Ann Thorac Surg 2003;76:933-935
© 2003 The Society of Thoracic Surgeons
Case report
Extended left colon interposition for esophageal replacement using arterial augmentation
Joseph H. Gorman, III, MD*a,
David W. Low, MDa,
T. Sloane Guy, IV, MDa,
Robert C. Gorman, MDa,
Ernest F. Rosato, MDa
a Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
Accepted for publication February 14, 2003.
* Address reprint requests to Dr Joseph H. Gorman, 3400 Spruce St, 6 Silverstein Pavilion, Department of Surgery, Hospital of the University of Pennsylvania, Philadelphia, PA, USA 19104
e-mail: gormanj{at}uphs.upenn.edu
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Abstract
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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.
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Introduction
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The most commonly used esophageal replacement for reconstruction after resection is a gastric tube fashioned from the greater curvature [1].
A segment of left colon is the usual second choice. This technique is used when the stomach is unusable because of caustic burn, scar, ulceration, or previous gastric resection, or most commonly after failed gastric pull-up [2].
In most patients, the left colon from sigmoid to mid-transverse colon is used with the vascular supply being based on the ascending branch of the left colonic artery. This portion of colon ordinarily reaches the neck, but there are times when additional length is necessary and the colon needs to be divided at the hepatic flexure. When this is done, the vascular supply of the proximal transverse colon can become jeopardized, particularly when the vascular arcade between the middle and left colic arteries is deficient [3].
Additional colonic length is almost always needed in the situation of the failed gastric pull-up. Previous resection of the necrotic stomach, adhesions associated with a multiple redo-laparotomy, and the need to use the substernal route to reach the cervical esophagus or pharynx, all conspire to produce a requirement for increased length of conduit. We present a case in which the arterial supercharge technique [4] was used to provide a colonic interposition with extended length in such a clinical situation.
The patient is a 45-year-old man with a history of gastroesophageal reflux and Barrett’s esophagus who underwent an uncomplicated transhiatal esophagectomy for treatment of high grade dysplasia arising in Barrett’s mucosa of the distal esophagus. Pathologic examination of the specimen confirmed the diagnosis and revealed no invasive cancer. The patient had an upper gastrointestinal barium study on postoperative day 7 that revealed a widely patent anastomosis with no leak and prompt gastric emptying. His oral intake was advanced for 2 days, and then he was discharged home on a regular diet.
Two weeks after discharge he returned to the hospital complaining of progressive shortness of breath. Chest roentgenogram revealed a moderately sized pleural effusion. Assessment of the fluid, obtained by pleurocentesis, revealed an amylase of greater than 5,000. Subsequent gastrograffin swallow demonstrated extravasations from the proximal gastric tube. The patient was taken to the operating room for reexploration. The proximal 20% of the gastric tube was found to be necrotic. The nonviable stomach was resected, a gastric tube was placed, and a cervical esophagostomy was performed. A feeding jejunostomy tube had been placed at the earlier operation. The patient recovered nicely and was discharged home on postoperative day 14 on jejunostomy tube feedings.
Six weeks after discharge the patient was returned to the operating room with the plan of performing a substernal left colonic interposition. At the time of operation, the colonic segment from the left colic artery to the middle colic artery was of insufficient length to reach from the foreshortened gastric remnant to the cervical esophagus by the substernal route. In order to extend the length of the conduit, the middle colic artery was divided at its origin with the superior mesenteric artery, and this pedicle was carefully preserved. The proximal colon was then divided at the hepatic flexure. The distal colon was divided at the sigmoid paying careful attention to preserve the left colic artery as the vascular pedicle. This maneuver allowed the colon to reach easily to the cervical esophagus without tension.
Before performing the esophago-colonic anastomosis, the proximal portion of the external carotid artery was exposed to facilitate the arterial reconstruction. The first branch of this artery, the superior thyroid artery, was too narrow and too short to establish a suitable microvascular connection. Therefore, a 10-cm segment of distal saphenous vein was harvested for use as an interposition graft between the external carotid artery and the free end of the middle colic artery. Before clamping the external carotid, 5,000 units of intravenous heparin were administered. The anastomosis between the middle colic artery and the reversed saphenous vein graft was done in an end-to-end fashion. A small aortic punch was used to create a circular hole in the external carotid, and an end-to-side anastomosis was completed. Both anastomoses were sewn with interrupted 7-0 monofilament suture (Fig 1).
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Fig 1. Image demonstrating the arterial supercharge technique and the length of colon used during the procedure. A reverse saphenous vein was used to connect the external carotid artery to the preserved middle colic artery pedicle.
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The esophago-colonic and gastro-colonic anastomoses were then carried out in a standard hand sewn fashion.
On postoperative day 7, a barium swallow revealed a widely patent anastomosis with no leak. He was discharged home on postoperative day 12 while tolerating a regular diet.
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Comment
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The use of a gastric tube fashioned from the greater curvature as an esophageal replacement is usually quite reliable. The Achilles heel of the procedure lies in the fact that the blood supply of the cranial 20% of the tube is based only on a microscopic network of capillaries and arterioles making it subject to potential vascular insufficiency [5]. Even in the most experienced hands, gastric tube necrosis complicates approximately 1 in every 125 transhiatal esophagectomies [1]. These situations require prompt surgical intervention. The result of such remedial surgery usually produces a difficult last chance situation in which the surgeon is faced with a long gut discontinuity and no ideal choice of conduit for reconstruction. As a result the esophageal surgeon needs to have a reliable and reproducible way to deal with this clinical scenario. We believe the case presented illustrates such a method.
The length of colon from the mid-transverse to sigmoid is in many cases barely long enough to serve as an adequate pedicle interposition. As a result, in trying to make it reach to the neck, tension is placed on the left colic artery pedicle. In fact, venous obstruction caused by pedicle tension and torsion is the most common way these procedures fail [2]. The so-called vascular supercharge of the colonic interposition has been described before, but it has not achieved widespread use [4]. Many surgeons believe the left colic artery pedicle provides adequate flow and that the supercharge technique is tedious and adds little. We have found the technique to be relatively straightforward and quite valuable in allowing more of the colon to be mobilized and used safely. The increased colonic length ultimately results in reduced tension on the left colonic vascular pedicle, as well as both the gastro-colonic and esophago-colonic anastomoses, all of which contribute to the long-term success of the operation.
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References
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- Orringer M.B., Marshall B., Iannettoni M.D. Transhiatal esophagectomy for treatment of benign and malignant esophageal disease. World J Surg 2001;25:196-203.[Medline]
- DeMeester S.R. Colon interposition following esophagectomy. Dis Esophagus 2001;14:169-172.[Medline]
- Cheng B., Chen K., Gao S., Tu Z. Colon interposition. Recent Res Cancer 2000;155:151-160.
- 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]
- Liebermann-Meffert D.M., Meier R., Siewert J.R. Vascular anatomy of the gastric tube used for esophageal reconstruction. Ann Thorac Surg 1992;54:1110-1115.[Abstract]
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Abstract
Introduction
