Underwent Colon Interposition Research Articles

Operative outcomes and long-term survival of patients undergoing colon interposition after esophagectomy for cancer.

BackgroundThe first choice of an esophageal substitute after esophagectomy for cancer is the stomach. However, the colon must be considered for reconstruction in specific situations. The purpose of this study was to clarify the frequency and clinical features of patients who underwent colon interposition in thoracic esophagectomy and to investigate the postoperative complications and survival.MethodsWe conducted a retrospective case–control study in the National Cancer Center Hospital East, Japan. Patients who underwent colon interposition after esophagectomy for cancer between 2010 and 2020 were analyzed.ResultsEighty‐eight patients underwent esophagectomy with colon interposition; 53.2% received preoperative treatment and 52.3% underwent thoracoscopic surgery. Clavien–Dindo grade >III postoperative complications occurred in 42% of the patients; anastomotic leakage was the most common complication, occurring in 26.1% of the cases. Univariate analysis of the factors associated with Clavien–Dindo grade <III complications showed that the period 2015–2020 and totally mechanical Collard anastomosis were significant factors, with odds ratios (OR) of 0.264 and 0.267 (p = 0.00327 and p = 0.00335), respectively. Totally mechanical Collard anastomosis was associated with a lower risk of anastomotic leakage by univariate and multivariate analysis (OR, 0.257, p = 0.00566 and OR, 0.285, p = 0.133, respectively). Three‐year overall survival was 54.2%. Univariate and multivariate analysis of overall survival showed that older age was a risk factor (OR, 1.08) for complications.ConclusionIn colon reconstruction after esophageal cancer resection, totally mechanical Collard anastomosis for cervical anastomosis may reduce the risk of Clavien–Dindo grade >III complications.

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.

Transhiatal isoperistaltic colon interposition without cervical oesophagostomy in long-gap oesophageal atresia.

Background:Oesophageal colonic interposition in oesophageal atresia (OA) patients is almost exclusively done as a staged operation with an initial oesophagostomy and gastrostomy followed by the definitive surgery months later. This study presents a series of patients in whom a cervical oesophagostomy was not performed before the substitution surgery.Patients and Methods:Records of EA patients were evaluated for those who underwent colon interposition without cervical oesophagostomy.Results:There were five patients: three with pure EA and two with proximal tracheo-oesophageal fistula. A delayed primary repair could not be performed because of intra-abdominally located distal pouch. The mean age at the time of definitive operation was 5.54 (±2.7) months and the mean weight was 6.24 (±1.3) kg. A right or a left colonic segment was used for interposition keeping the proximal anastomosis within the thorax. The post-operative results were quite satisfactory within a median follow-up period of 33.2 months.Conclusion:Avoiding cervical oesophagostomy and its inherent complications and drawbacks is possible in a subset of patients with long-gap EA who underwent colonic substitution surgery. This approach may be seen as an extension of the consensus that the native oesophagus should be preserved whenever possible, because it uses the native oesophagus in its entirety.

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.

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

Difficult caustic esophageal strictures may need a more sophisticated dilatation technique before referring for esophageal replacement surgery. Retrospective 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. Among 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. Every 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. This is a case series with no comparison group (level IV).

PS01.166: COLONIC INTERPOSITION FOR ESOPHAGEAL REPLACEMENT AFTER ESOPHAGECTOMY FOR CANCER: A SINGLE CENTER EXPERIENCE

Abstract Background The method of choice for esophageal replacement after esophagectomy for cancer is the gastric tube. However when the stomach is not available a colon graft interposition can be performed. The purpose of this retrospective study was to review our experience with colon interposition following esophagectomy for cancer and to assess the early surgical outcomes. Methods We reviewed clinical data from 26 consecutive patients who underwent colon interposition after esophagectomy for cancer between January 1990 and December 2017 at the Brazilian National Cancer Institute. Outcomes were compared with data in international publications on colon interposition. Results There were 22 (85%) males and 4 females with a mean age of 56 years (range, 28 to 79 years). Indications were adenocarcinoma in 21 (81%) and squamous cell carcinoma in 5 (19%). Seven (30%) patients received neoadjuvant treatment: in 3 cases chemotherapy and in 4 patients chemoradiation. Transhiatal esophagectomy and transthoracic esophagectomy were performed in 21 (81%) and 5 patients, respectively. The mean operative time was 389 min (range 120–660 min). The most common option for colon conduit was the left colon (63%). We performed hand-sewn anastomosis in the neck in all cases. Surgical morbidity was 65%, most commonly due to pulmonary complications. Anastomotic leakage occurred in 13 patients (50%). One case graft necrosis were observed and 9 (35%) reoperations were necessary. In-hospital mortality was 15%. Conclusion Our results are in line with the literature and demonstrate that colon interposition after esophagectomy is feasible and, despite having a significant morbimortality, appears to be a valuable alternative for the challenging situation where the stomach is not available. Disclosure All authors have declared no conflicts of interest.

RA05.05: STOMACH PRESERVED ILEOCOLIC INTERPOSITION AFTER ESOPHAGECTOMY FOR ESOPHAGEAL CANCER

Abstract Background A stomach is the first choice as an esophageal substitute after esophagectomy for cancer. In case with a history of gastrectomy, concurrent gastric disease, the ileo-colon is used as an esophageal substitute in our hospital. From 2007, as a method of preservation of the gastrointestinal function, we have provided the reconstruction of stomach preserved ileo-colic interposition. Methods 1990–2017.12, 227 patients underwent colon interposition after esophagectomy with extended lymphadenectomy. Until 1997, we selected the colon graft based on colon vessel finding during surgery. From 1998, we assumed ileo-colon first choice. From 2007, we started stomach preserved ileo-colic interposition. Between 2007 and 2017, we performed this method in 108/142 colon interposition patients. We examined these 108 patients to know the recent result of ileo-colon interposition. Results An average of 108 patients is 61 years. The cases without preoperative treatment was 38 cases (35%). Endoscopic resection was done in 23 cases (21%). 38 received preoperative chemo and 9 CRT. Clinical TNM was I/II/III/IV = 62/20/24/2. We performed lymphadenectomy with three field in 70 and two in 38. Route of reconstruction was retrosternal in 99(92%), a posterior mediastinal in 8. Microvascular anastomosis was conducted in one. The anastomosis of all cases performed hand-sewn end-to-side anastomosis in neck. The incidence of postoperative morbidity is one patient had anastomotic minor leakage (1%), one had pneumonia to need intubation. 4 patients experienced bowel obstruction, 1 required surgery. Endoscopy had done 4–12 month later, there were no patients have reflux esophagitis or anastomotic stenosis. 12 patients had colon-gastric anastomotic ulcer. PPI was started. The weight rate of decline of the 12 months after surgery was an average of 9%. 32% patients have diarrhea. Conclusion Stomach preserved ileo-colic interposition after esophagectomy with extended lymphadenectomy is feasible and have a favorable outcome. Keep up long-term quality of life and decrease in complications after the long-term progress is expected. Disclosure All authors have declared no conflicts of interest.

Surgical Outcome of Colon Interposition in Esophageal Cancer Surgery: Analysis of Risk Factors for Conduit-Related Morbidity.

We aimed to assess the feasibility, surgical outcomes, and conduit-related complications of colon interposition in patients with esophageal cancer. Patients with esophageal cancer who underwent colon interposition for esophageal reconstruction between June 2000 and June 2013 were retrospectively reviewed. A total of 67 consecutive patients (mean age, 62.2 ± 7.9 years) were enrolled. During this time period, 944 patients underwent esophageal reconstruction using gastric conduit. Twelve patients (17.9%) also received neoadjuvant chemoradiotherapy (nCRT). The median follow-up duration was 44 months (range, 1-168 months); median survival duration was 63 months (range, 1-168 months); and 3- and 5-year overall survival rates were 61.6 and 49.4%, respectively. A total of 43 patients (64.2%) experienced at least 1 postoperative morbidity. According to the Clavien-Dindo grading system, 36 patients (54%) experienced postoperative morbidity of higher than Grade III. Pulmonary complications were most commonly observed complications among the patients (18 patients, 26.9%). Anastomosis site leakage developed in 11 patients (16.4%), and 3 of these patients (6.0%) eventually experienced graft failure. On multivariate analysis, nCRT was determined as a significant risk factor for conduit-related complications (leakage, graft failure, fistula, and stricture). Colon interposition is associated with relatively high complication rates, whereas nCRT is associated with conduit morbidity.

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

The 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. A 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. In 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. Pharyngocoloplasty 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. II.

Interdisciplinary approach to esophageal replacement and major airway reconstruction

Severe esophageal disease warranting replacement often presents with additional airway anomalies in children. Colon interposition and airway reconstruction have separately proven successful in attaining satisfactory outcomes. The aim of this study was to determine outcomes associated with an interdisciplinary approach to care of the patient with complex esophageal and airway disease. After IRB approval, a retrospective cohort study was performed spanning 2011 through 2015. Eleven patients underwent colon interposition and airway surgery. Review of medical records was performed, extracting patient demographics, clinical and operative courses and outcomes. The mean age of patients was 44months (range 2-108). 91% (n=10) were transferred to our institution with primary diagnoses of caustic ingestion (45%, n=5), long gap esophageal atresia (27% n=3), tracheoesophageal fistula (18%, n=2) and necrotizing pharyngitis (9% n=1). All patients had associated airway anomalies. Pulmonology, gastroenterology and speech therapy were involved in preoperative evaluation and postoperative care of all patients. Intraoperatively, a multi-team approach was utilized. The most common postoperative complication was esophageal stricture (54%, n=6). All patients are capable of taking some to full nutrition per orum. Colonic interposition with major airway reconstruction at our institution attains satisfactory functional results through utilization of a multidisciplinary approach.

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.

Esophageal replacement by colon interposition with microvascular surgery for patients with thoracic esophageal cancer: the utility of superdrainage

Replacing the thoracic esophagus with the colon is one mode of reconstruction after esophagectomy for esophageal cancer. There is, however, a high incidence of postoperative necrosis of the transposed colon. This study evaluated the outcomes of colon interposition with the routine use of superdrainage by microvascular surgery. Twenty-one patients underwent colon interposition from 2004 to 2009. The strategy for colon interposition was to: (i) use the right hemicolon; (ii) reconstruct via the subcutaneous route; (iii) perform a microvascular venous anastomosis for all patients; and (iv) perform a microvascular arterial anastomosis when the arterial blood flow was insufficient. The clinicopathologic features, surgical findings, and outcomes were investigated. The colon was used because of a previous gastrectomy in 18 patients (85.7%) and synchronous gastric cancer in three patients (14.3%). Eight patients (38.1%) underwent preoperative chemoradiotherapy including three (14.3%) treated with definitive chemoradiotherapy. Seven patients (33.3%) underwent microvascular arterial anastomosis to supplement the right colon blood supply. Pneumonia occurred in four patients (19.0%). Anastomotic leakage was observed in five patients (23.8%); however, no colon necrosis was observed. The 3-year and 5-year overall survival rates were both 50.6%. Colon interposition with superdrainage results in successful treatment outcomes. This technique is one option for colon interposition employing the right hemicolon.

Late Morbidity After Colon Interposition for Corrosive Esophageal Injury

The aim of this study was to report our experience in the management of late morbidity after colonic interposition for caustic injury and to assess the influence of coloplasty dysfunction on patient outcome. Reports on coloplasty dysfunction after colon interposition for corrosive esophageal injuries are scarce in the literature. Dysfunction of the colonic substitute might jeopardize an already fragile functional result, and appropriate management can improve outcome. Long-term follow-up (>6 months) was conducted in 223 patients (125 men; median age, 35 years) who underwent colonic interposition for caustic injuries between 1987 and 2006. Statistical tests were performed on this cohort to identify risk factors for late morbidity and functional outcome. During the same period, 28 patients who underwent colon interposition for caustic injury in another center were referred for treatment of coloplasty dysfunction. Data from these patients were used together with those of our patients to describe specific coloplasty-related complications and their management. With a median follow-up of 5 years (range: 6 months-20 years), late complications were recorded in 125 (55%) of our patients (stenosis 36%, reflux 11%, redundancy 5%). A delay in reconstruction <6 months (P = 0.03) and absence of thoracic inlet enlargement (P = 0.002) were independent predictive factors for cervical anastomotic stenosis. Functional failure was recorded in 52 patients (23%) and was associated with a delay in reconstruction <6 months (P = 0.009) and emergency tracheotomy (P = 0.002). Coloplasty dysfunction was responsible for half of the recorded failures. Revision surgery for coloplasty dysfunction was performed in 96 patients (68 local, 28 referred) with an overall 70% success rate. Late complications occurred in half of the patients after colonic interposition for corrosive injuries and accounted for half of the functional failures. Prolonged surgical follow-up and appropriate management of coloplasty dysfunction are key factors for long-term success after esophageal reconstruction for caustic injuries.

Colon Interposition After Esophagectomy With Extended Lymphadenectomy for Esophageal Cancer

The purpose of this retrospective study was to investigate the feasibility of colon interposition procedures after esophagectomy with extended lymphadenectomy. Between 1990 and 2008, 95 consecutive patients underwent colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer in our Institution. We reviewed clinical data and long-term survival, and also investigated the association between anastomotic leakage and clinicopathologic findings. We applied three-field lymphadenectomy to 71 patients and two-field to 24 patients, by a right thoracotomy. Ninety-two patients underwent reconstruction by a retrosternal route, and a posterior mediastinal route was applied to only three patients. We performed hand-sewn anastomosis in the neck in all cases. Three patients required microvascular surgery. Sixty-one patients (64%) experienced postoperative morbidity, most commonly pulmonary complications. Anastomotic leakage occurred in 12 patients (13%). No colon conduit necrosis was detected. Overall mortality, including hospital mortality, was 5.3%. Dysphagia (39%) and diarrhea (38%) were common and stricture was low (6%) after discharge. The overall 5-year survival rate was 43%. During the latter period (1998 to 2008), when ileocolon grafts evolved as the primary choice for interposition, the rate of leakage decreased from 17% (1990 to 1997) to 5.4%. No mortality was recorded during the latter period. Results from this study demonstrate that colon interposition after esophagectomy with extended lymphadenectomy is feasible and can have a favorable outcome.

Long‐term Outcome of Colon Interposition After Esophagectomy in Children

Tissues derived from the colon, stomach, and jejunum have been used to replace the esophagus in childhood to cure esophageal atresia or stricture secondary to gastroesophageal reflux or the ingestion of corrosive agents. The outcome in adulthood of colon interposition performed at an early age has yet to be satisfactorily assessed. The aim of this single-center retrospective study was to evaluate the long-term nutritional, digestive, and respiratory outcome of all patients (n = 32) who underwent colon interposition during childhood in our hospital (1970-2001). Medical records of these subjects were reviewed and their nutritional (weight, height, 24-hour food diary), digestive (questionnaire), and pulmonary function status evaluated. Of the patients, 17 had esophageal atresia (7 males, median age at surgery 11 months, range 0.5-61) and 15 had ingested corrosive substances (10 males, median age at surgery 50 months, range 22-113). Complications occurred less than 1 year postoperatively in 53% and long-term complications (occurring >1 year after surgery) in 84%. Long-term complications were common: digestive symptoms were found in 85% (most frequently observed during the first 5 years of follow-up), abnormal lung function in 7 (58%) of those tested (n = 12), feeding difficulties in 50%, scoliosis in 35%, and nutritional complications in 25%. Our study showed a high rate of sequelae following esophageal replacement. This highlights the need for multidisciplinary long-term follow-up into adulthood, and research into alternatives to colon interposition as treatment for esophageal strictures.

Acute lung injury following an esophagectomy for esophageal cancer, with special reference to the clinical factors and cytokine levels of peripheral blood and pleural drainage fluid

Acute lung injury (ALI) is one of most serious complications to occur after an esophagectomy for esophageal cancer. However, the pathogenesis of ALI is still unclear. The cytokine levels of pleural drainage fluid as well as peripheral blood were measured in 27 patients who had undergone an extended radical esophagectomy. Both the clinical factors and cytokine levels were compared between 11 patients with (group I) and 16 without ALI (group II). ALI occurred more frequently in patients who underwent colon interposition than in those who received a gastric tube reconstruction (86%vs 25%, P = 0.009). The operation time of group I was significantly longer than that of group II. A logistic regression analysis revealed colon interposition to be an independent factor associated with the ALI (P < 0.05). Postoperative anastomotic leakage and systemic inflammatory response syndrome (SIRS) occurred more frequently in group I than in group II (P < 0.01). Both the serum interleukin-6 (IL-6) and IL-8 levels of group I were significantly higher than those of group II. IL-1beta and tumor necrosis factor-alpha were undetectable in the peripheral blood, whereas they were detectable in the pleural effusion. The IL-1beta of pleural effusion was higher in group I than group II. In conclusion, greater surgical stress, such as a longer operative time, is thus considered to be associated with the first attack of ALI. The adverse events developing in the extra-thoracic site, such as necrosis and local infection around anastomosis may therefore be the second attack. Furthermore, ALI may cause not only SIRS but also other complications such as anastomotic leakage.

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: Current Indications and Long-Term Function

In contrast to the use of the stomach as an esophageal substitute, the use of the colon is becoming uncommon. 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. 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). Colon interposition for esophageal substitution, usually performed when the stomach is not available, provides satisfactory function when placed in the esophageal bed.

Long-term functional results and quality of life after colon interposition for long-gap oesophageal atresia.

Out of a series of 146 patients with oesophageal atresia 9 (6.2%) underwent colon interposition from 1963 to 1971. All eight surviving patients were seen at follow-up after a mean of 22 years. Three patients were free of specific symptoms according to the criteria of DeMeester, two had moderate and three severe distress. The mean time for consuming a standardized test meal was 15 minutes, compared to 8 minutes in healthy controls. Patients required 1-9 minutes to transport liquid barium through the transplant, compared to < 10 seconds in control subjects. Histological evaluation revealed a normal architecture of the colonic and ileal epithelium in three patients who underwent endoscopy. In none of these patients were contractions in the colon graft related to the act of swallowing recorded on manometry. Unimpaired quality of life was indicated by the Spitzer index which scored a mean of nine out of ten points. However, on a 100point visual analogue scale patients scored their global quality of life 66 and the mean Gastrointestinal Quality of Life Index was 92.2, compared to 107.6 in healthy control subjects (p < 0.05). This impairment was exclusively due to specific symptoms which scored 49.3 in patients and 59 in healthy individuals (p < 0.05). Physical and social functions, emotions, and inconvenience of a medical treatment were similar to control subjects. We conclude that colon interposition for long-gap oesophageal atresia achieves acceptable long-term functional results. However, specific symptoms lead to a considerable impairment in quality of life.

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.