Ann Thorac Surg 2002;74:921-923
© 2002 The Society of Thoracic Surgeons
Case report
Salvage of right colon interposition by microsurgical venous anastomosis
H.D.L. Patel, MD, PhDa,
Yi-Chieh Chen, MDa,
Hung-Chi Chen, MD, FACS*a
a Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, Kuei Shan, Taoyuan, Taiwan
Accepted for publication April 1, 2002.
* Address reprint requests to Dr Chen, Department of Plastic and Reconstructive Surgery, Chang Gung Memorial Hospital, No. 5, Fu-Hsing St, Kuei-Shan, Taoyuan 333, Taiwan
e-mail: pschenyc{at}yahoo.com.tw
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Abstract
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Venous insufficiency of a right colon interposition in esophageal reconstruction can be a fatal complication resulting in total failure. A case is presented of the salvage of the right colon interposition by additional microsurgical venous anastomosis to relieve the problem of venous stasis. The outcome was successful in a young patient with a complicated medical history.
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Introduction
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Since the first description of the use of the colon independently as an esophageal substitute by Vuillet and Kelling in 1911, its use for a variety of benign and neoplastic conditions has been well established. There are many reports describing the morbidity and mortality associated with this procedure. Most authors emphasize the importance of the adequate marginal arterial flow to the graft survival. Ventemiglia and associates [1] in 1977 and Peters and associates [2] in 1995 reported a case of graft necrosis separately. Both patients had favorable arterial patterns confirmed by preoperative mesenteric arteriography. The cause of their graft failure was related to venous insufficiency. Here we describe a procedure for salvage of the interposed right colon segment when confronted with anatomic variation in mesenteric vasculature resulting in venous insufficiency.
A 6-year-old girl presented with complications of four previous surgical attempts at repair of her tracheoesophageal fistula. The esophageal atresia and tracheoesophageal fistula required operative intervention on the second day of life at another institute. The operative procedures included ligation of the fistula and esophageal anastomosis. However, 1 year later she required further surgery as a result of dysphagia due to a stricture and therefore had further resection and reanastomosis, which unfortunately were complicated by constant leakage with persistent pneumonia necessitating a gastrostomy for feeding. At this stage she was referred to our institute.
The patient’s main complaints on presentation were pneumonia, dysphagia, and weight loss as a direct result of tracheoesophageal fistula and esophageal stricture. Preoperative investigations included an magnetic resonance imaging scan, which revealed an esophageal stricture of the thoracic part and a small tracheoesophageal fistula above the previous anastomotic site. She underwent surgery that included esophagectomy, right colonic interposition based on ascending branch of left colic artery, and Rous-en-Y colonojejunostomy. After dividing the mesocolon and mobilizing the right colon from its retroperitoneal attachment, the right colon appeared severely congested and swollen with diffuse serosal petechia. Significantly engorged right colic and ileocolic veins were noted with no marginal venous communication to the middle colic vein (Fig 1).
It required additional venous drainage for the right colon graft to survive. The interposed colon segment was transposed by the subcutaneous route to reconstruct the thoracic esophagus, with the lower end anastomosed to the Roux limb of the Rous-en-Y jejuno-jejunostomy to prevent postoperative reflux and aspiration. The upper end was joined to the previous pharyngeal remnant and a mesenteric vein of the right colon about 3 mm in diameter was anastomosed to a branch of the internal jugular vein using microscopy by interrupted 10-0 nylon sutures. The congestion and swelling of the right colon subsided and the color turned pink promptly after drainage of the congested veins. The patient made a full postoperative recovery.
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Fig 1. Diagram showing additional venous anastomosis between the right colic vein and a branch of the internal jugular vein (1). Both the mesenteric and internal jugular venous systems can be accessed easily by experienced hands. Note there was no venous communication between the proximal and distal segment of the colon graft (2). The mesenteric artery is not shown.
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Comment
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Reconstruction of the esophagus after congenital atresia resents a surgical challenge. In the last few decades colon segments have been frequently used for total and subtotal reconstruction of the esophagus. The vasculature of the colon makes it possible to obtain a long segment of sufficient length for total or subtotal esophageal reconstruction based on the marginal artery and vein pass uninterrupted from the ascending branches of the ileocolic vessels to the descending branches of the sigmoid vessels. We prefer the use of the right and transverse colon in long-segment colon interposition because its isoperistaltic anastomosis affords a favorable functional outcome and reduces morbidity. The left colon is usually antiperistaltic after long-segment interposition and this may result in postoperative reflux and food intolerance.
The key to a successful right and transverse colon transfer is a long segment of bowel with an uninterrupted marginal artery and vein. However, vascular anatomy in the right colon is not as reliable as the left colon [1–4]. Interruption of the marginal vessels with arterial or venous insufficiency may both leads to distal graft necrosis and fatal complications in right colon interposition. Adequate marginal artery can be confirmed preoperatively by mesenteric arteriography or intraoperatively by direct inspection of the vascular pattern under transillumination, palpation of the arterial pulsation, or Doppler examination. Venous insufficiency however is difficult to detect before ligation of the pedicles. This is the reason that use of the right and transverse colon has not gained popularity. Our case showed such an ominous situation regarding the venous insufficiency; the only way to salvage the congested graft and maintain viability of a pedicled colon is immediate alternate drainage of its venous flow. With microsurgical techniques this situation can be easily remedied by creating an additional pathway for venous return. Arterial supercharge may also be considered if equivocal distal perfusion of the colon graft is noted intraoperatively. Adequacy of the circulation of the right colon graft should be evaluated before the graft is pulled through the subcutaneous tunnel in order to make sure that the vascular compromise, if it develops, is not caused by external compression to the vessels. The subcutaneous tunnel should be widely dissected to prevent any possible compression on the graft, especially over the inlet and outlet of the tunnel.
Revascularization of an ischemic colon transfer using microsurgical techniques has been described in a case report by Sung and coworkers [5]. They performed additional anastomosis of the internal mammary vessels to the ileocolic vessels with successful outcome. O’Rourke and Threlfall [6] first described additional microvascular anastomosis of the colon graft to ensure adequate distal perfusion in 14 patients, with no case of colon graft necrosis or anastomotic leakage. This study was repeated by Fujita and associates [7] who evaluated the impact of microvascular supercharge on colon interposition for esophageal replacement and concluded that additional microvascular anastomosis prevented serious complications caused by graft ischemia.
These studies have been carried out in adult patients in whom systemic vascular disease could compromise the blood supply as a result of atherosclerotic vessels and focused in particular on increasing the arterial flow to the distal part of the colon segment. To date there have been no reports of additional microsurgical venous anastomosis for salvage of the interposed right colon segment in a young healthy patient.
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References
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- Ventemiglia R., Khalil K.G., Frazier O.H., et al. The role of preoperative mesenteric arteriography in colon interposition. J Thorac Cardiovasc Surg 1997;74:98-104.[Abstract]
- Peters J.H., Kronson J.W., Katz M., et al. Arterial anatomic considerations in colon interposition for esophageal replacement. Arch Surg 1995;130:858-863.[Abstract/Free Full Text]
- Sonneland J., Anson B.J., Beaton L.E. Surgical anatomy of the arterial supply to the colon from the superior mesenteric artery based upon a study of 600 specimen. Surg Gynecol Obstet 1958;106:385-398.[Medline]
- Nicks R. Colonic replacement of the oesophagus. Some observations on infarction and wound leakage. Br J Surg 1967;54:124-128.[Medline]
- Sung S.C., Chung I.Y., Jun H.J., et al. Revascularization of the ischemic colon transplant using the internal mammary vessels. Ann Thorac Surg 1994;58:555-557.[Abstract]
- O’Rourke I.C., Threlfall G.N. Colonic interposition for oesophageal reconstruction with special reference to microvascular reinforcement of graft circulation. Aust NZ J Surg 1986;56:767-771.[Medline]
- Fujita H., Yamana H., Sueyoshi S., et al. Impact on outcome of additional microvascular anastomosis—supercharge—on colon interposition for esophageal replacement: comparative and multivariate analysis. World J Surg 1997;21:998-1003.[Medline]
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Abstract
Introduction
