Ann Thorac Surg 2001;71:1695-1697
© 2001 The Society of Thoracic Surgeons
Case report
Redoing reconstruction of the esophagus using remnants of the ileo-left colon aided by microvascular anastomosis
Yau-Lin Tseng, MDa,
Ming-Ho Wu, MDa,
Mu-Yen Lin, MDa,
Jing-Wei Lee, MDa
a Divisions of Thoracic Surgery and Plastic Surgery, Department of Surgery, College of Medicine, National Cheng Kung University, Tainan, Taiwan
Accepted for publication July 15, 2000.
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Abstract
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Theoretically, the jejunum, fasciocutaneous or myocutaneous flap is recommended as an esophageal substitute in redoing reconstruction of the esophagus after a second incidence of corrosive injury. However, other esophageal substitutes should also be considered. We present a case of a 42-year-old woman who underwent esophageal reconstruction using an ileocolon graft for corrosive esophageal stricture ten years before. The patient ingested caustic drain cleaner again and underwent resection of the ileocolon graft secondary to corrosive necrosis. Two and a half months after the second incidence of corrosive injury, reconstruction of the esophagus was again performed using a graft of remnant ileo-left colon aided by microvascular anastomosis. The patient was able to swallow a regular diet after the procedure. Remnant ileo-left colon is a good alternative esophageal substitute in cases of repeated corrosive injury.
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Introduction
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The substitutes most commonly used for replacement of the esophagus include portions from the stomach, colon, and jejunum [1, 2]. On patients with corrosive injury in which the stomach is also frequently injured, the colon or jejunum is the best choice of graft material [3]. However, in cases involving failure of the colon graft or injury to the neoesophagus, surgeons may choose pedicled intestine, extended jejunum, or other flaps for reconstruction [4, 5]. We present a case in which we used remnant ileo-left colon for a second reconstruction of the esophagus. Although severe adhesions in the abdominal cavity may be present, reconstruction of the esophagus can be performed with available remnant alimentary tract with the aid of microvascular surgery.
A 42-year-old female patient had a history of substernal ileocolon reconstruction for corrosive esophageal stricture ten years before (Fig 1). She was referred to our hospital ten days after drinking Drano drain cleaner for the second time. In the emergency department, she presented with sepsis and dyspnea. Physically, she had tachycardia (112/min), fever (39.2°C), tachypnea (42/min), pale conjuntiva and decreased breathing sounds in the right chest. Chest film revealed right pyopneumothorax. Arterial blood gas analysis showed pH 7.49, PCO2 37.6 mm Hg, PO2 34 mm Hg, Base excess –6.6 mmol/L without oxygen supply. After tube thoracostomy (500 ml of dirty pus was drained), emergency right thoracotomy for resection of the neo-esophagus, decortication, and laparotomy for feeding gastrostomy were performed. The neoesophagus was necrotic and perforated. She did well after the operation and was discharged on the 36th postoperative day.
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Fig 1. The ileocolon interposition was performed ten years prior. Gray hatched area was resected on the second incidence of corrosive injury at our hospital.
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Two and a half months after the second corrosive injury, she was admitted for reconstruction of the esophagus. After dissection of abdominal adhesions via midline laparotomy, we decided to use the remnant ileo-colon as an interposed graft for reconstruction. The graft consisted of a segment of pedicled ileum, 12-cm in length, and left colon, 33 cm in length, which was anastomosed in the previous operation. The blood supply of the ileum and left colon graft was dependent on the ileal artery and in situ left colic artery, without an arcade connection between the ileul and left colonic segments. This graft was pulled up in front of the stomach to the neck via the substernal route. The transposed ileum was anastomosed to the esophagus. Then the ileal artery of the ileal pedicle was anastomosed to the transverse cervical artery, and the vein of the ileum was anastomosed to the external jugular vein with interrupted 9–0 Propylene; the left colic artery was left in situ. Warm ischemia time of the ileum was 45 minutes. End to side cologastrostomy was then performed. Finally, the end of the remaining intraabdominal ileum was anastomosed to the sigmoid colon (Fig 2). A nasogastric tube was put into the stomach via the ileo-colon graft. Feeding was started on the 5th postoperative day. Esophagography revealed good passage of contrast medium on the 10th postoperative day. The patient started oral feeding on the 12th postoperative day. Wound infection was the only complication. After debridement and secondary closure of the wound, she was uneventfully discharged on the 27th postoperative day. She was able to swallow a regular diet and stool passage was occurring two to three times per day at the six-month follow-up.
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Fig 2. Redoing reconstruction of the esophagus after a second incidence of corrosive injury. (A) Blood vessels of the ileum; (B) previous ileo-colostomy; (C) in situ leftcolic artery dependent colon; and (D) gray hatched area was the graft used in this operation.
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Comment
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In the 420 caustic injured patients at our hospital during the past 12 years, only three attempted suicide a second time with a corrosive agent. This patient was the only survivor. In treatment of corrosive esophageal stricture, we prefer to use the colon or ileo-colon as graft material for initial reconstruction because the stomach is always injured. Jejunum should be used as a backup when the colon graft is not available. We initially decided to use jejunal transposition for reconstruction in this patient. After lysis of the abdominal adhesions and careful evaluation of the jejunum, ileum, and colon, we found that the remaining left colon, which was supplied by the left colic artery, was doing well but its length was not enough to reach the cervical esophageal stump. In this situation, free intestinal transfer was a choice to add length of the colon graft [6, 7]. To simplify the operative procedure, we chose the remnant ileo-colon instead of a free jejunal transfer. The functional result of this patient is good during outpatient follow-up.
We recommend this surgical technique, as a good alternative for reconstructing the esophagus a second time.
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References
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- Wilkins EW. Technique of esophageal reconstructionIn: Zuidema GD, editor. Surgery of the alimentary tract. 3rd ed.. Philadelphia: WB Saunders; 1991. pp. 387-407.
- Akiyama H, Hiayama M, Miyazono H. Total esophageal reconstruction after extraction of the esophagus Ann Surg 1984;182:547-552.
- Wu MM, Lai WW. Esophageal reconstruction for esophageal stricture or resection after corrosive injury Ann Thorac Surg 1992;53:798-802.[Abstract/Free Full Text]
- Hirabayashi S, Miyata M, Shoji M, et al. Reconstruction of the thoracic esophagus, with extended jejunum used as a substitute, with the aid of microvascular anastomosis Surg 1993;113:515-517.
- Gorbunov GN, Marinichev VL, Volkov ON, et al. Microvascular reconstruction of the esophagus with pedicled small intestine Ann Plast Surg 1993;31:439-442.[Medline]
- Ong GB, Lam KH, Lam PHM, et al. Resection for carcinoma of the superior mediastinal segment of the esophagus World J Surg 1978;2:497-504.[Medline]
- Spencer PW, Fisher J. Esophageal reconstruction. free jejunal transfer or circulatory augmentation of pedicled intestinal interposition using microvascular surgery. In: Delarue NC, editor. Esophageal cancer-International trends in general thoracic surgery, volume 4. 30. St Louis: CV Mosby; 1988. pp. 250-255.
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Abstract
Introduction
