Colon Interposition Research Articles

2054 Crohn’s Colitis Creeping Into a Colonic Conduit

INTRODUCTION: Crohn’s disease is an inflammatory bowel disease (IBD) that can affect any part of the digestive tract and may present with diarrhea, abdominal pain, and/or weight loss. A subset of patients with Crohn's disease are asymptomatic and are diagnosed endoscopically before the onset of symptoms. Here, we report an unusual presentation of Crohn’s disease which was diagnosed following postoperative complications from a sleeve gastrectomy. CASE DESCRIPTION/METHODS: A 46-year-old obese but otherwise healthy female underwent an elective laparoscopic sleeve gastrectomy for weight loss. She had an uneventful perioperative course, however returned one week post op with severe abdominal pain and was found to have staple line dehiscence, esophageal leak and mediastinal fistula requiring multiple repairs, including a failed roux-en-Y esophagojejunostomy and eventually required gastrectomy with esophageal stump. She was transferred to our facility for surgical consultation and underwent right thoracotomy for persistent esophageal leak requiring esophagostomy revision and creation of a spit fistula. Given esophageal discontinuity, a reconstruction with colonic interposition was suggested. In preparation, the patient underwent a colonoscopy with surprising findings of cecal, proximal ascending, and distal sigmoid colonic inflammation [Figure 1]. Biopsies revealed chronic active colitis with cryptitis, suggestive of Crohn’s disease. She denied any symptoms preoperatively and has no family history of IBD. Labs showed elevated calprotectin at 222 ug/g and mild leukocytosis. Magnetic resonance enterography was unremarkable. She was started on Infliximab 5 mg/kg at 0, 2, 6, then every 8 weeks with normalization of calprotectin after 3 doses. She eventually underwent takedown of her spit fistula and jejunal interposition to re-establish esophageal continuity [Figure 2]. DISCUSSION: This case raises the question of whether the postoperative complication was caused by underlying upper gastrointestinal tract Crohn’s disease. Conversely, it is possible the patient’s numerous gastrointestinal procedures triggered colonic mucosal disease in this susceptible individual. Although this presentation is rare, if similar presentations occur in the future, we may need to consider a role for either preoperative endoscopy or screening with inflammatory markers prior to elective bariatric procedures as this diagnosis could have potentially harmful consequences in the post-operative period.

Colon interposition in the treatment of corrosive esophageal strictures: 100 patients in seven years

Background: The purpose of this study is to represent the change in our concept of principles and techniques of esophagocoloplasty (midcolon esophagocoloplasty) with repetitive performance of the operation and approach of early surgical intervention (within 4-6 month of corrosive ingestion) in place of repetitive trials of dilatations and medical management, provides early better quality of life with lesser period of suffering and saving expenditure of treatment.Methods: This retrospective study comprises of consecutive 100 patients operated for colon interposition for corrosive stricture of esophagus done at two university linked government teaching hospitals during March 2011 to March 2018. Out of 100 patients, 77 female and 23 male (3:1), mean age 30.6 years (range from 21 to 47 years), mean hospital stay was 14.5 days (range 10 to 25 days) and mean operative duration was 4.5 hours (range 2.5 to 7 hours).Results: The 30 day in hospital mortality rate was 9%. There were 14 instances of leak at the esophagocolic anastomosis (14%), graft necrosis occurred in 01 patient, 08 patients (8%) developed stenosis at the esophagocolic anastomosis. More than 90% patients (n=77) had ‘Good’ result, 06 patients had ‘Fair’ and 02 had ‘Poor’ result.Conclusions: Midcolon graft is a solution for confusion in judgment of adequate length of graft and offer uniformity in procedure with effectively lesser operative time. Early (4-6 months after ingestion) operative intervention is advantageous to patients suffering from crippling dysphagia with repeated admission and expenditure from multiple endoscopic dilatations.

Barium swallow sequence after colon interposition as a first stage in Patient 4

Barium swallow sequence after colon interposition as a first stage in Patient 4

Preserving the native esophagus in caustic esophageal stricture using novel strategies including fundoplication, resection and myotomy

Esophageal stricture is a well-known complication following caustic ingestion. Esophageal dilatation is the commonest approach to treat this complication. However, patients with a refractory esophageal stricture will require surgical interventions such as esophagectomy with gastric pull up or other forms of esophageal replacement with colonic or small intestinal interposition. We describe two patients with caustic-induced esophageal stricture managed successfully by using novel surgical strategies to preserve the native esophagus. One child underwent resection of the strictures and the subsequent esophageal gap was bridged by lengthening the esophagus using a Livaditis myotomy technique. The other had a fundoplication to manage her reflux which was complicating her clinical course, followed by subsequent myotomy to manage her residual upper esophageal stricture. Patients with short-segment, post-caustic esophageal stricture may be amenable to less drastic surgical procedures using myotomy, thereby preserving the native esophagus, instead of requiring esophageal replacement by another gastrointestinal conduit.

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.

DOZ047.36: Thoracoscopic esophageal internal axial traction for long- gap esophageal atresia

Abstract Aim of the Study Long-gap esophageal atresia (LGEA) remains a surgical challenge. This study aimed to report the results of thoracoscopic esophageal axial internal traction in LGEA. Methods This multicenter observational study included retrospectively neonates who underwent primary thoracoscopic esophageal axial internal traction for LGEA between June 2017 and July 2018. LGEA was defined as the technical impossibility to perform a primary esophageal anastomosis. The Ethical Review Board of our institution approved the study. Main Results Eight neonates were included with a median gestational age at birth of 35 weeks [25; 37] and a median birth weight of 2266 g [890; 3800], 6 types I and 2 types II according to Ladd's classification. Initial median gap between 2 esophageal ends was 5 vertebral bodies [4.5; 7]. Internal traction was performed at a median age of 5 weeks of life [1; 17] with a median operative time of 87 minutes. Four patients required at least 2 internal traction procedures. After a mean traction time of 1.5 weeks [1; 13.5], esophageal anastomosis was successfully performed in 7 patients (5 thoracoscopies, 2 thoracotomies) with a median operative time of 165 minutes. One patient needed a colonic interposition. Five of these 7 patients required an esophageal endoscopic dilatation (median number: 4 [2; 6]). Median follow-up was 9.75 months [3; 16]. Conclusions Thoracoscopic esophageal axial internal traction for LGEA was a safe and feasible procedure that allowed an esophageal anastomosis in 7 of the 8 patients. Improvement of the procedure requires setting a common protocol concerning the timing of the first internal axial traction and the duration of traction before considering esophageal anastomosis.

DOZ047.93: Thoracoscopic multistage repair of long-gap esophageal atresia using internal traction suture technique—evolution of the method

Abstract Treatment of long-gap esophageal atresia poses a great challenge for a surgeon. A new multistage thoracoscopic repair of long-gap esophageal atresia using internal traction technique was developed that evolved with time and growing experience. The goal of this study is to present the changes in the strategy and important technical aspects of the operative method based on a retrospective analysis of performed surgeries. Methods and Materials Thirty-five cases of newborns with long-gap esophageal atresia (type A-26 cases and B-9 cases exclusively) were operated thoracoscopically between 2008 and 2019 using internal traction technique in different pediatric surgery centers (Poland–28, Czech–1, Ukraine–1, Switzerland–2, Egypt–2, Russia–1). The idea of the internal traction technique was to place the suture between thoracoscopically mobilized esophageal pouches and keep a static tension between them for a period of time. Patients were operated on as early as it was possible after birth. Results Of the 35 newborns operated on using internal traction 2 patients died before the final stage from not surgically-related causes. Two patients had complications that required neck fistula and had later Collis–Nissen and colon interposition, respectively. One case is awaiting the final procedure. For 31 cases the final esophageal anastomosis was completed in two stages–16 cases, three stages–9, four stages–2, five stages–2, and six stages–1. At the beginning the time between stages was planned for 4 weeks (for some cases it was even longer) and it was shortened for the last three cases to 5 days. It allowed avoiding gastrostomy in two cases. The internal traction was modified from using two traction loops to one traction loop with two slipping knots on each branch of the loop. The clips were applied transversely through the tip of each pouch and part of the traction loop to prevent disruption and pouch perforation. It also allowed increasing of the created static traction force. Conclusion Results of the study may indicate that in a majority of long-gap esophageal atresia it is possible to preserve the native esophagus by a thoracoscopic approach using an internal traction suture technique. Shortened time between stages allowed completion of the final esophageal anastomosis with gastrostomy avoidance.

DOZ047.10: Acquired tracheoesophageal fistulas after esophageal atresia repair

Abstract Aim Tracheoesophageal fistula (TEF) recurrence is a frequent but challenging complication after esophageal atresia (EA) repair. Although most recurrent TEFs are commonly seen at the original fistula site, long new fistulas localized differently from the congenital TEF sites are called acquired TEFs (acq-TEF). Acq-TEFs are long new fistulas with unusual locations, including fistulas from the esophagus to anywhere on the airway such as the bronchus, trachea, or lung parenchyma. Herein, we aimed to discuss diagnostic and management challenges in different localizations of acquired TEF. Methods The medical records of patients admitted with acq-TEF in the last 5 years were retrospectively evaluated. The demographic features, admission complaints, physical and radiological findings, TEF localization and management were recorded. Results From 16 TEF recurrences, 4 TEFs were acquired fistulas. Admission age ranged from 3 months to 8 years. The female/male ratio was 2/2. The complaints were recurrent respiratory tract infections, choking, and coughing in all cases. Three of the cases had proximal EA + distal TEF; the other case was isolated EA. Primary repair was performed in 3 cases and colon interposition was performed in 1 case. Anastomotic leak and mediastinitis after initial operation were seen in 3 cases. Three acq-TEFs were to the cervical part of the trachea, one was from the colon conduit to the trachea, one was to right bronchus by passing through the intrathoracic abscess cavity, and one was directly to the right bronchus. In all cases the TEFs were shown in sine-esophagography and confirmed with bronchoscopy during operation. TEF was repaired by thoracotomy incision in 3 cases and callor incision in 1 case. The second acq-TEF of Case 1 was closed spontaneously. Muscle flap or pleura was placed between suture lines in all cases. All TEFs were confirmed to be closed with esophagography in all cases at postoperative period. Conclusion Acq-TEF is mostly seen secondary to local or diffuse mediastinitis. Besides its classical location of TEF, acq-TEFs may be seen at unusual rare localizations such as esophagus to right bronchus, esophagus to abscess cavity, and conduit to trachea. They cause both diagnostic and surgical challenge. Clinicians should be aware of these different localizations of Acq-TEFs in order to evaluate and manage these patients more comprehensively.

Gastric tube cancer after esophagectomy for cancer: a systematic review.

Gastric conduit used for reconstruction after esophagectomy for cancer has the potential to develop a metachronous neoplasm known as gastric tube cancer (GTC). The aim of this study was to review literature and evaluate outcomes and possible treatment strategies for GTC. A comprehensive systematic literature search was conducted using PubMed, EMBASE, Scopus, and the Cochrane Library Central Register of Controlled Trials. No restriction was set for the type of publication, number, age, or sex of the patients. The search was limited to articles in English. Characteristics of esophageal cancer (EC) and its treatment and GTC and its treatment were analyzed. A total of 28 studies were analyzed, 12 retrospective analyses and 16 case reports, involving 229 patients with 250 GTCs in total. The majority of ECs (88.2%) were squamous cell carcinomas. In 120 patients (52.4%) a posterior mediastinal reconstructive route was used when esophagectomy was performed. The mean interval between esophagectomy and diagnosis of GTC was 55.8 months, with a median interval of 56.8 months (4-236 months). One hundred and twenty-four GTCs (49.6%) were located in the lower part of the gastric tube. One hundred and forty patients were endoscopically treated. Eighty-five patients underwent surgery. Thirty-six total gastrectomies with lymphadenectomy with colon or jejunal interposition were performed. Forty-three subtotal gastrectomies and 6 wedge resections were performed. The main reported postoperative complications were anastomotic leak, vocal cord palsy, and respiratory failure. Twenty-five patients were treated with palliative chemotherapy. Three-year survival rates were 69.3% for endoscopically treated patients, 58.8% for surgically resected patients, and 4% for patients who underwent palliative treatment. The feasibility of endoscopic resections in patients diagnosed with superficial GTC has been reported. Surgical treatment represented the preferred treatment method in operable patients with locally invasive tumor. Patients treated with conservative therapy have a scarce prognosis. The development of GTC should be taken into consideration during the extended follow-up of patients undergoing esophagectomy for cancer. Total gastrectomypluslymphadenectomy should be considered the preferred treatment modality in operable patients with locally invasive tumor, when endoscopy is contraindicated. Long-term yearly endoscopic follow-up is recommended.

Microsurgical options after the failure of left colon interposition graft in esophagogastric reconstruction.

Colon interposition is commonly used for esophageal reconstruction in patients with a previous gastrectomy. However, when colon interposition fails and alternative reconstruction is required, there are few options for reconstructing the long segment from the esophagus to the stomach. Here, we report on cases of esophagogastric reconstruction with limited alternative options after the failure of transverse and left colon interposition. In these cases, reconstruction was performed using two different microvascular methods: double-pedicle jejunal free flap and supercharged ileocolic interposition graft.

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

The Difficult Esophageal Conduit.

A variety of esophageal diseases are treated with esophagectomy, from benign to esophageal cancer. Careful attention must be given to management of the difficult conduit, including patients who have had prior gastric surgery and other procedures, patients with conditions such as diabetic gastroparesis, which can affect the stomach as a future usable conduit, and patients who have an absent or unusable stomach. In these situations, consideration should be raised for the use of alternative conduits, including jejunal and colonic interposition conduits. The esophageal surgeon should also be adept at management of intraoperative difficulties with the conduit.

Esophageal Replacement in Children: A 10-Year, Single-Center Experience

Objective: Various esophageal replacement grafts have been used in children, although none can equal the native esophagus. The purpose of this study was to review the complications and outcomes associated with using different techniques in a single institute. Methods: A retrospective medical record review was conducted from 2006 to 2016. Patient demographics, perioperative clinical courses, complications and long-term outcomes were reported as percentages and categorized according to the surgical procedure performed. Results: A total of 15 children underwent esophageal replacement procedures, comprising 7 (47%) isoperistaltic gastric tubes, 3 (20%) colonic interpositions, 3 (20%) gastric transpositions and 2 (13%) reversed gastric tubes. Indications for esophageal replacement included long-gap esophageal atresia (5; 33%), esophageal atresia with severe postoperative complications (6; 40%), and caustic injury (4; 27%).The mean age of patients was 2.9 years (range: 0.2–15 years). The average follow-up duration was 3.6 years (range: 0.4–8 years). There was no perioperative mortality and no graft loss in any group. The long-term outcomes were acceptable, with no late stricture. Eighty-six percent of the patients in the isoperistaltic gastric tube group and all patients in the other procedural groups achieved full oral feeding. Nevertheless, the patients had various degrees of malnutrition. Conclusion: Esophageal replacement remains a major challenge in children. Our experience indicates that children can be safely operated on using any of these methods, with acceptable outcomes and no deaths. Nevertheless, the long-term consequences and complications should be monitored throughout adulthood.

AB159. 173. Colonic interposition for oesophageal reconstruction: a case series

Background: Colonic interposition is rarely used as a first line option for oesophageal reconstruction however it has been shown to be a durable, safe option. It involves three anastomoses therefore the operating time is longer and the potential for post-operative complications is higher.

Retrograde endoscopic dilatation for difficult caustic esophageal strictures: Feasibility and effectiveness

BackgroundDifficult caustic esophageal strictures may need a more sophisticated dilatation technique before referring for esophageal replacement surgery. Patients & methodRetrospective review of caustic esophageal strictures managed at our center between January 2010 and June 2018 was done. Twenty two patients labeled as undilatable strictures were enrolled. These patients had another trial for endoscopic dilatation using retrograde approach. ResultsAmong these 22 patients, 5 patients could be dilated by antegrade approach. Seventeen patients had a trial of retrograde dilatation after failed antegrade endoscopy. Retrograde dilatation was successful in 14 patients (82%). Nasogastric tube was left following dilatation in 4 patients to facilitate next sessions. Collectively, 19 out of the 22 patients could have their esophagus dilated in the first instance (86%). Among retrograde dilated patients; eight patients succeeded to retain their native esophagus (57%), two patients are still on dilatation with marked improvement (14%), and three patients underwent colon interposition owing to refractory stricture despite frequent dilatations. ConclusionEvery attempt should be tried to preserve the native esophagus. Retrograde endoscopic dilatation is a valuable alternative for undilatable stricture before referring the patient for replacement surgery. Level of evidenceThis is a case series with no comparison group (level IV).

How to Deal with Graft Ischemia While Performing Colon Interposition for Esophageal Reconstruction

The colon has become an effective and reliable graft for esophageal reconstruction. The in-depth knowledge of colon vascular anatomy is very essential to select an optimal graft. However, the colon interposition remains a surgical procedure associated with a high risk of graft ischemia. The graft ischemia is a dreaded complication which can impact the graft viability and the surgical outcomes. Various investigations have been used to assess graft blood supply and confirm the diagnosis of ischemia during colon interposition .Several strategies have been described to deal with this complication when it occurs intraoperatively. According to the patient conditions, the surgeon should be able to define the appropriate treatment strategy to deal with this complication. As colon interposition is a high-risk procedure, the preoperative identification of the risk factors, optimization of patient condition, and meticulous operative technique are required to reduce the risk of graft ischemia while selecting a colon graft for esophageal reconstruction.

Surgical repair of substernal colonic interposition proximal anastomotic stricture

A 24-year-old male had undergone substernal right colon interposition for benign esophageal stricture following ingestion of a corrosive chemical 6 years earlier. The operation was complicated by postoperative anastomotic leak which though successfully managed conservatively, resulted in dysphagia 1 year later. The patient was noncompliant with follow-up visits despite worsening symptoms and presented 5 years later with complete dysphagia. Barium esophagogram revealed severe cervical anastomotic stricture. He subsequently underwent an uneventful sternotomy and revision of the anastomotic stricture with relief of his dysphagia. Though rare, this procedure can be safely performed without injury to the substernal colon by carefully freeing any underlying adhesions prior to inserting the sternal saw.

Goal-directed therapy during transthoracic oesophageal resection does not improve outcome: Randomised controlled trial.

Goal-directed therapy (GDT) is expected to be of highest benefit in high-risk surgery. Therefore, GDT is recommended during oesophageal resection, which carries a high risk of postoperative complications. The aim of this study was to confirm the hypothesis that GDT during oesophageal resection improves outcome compared with standard care. A randomised controlled study. Two Swedish university hospitals, between October 2011 and October 2015. Sixty-four patients scheduled for elective transthoracic oesophageal resection were randomised. Exclusion criteria included colonic interposition and significant aortic or mitral valve insufficiency. A three-step GDT protocol included stroke volume optimisation using colloid boluses as assessed by pulse-contour analysis, dobutamine infusion if cardiac index was below 2.5 l min m and norepinephrine infusion if mean arterial blood pressure was below 65 mmHg. The incidence of complications per patient at 5 and 30 days postoperatively as assessed using a predefined list. Fifty-nine patients were available for analysis. Patients in the intervention group received more colloid fluid (2190 ± 875 vs. 1596 ± 759 ml, P < 0.01) and dobutamine more frequently (27/30 vs. 9/29, P < 0.01). The median [interquartile range, IQR] incidence of complications per patient 5 days after surgery was 2 [0 to 3] in the intervention group and 1 [0 to 2] in the control group (P = 0.10), and after 30 days 4 [2 to 6] in the intervention group and 2 [1 to 4] in the control group (P = 0.10). Goal-directed therapy during oesophageal resection did not result in a reduction of the incidence of postoperative complications. Clinicaltrials.gov identifier: NCT01416077.

Quality of life of patients with a colonic interposition postoesophagectomy.

After oesophagectomy, stomach grafts are most frequently used to restore intestinal continuity. Less frequently, a colonic graft is used. There is quite a large body of literature addressing the functional outcome after gastric pull-up, but little is known about the functional results of colonic interposition (CI). The aim of this study was to assess the short-term outcomes and the long-term quality of life and function of the CI postoesophagectomy. Between 2002 and 2016, we retrospectively collected data on 80 patients with CI from personal health records at the Ghent University hospital. We prospectively compared the European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30, EORTC QLQ-OG25 and Swallowing Quality of Life (SWAL-QOL) questionnaire scores to the healthy reference group and the gastric tube (GT) group. The 30-day mortality rate was 5%. Anastomotic leakage occurred in 37.5% and stenosis in 20% of the patients. The median overall survival of all patients was 33.9 months (95% confidence interval 8.3-59.4). The mean general health score of the CI patients was less than the healthy reference group but comparable to the GT group (CI = 62.1 vs healthy reference group = 71.2 vs GT = 60). Fifty percent of the patients reported their health as good and 15% as very good. The mean functional results with a CI were better than with a GT. Compared to GT patients, CI patients had less dyspnoea, reflux and dysphagia, but they reported more food selection, diarrhoea and weight loss. Despite the high complication rate, the severity of the disease and the demanding operation, patients perceived themselves as being in good health and reported very good long-term functionality after CI. B670201630635.