63.3%), under the sternum in 21 patients, and under the skin in 1 patient. Results. Colon interposition represented 18.5% of all operations performed for esophageal substitution during the study period. The choice of the colon resulted from an inadequate stomach in 33 cases (55%). The operative mortality rate was 8.3%. Seven patients (13.5%) required dilation of the esophagocolonic anastomosis. At last follow-up, 34 patients (65.4%) had no difficulty eating. Multivariate analysis identified the conduit position in the posterior mediastinum as the sole independent predictor of a good functional result ( p = 0.002). Conclusions. Colon interposition for esophageal substitution, usually performed when the stomach is not available, provides satisfactory function when placed in the esophageal bed.

One-stage esophagectomy and in situ colon interposition for esophageal replacement in children

Purpose: Esophageal replacement has been achieved using stomach, gastric tube, small intestine, and colon in various positions and in single or multiple stages. Long-term functional results are of prime importance in children with benign disease. The aim of this study is to present the immediate and long-term results of one-stage esophagectomy and in situ colon interposition esophageal replacement in children. Methods: Seven children have undergone onestage esophagectomy and in situ colon interposition esophageal replacement for stricture secondary to caustic ingestion (n = 4), battery ingestion (n = 2), and epidermolysis bullosa (n = 1). Technique: Via thoracoabdominal and cervical incisions, the transverse colon, isolated on the left colic artery, is pulled through the esophageal hiatus and normal esophageal bed into the neck at the time of simultaneous esophagectomy. The stomach is partially wrapped around the colon as an antireflux procedure and a pyloroplasty are performed. Results: There was no immediate postoperative morbidity or mortality. All patients were discharged taking a soft diet by mouth. There were no anastamotic leaks or strictures, and functional swallowing is excellent. Contrast studies show no dilation of the colon in the chest. Growth and development have been normal up to 7 years postoperatively. Conclusion: The one-stage esophagectomy and in situ colon interposition is an excellent technique for esophageal replacement in children. Continued evaluation of this technique will be necessary to confirm these preliminary results.

Arterial Anatomic Considerations in Colon Interposition for Esophageal Replacement

Little has been written regarding the arterial anatomy predictive of success following esophagectomy and colon interposition. Retrospective review. University teaching hospital. Twenty-five patients undergoing planned left colon interposition. Colon interposition was performed via an isoperistaltic left colon graft based on the ascending branch of the left colic artery. Five angiographic features were considered important to successful use of the left colon: (1) a patient inferior mesenteric artery, (2) a visible ascending branch of the left colic artery, (3) a well-defined anastomosis between the middle colic and left colic systems, (4) a single middle colic trunk prior to its division into right and left branches, and (5) a separate origin of the right colic artery. Venous drainage via a patent marginal vein, inferior mesenteric vein, and superior hemorrhoidal veins was preserved in all patients. Left colon interposition could be performed in 21 (84%) of 25 patients. Eighty percent of the patients (20/25) had at least four of the five criteria thought necessary for optimal graft perfusion. Three or fewer criteria were present in five patients, three of whom underwent gastric interposition. The inferior mesenteric artery was patent in all patients except one who required a right colon interposition. Ninety-two percent (23/25) demonstrated an adequate ascending left colic artery. The superior-inferior mesenteric artery anastomosis was seen in 52% (13/25). A single-trunked middle colic artery was present 80% (20/25) of the time. A single incidence of graft necrosis occurred secondary to venous insufficiency. Ninety-six percent of patients (24/25) were able to swallow without difficulty at the time of discharge from the hospital. Replacement of the esophagus with colon can be successful in over 80% of patients screened by angiographic criteria. Patients with an occluded or stenotic inferior mesenteric artery or variant middle colic arterial anatomy should undergo an alternate reconstruction.

Esophageal replacement by colon interposition

Between 1985 and 1993, 32 patients (24 male and 8 female) underwent colon interposition for replacement of the esophagus at the Mayo Clinic. Median age was 58.5 years (range, 1 to 79 years). The colon was used because of an inadequate stomach in 27 patients (84%) and as the conduit of choice in 5 (16%). Esophageal cancer was present in 15 patients (47%). The left colon was used in 20 patients (63%) and the right, in 12 (38%). The colon was placed substernally in 19 patients (59%) and in the esophageal bed in 13 (41%). The operative mortality was 9%; cause of death was ischemic necrosis of right colon conduits in 2 patients and adult respiratory distress syndrome in 1 patient. Major complications occurred in 4 additional patients and included ischemic colitis of a right colon conduit, Roux-en-Y limb obstruction, chylothorax, and an anastomotic leak. Follow-up was complete for all patients and ranged from 15 months to 7 years (median follow-up, 2.3 years). Eleven patients died during follow-up. The cause of death was metastatic esophageal cancer in 9 patients, myocardial infarction in 1 patient, and respiratory failure in 1 patient. At last follow-up, 26 of the 29 operative survivors had little or no difficulty eating. Two patients had dumping symptoms, and 1 patient had severe dysphagia. Seven patients required dilation of the esophagocolonic anastomosis. We conclude that colon interposition for esophageal replacement provides acceptable long-term function; however, early morbidity and mortality are considerable.

Esophageal Replacement with Colon in Children: Functional Results and Long-term Growth

Twenty-three children consecutively undergoing colon interposition for esophageal replacement were evaluated with barium swallows, clinical interviews, and questionnaires. Fourteen patients underwent colon interposition because of caustic burns of the esophagus only or of the hypopharynx and esophagus. Nine children had long-segment esophageal atresia or esophageal atresia with tracheoesophageal fistula and are included in our operative group. The mean follow-up was 12.8 years for all patients. Strictures, leaks, and colon ischemia at the proximal anastomosis represent the major morbidity for the operative procedure. Analysis of growth charts reveals that patients who ingest lye tend to remain in the 50th percentile after colon transplant, while patients with esophageal atresia or tracheoesophageal fistula who had been in the 12th percentile preoperatively improved to the 33rd percentile after successful transplantation. Radiographic examinations, functional results, and growth curves demonstrated excellent results in 20 patients. Although the choice of a conduit for esophageal replacement is controversial, the surgeon can expect good long-term function and growth with the use of colon in children.