Colonic Reconstruction Research Articles

Minimally invasive resection of synchronous thoracic esophageal and gastric carcinomas followed by reconstruction: a case report.

We report on a case of synchronous carcinomas of the esophagus and stomach. A 68-year-old man was referred to our hospital for an abnormality found during his medical examination. Further evaluation revealed squamous cell carcinoma in the thoracic lower esophagus and gastric adenocarcinoma located in the middle third of the stomach. Thoracoscopic esophagectomy in the prone position (TSEP), laparoscopic total gastrectomy (LTG) with three-field lymph node dissection, and laparoscopically assisted colon reconstruction (LACR) were performed. The patient did not have any major postoperative complications. His pathological examination revealed no metastases in 56 harvested lymph nodes and no residual tumor. He was followed up for 30 months without recurrence. To our knowledge, this is the first report of esophageal and gastric synchronous carcinomas that were successfully treated with a combination of TSEP, LTG, and LACR. These operations may be a feasible and appropriate treatment for this disease.

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

Vasopressor use after initial damage control laparotomy increases risk for anastomotic disruption in the management of destructive colon injuries

BackgroundManagement of destructive colon injuries during damage control (DC) laparotomy is debated. The authors reviewed a single institution's experience with destructive colon injuries to identify risk factors for anastomotic failure after colon reconstruction. MethodsThe authors identified all trauma patients sustaining destructive colon injuries between 2002 and 2011 from their medical center's trauma registry. Anastomotic leak was defined as suture or staple line disruption or enteral fistula formation. ResultsOf 171 identified patients, 68 had DC procedures, 41 (60%) had subsequent anastomoses performed during the same hospitalization, and 27 (40%) were diverted. The colon anastomotic leak rate in patients who underwent DC laparotomy was higher than in patients who were reconstructed at the primary operation in a non-DC setting (17% vs 6%, P = .09). The use of vasopressors after the initial DC operation more than quadrupled the leak rate to 50% (P = .02). ConclusionsColonic anastomotic disruptions yield deadly consequences, and diversion rather than anastomosis should be used in patients who require vasopressor support after the initial DC procedure.

Laparoscopic Hemicolectomy in Ascending Colon Cancer with Situs Inversus Totalis

Introduction: Situs inversus totalis (SIT), occurring at a frequency of 1:5000–1:10,000 live births,1 is characterized by a complete right-to-left transposition of the thoracic and abdominal organs. Only five cases of laparoscopic colon surgery in an SIT patient have been reported. The present case describes a laparoscopic hemicolectomy necessitated by ascending colon cancer in a patient with SIT. Patient and Methods: A 54-year-old woman with ascending colon cancer was referred to our hospital. Preoperative chest radiography showed dextrocardia, and computed tomography showed complete transposition of the abdominal viscera, confirming a diagnosis of SIT. The patient, free of distant metastasis, underwent laparoscopic right hemicolectomy and radical lymphadenectomy, performed by a surgeon experienced in laparoscopic colectomies. After inducing general anesthesia, the patient was placed in a modified lithotomy position, with the operator and scopist situated on the patient's right and the first assistant on the patient's left, similar to the positioning used in laparoscopic anterior resections. A 10-mm umbilicus trocar was inserted for the camera, and 5-mm trocars were placed in the right and left iliac fossa and subcostal areas, as working ports. Trocars were inserted symmetrically, we usually use this trocar system in Rt. hemicolectomy. The ascending colon, located on left side of patient, was mobilized along with the tumor, and the ileocolic vessels and right colic artery were identified and ligated. Radical lymphadenectomy was performed after ligation of the root of the middle colic artery and the right branch of middle colic artery. The umbilical wound was extended by ∼5 cm to allow for extracorporeal anastomosis and removal of the tumor; colon reconstruction was performed using a double-stapling technique. Results and Conclusions: The operation time was 120 minutes, with minimal blood loss. The resected tumor was a 1.5×1.2-cm Bormann type II moderately differentiated adenocarcinoma. The depth of the tumor's invasion into the submucosa was classified as pT1; no lymph node metastasis or angiolymphatic invasion was observed. The patient, discharged 7 days after surgery, did not receive postoperative adjuvant chemotherapy, and was free of complications and evidence of recurrence at her 2-year follow-up examination. Previous reports on cases of laparoscopic surgery in SIT patients1–3,11–14 have described the technical difficulties associated with the abnormal anatomy. In the present case, the surgical team needed to understand the modified vessel anatomy and orientation to avoid confusing the right colic artery with the ileocolic artery. Meticulous preoperative planning, including the selection of proper locations for the trocars, positioning of surgical personnel, and selection of a well-experienced surgeon, was essential for the successful outcome. The authors did not receive any grant or financial support to perform this study. Runtime of video: 7 mins 13 secs

Pedunculated Gastric Conduit Interposition with Duodenal Transection after Salvage Esophagectomy: An Option for Increasing the Flexibility of the Gastric Conduit

A gastric conduit is the first choice for esophageal reconstruction because of its robust blood supply and the need for only a single anastomosis to re-establish continuity with good results. In cases where the stomach is unavailable, a colon conduit is preferentially selected as an esophageal substitute. However, a colon reconstruction is more highly nvasive compared with a gastric conduit reconstruction. alvage esophagectomy after definitive chemoradiotherapy s associated with high morbidity and mortality rates. Gasric conduit necrosis is one of the most critical complicaions after salvage esophagectomy, potentially leading to n-hospital death. Gastric conduit necrosis can occur when he upper part of the stomach is included in the radiation rea of definitive radiotherapy; a damaged stomach with dematous changes and/or redness should be resected (Fig. ). In such cases, we have previously performed free-jejunal raft interposition or used a colon conduit to avoid anasomosis of the damaged stomach to the cervical esophagus. ere, we present our experience with duodenal transecion, which preserves the right gastroepiploic vessels, enbling safe anastomosis at the lower level of the gastric onduit, where the effect of definitive radiation therapy is bsent. Given the non-necessity for microvascular anastoosis, this method might represent a suitable minimally nvasive technique that minimizes organ sacrifice in this urgical setting.

Indirect Colonic Injury After Military Wounding: A Case Series

Colonic trauma in wartime most commonly results from direct injury along the path of a penetrating missile. Rarely, the colon may be injured by primary blast effect or by propagation of energy by the missile, remote from the track of the projectile. This article describes the clinical presentation and operative findings in five patients who sustained high energy-transfer gunshot wounds (GSWs) or fragmentation injuries from blast who were found to have sustained colonic injuries anatomically remote from the missile track/s. Military surgeons should be aware of the phenomenon of indirect injury to the colon after high-energy transfer GSW and blast injury. A high index of suspicion should be maintained and cross-sectional imaging used where feasible. Primary colonic reconstruction was used safely in these patients with indirect colonic injuries.

Colonic volvulus detected by CT scan in a case with mental retardation and prune belly syndrome

Colonic volvulus is a rare disease in children. Delayed diagnosis of the condition can often be fatal, especially in pediatric patients with mental retardation. We herein present the case of a female pediatric patient with colonic volvulus, prune belly syndrome, and mental retardation. Preoperative CT scans showed the characteristic signs of this disease. The volvulus occurred in the proximal colon of the colostomy. The release of the colonic volvulus and reconstruction of the colostomy were performed without the resection of the ischemic colon. The postoperative clinical course was uneventful.

Management of synchronous tumours of the oesophagus and pancreatic head: a novel approach

Synchronous tumours of the oesophagus and pancreatic head are very rare. This report describes a unique case of an adenocarcinoma of the distal oesophagus and a neuroendocrine tumour of the pancreatic head diagnosed synchronously but successfully managed metachronously. Initially, the patient underwent an oesophagectomy, with a colonic reconstruction following some months later by pylorus-preserving pancreaticoduodenectomy. A staged resection was performed after a review of the literature suggested increased morbidity with synchronous major abdominal operations.

Functional outcome of gastrointestinal tract and quality of life after esophageal reconstruction of esophagus cancer

Background/Aim:Information about functional outcome and quality of life after esophagectomy and esophageal reconstruction (ER) for the treatment of esophageal cancer, as evaluated by the patients themselves is limited. We aimed to study the post-surgical outcome of such patients to detect for the development of any complications that may arise from the surgery as well as to evaluate their quality of life following the surgery.Methods:From 1993 to 2003, 240 patients with stage I, II, or III esophageal carcinoma underwent esophagectomy at Razi Teaching Hospital located in the north of Iran. Of these, 192 patients filled out a questionnaire during a 2-year period (ranging from 12 to 48 months after surgical reconstruction). Among them, there were 134 men (69%) and 58 women (31%), and the mean age at the time of ER was 48 years (ranging from 22 to 75 years). Transhiatal esophagectomy, extended esophagectomy (three field operation), and Ivor-Lewis resection were done in 142 (73.95%), 30 (15.62%), and 20 patients (10.42%), respectively. Intestinal continuity after esophageal resection was established with stomach in 154 patients (80%), colon in 28 patients (14%), and small bowel in 10 patients (5.2%). Cervical anastomosis was established in 172 patients (89.6%), while intrathoracic anastomosis was performed in 20 patients (10.4%).Results:After ER, 66 patients (34.4%) suffered from dysphagia to solids and 50 patients (26%) required at least one or three postoperative dilatations for alleviation of symptoms. Gastroesophageal reflux was seen in 32 patients (16.66%) and was more common in thoracic anastomosis patients than in cervical anastomosis patients. Heartburn was present in 33 cases (17%), 30 of whom required medication (37%). The number of meals per day was three to four in 116 patients (60%), more than four in 51 patients (29%), and less than three in 19 patients (9.82%). The number of bowel movement per day increased in 52 patients (27%), decreased in 60 cases (31%), and unchanged in 80 patients (41%). Weight gain was reported by 38 patients (19.8%), and weight loss was reported by 50 patients (26%). No change in weight occurred in 100 patients (52%). Overall satisfaction was excellent in 29 patients (15%). Overall quality of life (work, pain-relief, vitality, and emotional status) was lower than in general population. Age, sex, and stage of cancer did not affect the functional outcome but affected the quality of life. Also patients who received cervical anastomosis and ER with colon had significantly fewer reflux symptoms. Most of the patients with colon reconstruction gained weight.Conclusions:Self-assessment of postoperative ER by the patients after esophagectomy for malignant disease demonstrates that undesirable symptoms are frequently present at short- and long-term follow-ups. Short- and long-term functional outcome is affected by the type of reconstruction after esophagectomy. Results of this study suggest that colon graft in ER is significantly advantageous compared with other methods because of the ability of patients to gain weight and avoid developing postoperative reflux.

Substernal long segment left colon interposition for oesophageal replacement

Long segments of colon, transposed on a vascular pedicle, have been used for oesophageal substitution for a long time. However the techniques employed for colonic reconstruction remain debated. We describe our substernal long segment replacement technique and emphasise several key aspects which are important in management of these patients. Optimising nutritional status and pulmonary function remain important aspects. Thymectomy allows room for the colonic segment preventing venous congestion. These patients are best managed in specialist units incorporating a multidisciplinary approach with good intensive care and radiological support.

Long-term and short-term evaluation of esophageal reconstruction using the colon or the jejunum in esophageal cancer patients after gastrectomy

For esophageal cancer patients, the gastric tube is the first choice as an esophageal substitute, with the colon or the jejunum being used when the stomach cannot be used. We retrospectively compared these two methods from the viewpoint of peri-operative complications and long-term bodyweight alteration. From 1998 to 2005 53 patients who had undergone subtotal esophagectomy due to thoracic esophageal cancers were given reconstruction with the colon (28 cases) or the jejunum (25 cases). Both intestines were reconstructed via the subcutaneous route and were anastomosed to the internal mammalian artery and vein for a supercharged blood supply. There was no difference in operating time and blood loss. Compared with the colon reconstruction group, the hospital stay of the jejunum reconstruction group was significantly shorter (65 days vs 45 days, P = 0.0120) and the incidence of anastomotic leakage tended to be less (13 cases, 46%vs 6 cases, 24%, P = 0.1507), while other operative morbidity did not differ between the two groups. Bodyweight loss, which is a serious postoperative sequela after esophagectomy, was less in the jejunum group than in the colon group, showing a significant difference at 12 months after surgery. Our retrospective study revealed the jejunum to be superior to the colon for the reconstruction after esophagectomy along with gastrectomy, with respect to anastomotic leakage and bodyweight loss. The next step will be to conduct a prospective large cohort study.

Surgical management of Crohn’s colitis

Crohn's disease in childhood is changing. The incidence is increasing, colonic disease is becoming more prevalent in younger children, and colon reconstruction is more acceptable. Genetic phenotypes are influencing decisions for surgery, and targeted immunotherapy has renewed hope for more durable remissions following less extensive resections. The tasks facing the surgeon evaluating a child with Crohn's colitis include confirming the specific diagnostic subtype and selecting the correct procedure. This chapter will review the unique aspects of pediatric Crohn's colitis and the increased complexity of surgical choice for this most challenging presentation. Recent success with less extensive surgery offers renewed hope for children with intractable colonic disease.

Analysis of the factors related to the decision of restoring intestinal continuity after Hartmann’s procedure

Hartmann's operation is widely used for the surgical treatment of complicated left colonic disease. However, many patients never undergo reanastomosis. This study analyzes the factors related to the decision of restoring intestinal continuity. Between 1997 and 2004, 162 patients underwent Hartmann's operation in our institution. Age, sex, anesthetic risk evaluation (ASA score), underlying disorder (neoplastic vs non-neoplastic), prevalence of colonic reconstruction, as well as postoperative length of hospital stay, perioperative mortality and complications due to the latter procedure were analyzed. Long-term survival was also recorded. Patients' mean age was 68.7 years (SD +/- 14.9); 104 were men (64.2%) and 58 were women (35.8%). Hartmann's operation mortality was 20.4%. Forty-two colonic continuity restorations were performed (25.9%). Mean time until reconstruction procedure was 13.3 months. There were no deaths (mortality 0%), but 23 cases suffered complications (54.8%). No suture dehiscence was observed. Estimated probability of being alive 1, 3, and 5 years after the initial operation was 64.1, 50.4, and 44.3%, respectively. Significant univariate predictors of reversal were male sex (p = 0.003), non-neoplastic disorder (p = 0.004), younger age (p = 0.001) and lower anesthetic risk (p = 0.009). In the multivariate analysis, independent predictive factors were age (OR: 0.94; 95% CI: 0.91-0.98), non-neoplastic disorder (OR: 0.16; 95% CI: 0.05-0.45), and lower anesthetic risk (OR: 0.22; 95% CI: 0.08-0.58). Hartmann's procedure implies a high mortality and a low percentage of restoration of intestinal continuity. In selected patients, closure of Hartmann's colostomy is a safe procedure, but has a significant morbidity.

Vaginal reconstruction with sigmoid colon in vaginal agenesis

This study was conducted to evaluate the anatomical and functional results of sigmoid colon vaginoplasty. From June 2000 to June 2005, 26 patients with congenital vaginal agenesis were evaluated and treated with sigmoid colon reconstruction at Ain Shams University Maternity Hospital as a primary procedure in 17 patients and a secondary procedure in 9 patients after previous failed Abbe-McIndoe vaginoplasty elsewhere. The anatomical results were good in 22 patients, while 3 patients suffered from introital stenosis. Two of them were treated successfully by dilatation while one required Z-plasty. Eight patients were lost to follow-up and only ten patients are currently sexually active as the rest were divorced or remained unmarried. Of the sexually active patients, 8 (80%) had satisfactory intercourse whereas 2 (20%) complained of dyspareunia. Sigmoid colon vaginoplasty has satisfactory long-term anatomical and functional results and should be considered as primary option for the treatment of vaginal agenesis.

Colonic interposition and supercharge for esophageal reconstruction

We evaluated the techniques of colonic interposition and supercharge for esophageal reconstruction and discussed the main considerations related to these procedures. In this study, we performed 51 esophageal reconstructions using colonic interposition. Twenty-eight of the 51 patients had synchronous or allochronic gastric malignancy. We selected colonic interposition for high anastomosis in 11 patients and also for esophageal bypass in 3 patients. This procedure was also selected to preserve gastric function in 5 patients. We recently performed the supercharge technique for colonic interposition in 41 patients. Despite the long duration and multistep nature of the operation procedure, no perioperative complications were noted. The patients returned to a good quality of life. The incidence of postoperative weight loss did not differ significantly between the colonic reconstruction group and the gastric reconstruction group. In terms of heartburn and dumping syndrome, the outcome was markedly better in the colonic reconstruction group (no cases of heartburn or dumping syndrome) than that in the gastric reconstruction group. For reconstruction of the esophagus, the colonic interposition and supercharge technique is advantageous and contributes to the patient's quality of life.

The transverse coloplasty pouch. Review of experimental data and clinical application

The transverse coloplasty pouch. Review of experimental data and clinical application. The transverse coloplasty pouch is a novel technique for sphincter preserving colonic reconstruction after total mesorectal excision. The method was developed in an animal model and resulted in favorable early functional results. Our results in patients with rectal cancer demonstrate that the technique is technically easy and safe. The transverse coloplasty pouch provides a neorectal reservoir of adequate volume and a favorable early functional outcome. It leads to a reduction in stool frequency compared with a straight anastomosis and the outcome is comparable to other colon reservoirs.

Clinical outcome and long-term survival rates after esophagectomy are not determined by age over 70 years

Esophagectomy is considered a high-risk procedure in patients aged 70 years or older. This study evaluates the impact of two age groups (younger than 70 and 70 years or older) on clinical outcome and longterm survival rates following this procedure. This prospective study included survival analysis and clinical evaluations at 3, 6, and 12 months after esophagectomy. All esophagectomy patients undergoing gastric (n = 125), jejunal (n = 10), or colonic (n = 4) reconstructions at our institution from 1984 to 1996 were included. Fifty patients were older than 70 years, 89 were younger, and 120 of these 139 patients had tumors. The overall hospital mortality rate was 1.4% (2 of 139), both in the younger age group. All leaks from anastomoses and grafts were nonfatal, and these problems occurred in seven patients in the younger age group and two in the older group. The mean preoperative weight was 70 kg, and there was a mean weight loss of 5 kg during the first three postoperative months only but none thereafter ( P <0.001). This was the same for patients with benign and malignant disorders, and for those aged over or under 70 years. Between 71% and 77% of the patients experienced no dysphagia at the three evaluations during the first postoperative year. The distribution of the different grades of dysphagia was equal in the two age groups at 3-month ( P = 0.339) and 12-month ( P = 0.669) follow-up. The 12-year survival rate was 28% and the 5-year rate was 31%, and this was correlated to tumor stage ( P = 0.002) but not to age over or under 70 years ( P = 0.299). The clinical outcome was the same regardless of whether patients were over or under 70 years of age. Tumor stage but not age over 70 years was the major predictive factor for long-term survival.

Carcinoma of the hypopharynx and the cervical oesophagus: a surgical challenge.

To report our results after reconstruction of the upper digestive tract for locally advanced carcinoma of the hypopharynx and cervical oesophagus. Open study. Teaching University hospital, Germany. Of the 517 patients who presented with carcinoma of the oesophagus between September 1985 and March 1997, 16 had a locally advanced tumour of the hypopharynx and 25 of the cervical oesophagus. Free jejunal grafts were used after circular resection in all patients with carcinoma of the hypopharynx, and for the 3 with oesophageal carcinoma in whom we obtained adequate resection margins. In the remainder stomach was used in 21 and colon in 1. Morbidity and mortality. After jejunal grafting 1 patient died within 30 days and 2 died in hospital. After gastric or colonic reconstruction 2 patients died within 30 days and 4 in hospital. There was 1 anastomotic leak, 1 transplant became necrotic and had to be replaced, in 2 patients the recurrent nerve was damaged, 1 patient developed a wound infection and 1 a cardiac infarction. After gastric or colonic replacement 7 patients had paralysed recurrent laryngeal nerves, there was 6 anastomotic leaks, 1 chylous leak, 1 haemorrhage, and in 1 the transplant necrosed. Despite the fact that we compared tumours in different sites, these results suggest that the jejunal graft is safer for upper oesophageal and hypopharyngeal reconstruction.

Construction of an artificial vagina with sigmoid colon in vaginal agenesis

OBJECTIVES: The study of 15 cases of colonic reconstruction for absent vagina. The outcome in cases of reconstruction of an artificial vagina using the colon is evaluated. METHODS: Fifteen female patients with congenital absence of vagina who were evaluated and treated with sigmoid colonic reconstruction at the Korle-Bu Teaching Hospital in Accra, Ghana were studied. RESULTS: This reconstructive method is successful in patients having a functioning vagina without progressive shrinkage or other symptoms. Disfigurement of the thighs and labia are avoided as is the need for active manipulation. CONCLUSION: Sigmoid colonic reconstruction for vaginal agenesis is an acceptable method especially in the developing world.

Recent advances in laryngo, pharyngo, esophageal reconstruction.

Laryngopharyngeal reconstruction has remained a challenging field since the performance of the first laryngectomy near the turn of the century. Cutaneous, myocutaneous and colonic reconstruction is still occasionally used but is fraught with a high stenosis and fistula rate. Gastric pull-up has remained the procedure of choice for single staged pedicled reconstruction. Free tissue transfer has brought a new era to this field by adding another single staged reconstruction. This publication reviews our experience with free jejunal transfer and reviews recent developments in laryngopharyngeal reconstruction.