Indications, Surgical Technique, and Long-Term Functional Results of Colon Interposition or Bypass

Abstract

Over a 17-year period, 92 patients with esophageal disease underwent colon interposition or bypass, with each operation performed by the same surgeon. The indication was cure of cancer in 20 patients, relief of dysphagia in 55 (cancer in 17 patients and benign in 38), loss of gastrointestinal (G.I.) continuity in ten, and tracheoesophageal fistula in seven patients (malignant in five, benign in 2). The thirty-day operative mortality rate was 5%, and the hospital mortality rate was 9%. Graft necrosis occurred in seven of 92 patients, four of whom later underwent a successful second reconstruction. Thirteen patients required subsequent revisional surgery. In 85 patients, the left colon based on the inferior mesenteric artery was used, and in seven, the right colon was used. Technical insights were gained to help preserve the blood supply to the graft and improve its function in transporting food. Thirty-four patients were available for interview 2-17 years after operation (median of 5 years) 28 of whom had benign disease, and six of whom had malignant disease); 82% of the patients felt they were cured of their preoperative symptoms, 18% improved, and none worsened. Eighty-eight per cent of the patients were able to receive an unrestricted diet. All patients except one were satisfied with the results of surgery, and, asked what they would do if they had to make the choice again, all responded that they would have the operation. Twenty-six of the interviewed patients had their eating ability evaluated with a test meal and the transit time of a liquid and solid barium bolus measured. Compared to controls, patients with colon interpositions consumed a smaller capacity meal over a longer period of time and were not dependent on liquids to flush the food through the colon graft. A colon interposition provides good quality of deglutition, is very durable, and is the organ of choice for patients who require an esophageal substitute and are potential candidates for long survival.

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

“…Many surgeons recommend to associate this procedure to the substernal esophageal reconstruction [3][4][5][18][19][20][21][22]. Statistically our study has some bias.…”

“…Therefore, the biggest disadvantage of the retrosternal approach is the potential risk for compression of the graft at the site of the thoracic inlet, which can lead to mechanical ischemia. To prevent this event, some surgeons suggested to the enlarge of the thoracic inlet [3][4][5]. The aim of this study is to report the impact of the enlargement of the thoracic inlet on the cervical anastomotic leakage after sub sternal colonic interposition for esophageal caustic stricture.…”

Surgical Management of Graft Redundancy after Colon Interposition for Esophageal Reconstruction

“…Redundancy of the interposed colon is a late mechanical complication and can occur several decades after initial reconstructive surgery [1]. The incidence of colon redundancy appears to augment with the duration of follow up and it varied between 8 and 21% [7][8][9][10]. This reported incidence is probably underestimated because many patients may adjust their life-style or make dietary modifications without ever seeking medical assistance and do not report occasional symptoms such as regurgitation or aspiration signs.…”

“…Examples include the opening of the thoracic inlet by removing manubrium and head of the left clavicle, widening the diaphragmatic hiatus and performing a wide, well vascularized cologastric anastomosis. In order to ensuring maintaining the cologastric anastomosis located intra-abdominally, the colon graft should be fixed on its antimesenteric border to the diaphragmatic wall to avoid intrathoracic ascension of the cologastric anastomosis [8,9]. The point of obstruction in patient 1 was to be adhesions at the retrosternal hiatus and acute angulation of graft created when it left the substernal space and passed intraabdominally.…”

Esophageal Reconstruction by Substernal Route: Impact of the Thoracic Inlet Enlargement on Cervical Anastomotic Complications: Leak and Stricture

“…The biggest disadvantage of the retrosternal approach is the potential compression risk of the graft at the site of the thoracic inlet, which can lead to mechanical ischemia. To prevent this event, some surgeons suggested the enlargement of the thoracic inlet by removing the left half of the sternal manubrium and the internal third of left clavicle [2][3][4]. This prospective study aims to evaluate whether the enlargement of the thoracic inlet during substernal colonic interposition can influence the incidence of cervical anastomotic complications.…”