Extended left colon interposition for esophageal replacement using arterial augmentation

Gastric necrosis after esophagectomy is a difficult clinical problem. Remedial operations to reestablish gut continuity usually rely on the use of the left colon as the neo-esophagus. Previous resection of the necrotic stomach, adhesions associated with a multiple redo-laparotomy and the need to use a substernal route to reach the cervical esophagus all conspire to produce a requirement for increased conduit length. We present a case in which the "arterial supercharge technique" was used to provide a colonic interposition with extended length in such a clinical situation.     

Early short segment left colon interposition for esophageal atresia

Colon Interposition is frequently used for correction of esophageal atresia. The use of both retrosternal right colon^1–5 and transthoracic left or transverse colon^2,6–10 has been recommended. Retrosternal right colon interposition may be complicated by break downs and/or stricture of the anastomosis between cervical pharyngo-esophagus and the proximal interposed colon;^3–5,9 by vascular compromise and ischemia of the colon segment;^2,5 and by peptic ulceration of the distal interposed colon where it is anastomosed to the stomach.¹¹ Long-segment transthoracic left colon interposition may be attended by the first two complications as well;¹⁰ utilization of the esophageal stump for the distal colo-esophageal anastomosis in this technique may prevent gastroesophgeal reflux.^8–10,12Because of these problems, other methods of treatment have been suggested. The use of a gastric tube as esophageal replacement has been recommended;^13–15 however, peptic ulceration of the gastric esophagus may result.¹⁶ Elongation of the upper and, sometimes, the lower esophageal pouch with delayed primary anastomosis has been advocated.^17–19 Anastomotic leaks and/or stricture frequently accompany this procedure.Short-segment transthoracic left colon interpositions for esophageal stricture or varices have been attended by relatively fewer complications.^6–8 Therefore, a modified procedure was adopted for wide-gap esophageal atresia in 1968. A short segment of left colon was interposed transthoracically between the distal esophageal stump and proximal esophageal pouch in two infants after several weeks of bougienage had stretched the proximal pouch well below the aortic arch, so that a colo-esophageal anastomosis could be accomplished within the thorax without difficulty.     

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.     

A revised method for pharyngoesophageal reconstruction using free jejunal transfer

Pharyngoesophageal reconstruction using free jejunal transfer is a reliable procedure, but the achievement of perfect functional results is still challenging. We present a devised method. Jejunoesophageal anastomosis is performed after 2 longitudinal incisions are made at the side corners of the esophageal stump. This maneuver not only enlarges the size of the esophageal stump but also provides a "Z-plasty-like" effect, which reduces the risk of delayed stricture formation. The pharyngojejunal anastomosis is performed in an end-to-end manner. Irrespective of the highest point of the pharyngeal defect, a longitudinal incision is made at the edge of the jejunal graft corresponding to the midpoint of the back wall of the pharyngeal stump. With this concept, considerable longitudinal tension is placed on the posterior side of the jejunal graft, whereas moderate tension is placed on the anterior side of the graft, which prevents the fistula formation that tends to occur in the anterior suture line. Twenty patients underwent the reconstruction using this operative procedure. In all cases, postoperative deglutition was satisfactory without jejunal redundancy or constriction. We believe that our method can be applied in most cases of pharyngoesophageal defects, providing simple and reasonable reconstruction using free jejunal transfer with stable results.     

Subcutaneous left colon reconstruction following pharyngo-laryngectomy

Twenty-nine patients with post-cricoid carcinoma were treated by pharyngo-laryngectomy and left colon reconstruction using the subcutaneous route. Six patients had unilateral block dissection of cervical nodes. Nineteen patients had a satisfactory result with two long-term survivors. Four patients had no worthwhile palliation and there were 6 perioperative deaths.     

结肠代食管重建术

虽然食管切除后胃是首选的替代器官,但当胃已被切除或有病变时,则结肠代食管通常为第一选择。因而,结肠代食管是食管重建不可或缺的手术方式。本文就结肠代食管的历史、解剖、技术要点及应用前景作一阐述,供大家参考。     

Short-segment colon interposition for end-stage achalasia

BACKGROUND: The reoperative procedures for achalasia vary. Repeat esophagomyotomy with or without antireflux procedure and esophageal resection of varying extent with reconstruction using stomach, jejunum, or colon have been reported. In this series, we have retrospectively reviewed our experience and reported the results with limited distal esophagectomy and short-colon interposition in the treatment of patients with recurrent symptoms of achalasia after prior failed esophagomyotomy. METHODS: Nine consecutive patients (5 men, 4 women; 27 to 74 years of age; mean, 52 years) with recurrent symptoms of achalasia and at least one failed prior esophagomyotomy underwent gastric cardiectomy, distal esophagectomy, and replacement with an at least 30-cm short-colon interposition through a left thoracoabdominal approach. Morbidity of the procedure and the length of hospital stay were recorded. The symptomatic evaluation, ability to have a meal, and overall patient satisfaction after the operations were assessed. RESULTS: Follow-up results were available in 8 patients. One patient had intestinal strangulation with graft failure 3 days after operation. Takedown of the graft and end-to-side esophagogastrostomy were successful. There was no mortality. Outcome assessment was completed at a median of 6 years (range, 1 to 12 years). Overall patient satisfaction was good in 6 patients, and fair and worse in 1 patient each. Most of the patients could have regular meals. Two patients had intermittent abdominal fullness after meals. Six of these 8 patients would have the operation again. CONCLUSIONS: Limited distal esophagectomy with short-colon interposition through a left thoracoabdominal approach is a safe and feasible alternative to near total esophagectomy in patients with achalasia who have prior failed esophagomyotomy. Improved alimentary function was observed in most of the patients after operation, which resulted in a better quality of life.     

Bilateral Jejuno-mesenteric flap for reconstruction of complicated pharyngoesophageal defect

The surgical management of an infectious and fistulous wound with a pharyngoesophageal tumor is one of the greatest challenges for head and neck and plastic surgeons. The free jejunal transfer has been the standard technique for pharyngoesophageal reconstruction, and the free omental flap has been one of the most reliable methods for reconstructing contaminated wounds. A jejuno-mesenteric flap is suitable for such complicated wounds. Pharyngoesophageal defects are reconstructed by the jejunum, and contaminated and heavily irradiated neck wounds are covered with the mesenteric flaps connected with a revascularized jejunum. The technique described here possesses the advantages of both a free jejunal flap and an omentum flap. Therefore, it is a reliable method for reconstructing the pharyngoesophageal defects of complicated wounds.     

Management of colon ischemia following colon interposition for esophageal substitution.

During the past four years three patients have been seen with ischemia of the colon segment following colon interposition. Colon interposition was done for esophageal cancer in two patients and for esophageal stricture following ingestion of lye. Colon ischemia was manifested as early as two weeks in one patient and as late as eight weeks in the others. Colon ischemia presented a frank gangrene with cervical fistula or as dysphagia due to stricture formation. Dysphagia in two patients prompted mechanical dilatation of the colon segment which led to perforation in both cases. All three patients had empyemas. The management of these patients includes proper diagnosis, drainage of abscesses and antibiotic treatment, hyperalimentation and visceral arteriography to delineate the residual colon for reinterposition. Two of the three patients in the series are long-term survivors and are well.     

Colonic interposition and supercharge for esophageal reconstruction

Aims We evaluated the techniques of colonic interposition and supercharge for esophageal reconstruction and discussed the main considerations related to these procedures. Patients and methods 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. Results 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. Conclusion For reconstruction of the esophagus, the colonic interposition and supercharge technique is advantageous and contributes to the patient’s quality of life.     

Polytetrafluoroethylene interposition grafts for carotid reconstruction.

Polytetrafluoroethylene interposition grafts were used for carotid reconstruction in 26 operations performed in 23 patients during a 7-year period. There were 10 men and 13 women with a mean age of 66 years. The indication for interposition graft placement was recurrent stenosis with inability to perform endarterectomy in nine operations, a severe kink or technical problem during endarterectomy in nine, aneurysmal changes of the artery in six, and thrombosis of the endarterectomy site segment with stroke in two. There were no perioperative deaths and no further perioperative neurologic complications. Follow-up with performance of yearly duplex scans was obtained in all patients, and the mean duration of follow-up was 36 months. One patient (4%) died of end-stage pulmonary disease during the study interval. Occlusion of the polytetrafluoroethylene graft occurred at 12 months in one patient (4%). Hemodynamically significant restenosis developed in two patients (8%), and two patients (8%) had mild restenosis. Evidence of a second restenosis developed in three of the nine patients who underwent polytetrafluoroethylene interposition graft placement for carotid restenosis. On the basis of our study results, we conclude that polytetrafluoroethylene can be used effectively for carotid reconstruction when an interposition graft is required. However, recurrent stenosis occurs. Patients who undergo polytetrafluoroethylene interposition graft placement for carotid restenosis appear to be at high risk for a second restenosis.     

Esophagectomy and colon interposition for benign esophageal stricture

Esophagectomy with colon interposition for nonmalignant esophageal stricture was evaluated in 41 patients, 18 with peptic and 23 with lye stricture. Four of the 41 patients died in the postoperative period and 12 had nonfatal complications of surgery. At long-term evaluation, 25 of 31 patients complained of postural regurgitation and 9 had disturbing symptoms related to retention in the graft. The long-term clinical and radiologic results showed no deterioration from the immediate postoperative period. The complications associated with colon interposition clearly restrict indications for its use in benign conditions. Interposition should be used in peptic stricture only when other methods have failed. In chronic lye stricture, interposition is justified by the irreversible nature of the lesion and its predisposition to malignant change.     

A case of total esophago-gastro-duodeno-jejunectomy and partial pancreatectomy for lye burns, and reconstruction with colon interposition

We report a unique case of extensive surgery for severe lye burns. It included total esophago-gastro-duodeno-jejunectomy and partial pancreatectomy. We were unable to find a similar successfully treated case in English-language literature. Ninety-one days after the initial emergency surgery, the patient successfully underwent reconstruction of alimentary tract with isoperistaltic left colon interposition between proximal cervical esophagus and ileum.