Ann Thorac Surg 2002;74:1708-1711
© 2002 The Society of Thoracic Surgeons
Case report
Surgical revision of dysfunctional colonic interposition after esophagoplasty
Kayvan Shokrollahi, MB, ChBa*,
Paul Barham, MD, FRCSa,
Jane M. Blazeby, MD, FRCSa,
Derek Alderson, MD, FRCSa
a Department of Upper GI Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
Accepted for publication May 30, 2002.
* Address reprint requests to Dr Shokrollahi, c/o Secretary to Professor D. Alderson, University Division of Surgery, Bristol Royal Infirmary, Malborough St, Bristol BS2 8HW, United Kingdom.
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Abstract
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The redundancy and dysfunction of colonic interpositions is a recognized late complication of esophageal replacement, often occurring decades after the original surgery. A 34-year-old man, whose long-gap esophageal atresia was corrected as a child with large bowel interposition, presented with severe dysphagia and recurrent aspiration pneumonia. Imaging and endoscopy revealed a grossly abnormal and dysfunctional neo-esophagus. Symptoms were refractory to medical therapies, and necessitated occupational retirement on medical grounds. His case illustrates a successful surgical technique for correcting this complication.
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Introduction
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The redundancy of colonic interposition grafts for esophageal replacement is a recognized late complication of this technique, occasionally requiring surgical intervention [1–3]. Such intervention depends upon the unique anatomy of the dysfunctional conduit, and has been tackled in a number of ways. Side-to-side colo-colic anastomosis using a linear stapler avoids the need for refashioning the colo-gastric anastomosis [4]. Others have advocated resection of the excess colon with a new colo-gastrostomy [5] or an end-to-end colo-colonic anastomosis [6]. These techniques are all different as they aim to correct abnormalities that are unique in their anatomy in each case. A successful technique for refashioning redundant colonic interposition grafts is described by means of a case history that also brings to light some novel symptomatology.
A 34-year-old man was referred to our unit with severe dysphagia and regurgitation resulting in recurrent aspiration pneumonia. He had originally undergone correction of a long-gap esophageal atresia in infancy by colonic interposition, which functioned well for about 29 years. He then began to experience dysphagia. Barium radiology and endoscopy suggested that there was functional hold-up at the level of the esophago-colic anastomosis. He underwent a series of endoscopic dilatations leading to endoscopic stenting with a plastic prosthesis. In doing so, the conduit was perforated necessitating thoracotomy to retrieve the device. He made a good recovery from this complication, but his symptoms persisted and he was retired from his career on medical grounds when he was referred to this unit. At this stage, the nature of his symptoms had progressed with intermittent episodes of postprandial swelling in his neck associated with marked edema of his left arm and chest wall. Resolution of the neck swelling was associated with gradual resolution of the edema. Repeat endoscopy indicated that the esophago-colic anastomosis was easily negotiated but that the colon was hugely dilated and the distal end could not be reached. A barium swallow was performed and showed a grossly dilated and tortuous conduit (Fig 1).
Due to the severity of symptoms and after informed consent, surgical intervention was undertaken. A left thoraco-abdominal incision was used. After dividing adhesions, the colo-gastric anastomosis was defined and then transected with a 75-mm linear cutting stapler, taking particular care to identify and preserve the ascending branch of the left colic artery and marginal vessels which lay on the posteromedial (mediastinal) aspect of the conduit. Dissection then proceeded proximally, staying close to the bowel wall, dividing only terminal vessels. This was continued above the aortic arch until the proximal colon could be made to reach the stomach without undue tension. This resulted in a resection of about 30 cm of colon, division of the proximal colon again being effected with a linear cutting stapler. A guide wire was then passed from the mouth into the colon, followed by an 18-mm Savary-Gillard esophageal dilator. This was used to calibrate and straighten the new conduit, which was narrowed by multiple firings of a 75-mm linear cutting stapler, beginning at the distal transverse stapled closure on the antimesenteric side in a longitudinal fashion, aiming to reduce the diameter of the retained colon to about 4 to 5 cm from 12 cm at maximal dilatation. This was continued with multiple firings up to the thoracic inlet. The narrowed colon was then brought under a moderate degree of tension down to the stomach, where a side-to-side stapled anastomosis was created between the anterior wall of the distal colon and the posterior wall of the stomach (Fig 2). The common opening was closed with a continuous 3-0 polyglactin suture.
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Fig 2. Operative procedure: Through a left thoraco-abdominal incision, the sigmoid area of redundant colon was resected with the proximal part of the gastric remnant and a new cologastric anastomosis was fashioned. The dilated lumen was narrowed using a linear stapler on the entire length of neo-esophagus along its antimesenteric border. (Pre-op = preoperative; Post-op = postoperative.)
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The diaphragm was closed and a series of interrupted sutures placed between the antimesenteric side of the colon and the crural fibers of the diaphragm to ensure that the colo-gastric anastomosis remained intraabdominal and under no tension. The wounds were closed in a routine fashion. The patient made an uncomplicated recovery. A barium swallow demonstrated good flow of contrast into the stomach without hold-up (Fig 3).
The patient’s symptoms of dysphagia and neck swelling with edema resolved completely and he was able to return to work. Twelve months later, he reported normal eating, no dysphagia, and he remained in full-time employment.
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Fig 3. Postoperative barium meal showing a straight and well-proportioned conduit (A) with easy passage of contrast into the stomach (B).
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Comment
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This technique has proved successful in the surgical management of a redundant colonic interposition and adds to the repertoire of methods previously described. The decision that most commonly has to be made is whether or not the stomach can be used as the conduit. While this can usually be determined preoperatively on the basis of previous operation records, barium radiology, or endoscopy, it is acknowledged that, in some cases, the decision can only be made intraoperatively. In this case, it was known that the fundus had been previously partially excised and it was felt that an adequate gastric conduit would not reach the neck. It seems illogical to only partially excise the colon to create an intrathoracic colo-gastric anastomosis, which exposes the patient to reflux as well as the likelihood of an unsatisfactory outcome, as long as redundant colon remains in the chest. Redundancy is well recognized but only requires surgical intervention in a minority, so large case series do not exist. Individual cases requiring operation often vary considerably in their anatomy both due to their pathology and to different previous surgical interventions, so it is valuable to document successful surgical approaches that might be used by others. We presume in this case that accumulation of food in the dilated colon produced a degree of venous obstruction leading to chest wall and upper limb edema.
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References
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- Jeyasingham K., Lerut T., Belsey R.H. Revisional surgery after colon interposition for benign oesophageal disease. Dis Esophagus 1999;12:7.[Medline]
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- Bonavina L., Chella B., Segalin A., Luzzani S. Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty. Ann Thorac Surg 1998;65:1446-1448.[Abstract/Free Full Text]
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Abstract
Introduction
