Ann Thorac Surg 2007;84:295-296
© 2007 The Society of Thoracic Surgeons
Case Reports
Ileocolon Graft Pedicled on Ileocolic Artery: An Alternative Esophageal Substitute for Corrosive Injury
Yu-Chih Liu, MD,
Yau-Lin Tseng, MD,
Ming-Ho Wu, MD,
Wu-Wei Lai, MD,
I.-Ling Hsu, MD,
Yi-Ting Yen, MD,
Jia-Ming Chang, MD*
Surgical Department, National Cheng-Kung University Hospital, Tainan, Taiwan
Accepted for publication February 22, 2007.
* Address correspondence to Dr Chang, Division of Thoracic Surgery, Department of Surgery, Medical College, National Cheng Kung University, No. 138, Sheng-Li Rd, Tainan, 704, Taiwan (Email: jameschang127{at}gmail.com).
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Abstract
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A variety of bowel interpositions have been well-developed for esophageal replacement surgery. However the choices are often limited in the case of alimentary corrosive injury due to frequent associated injuries. Herein we present a case of caustic injury with compromised mesocolon. Successful reconstruction of the alimentary integrity was accomplished using an ileocolic graft pedicled on an ileocolic artery.
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Introduction
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Esophageal reconstruction has been introduced and modified for almost a century. The ideal graft for esophageal substitute is chosen for each patient based on substitute availability, constant and reliable blood supply, functional propulsion to solids, and low reflux tendency. In a case wherein the vascularity is compromised, alternative procedures can be more technically demanding and the perfusion of the chosen graft should be examined thoroughly prior to harvest to avoid unnecessary failure. We herein share our unique experience with ileocolic graft (ICG) interposition, vascularized on the ileocolic artery (ICA).
A 78-year-old woman ingested hydrochloric acid during a suicide attempt and underwent an emergency laparotomy. Operative findings showed a whole layer necrosis of the stomach and esophagus with turbid ascites. A transhiatal esophagectomy with cervical esophagostomy, total gastrectomy, and feeding jejunostomy were performed.
Eighteen months later, esophageal reconstruction using an middle colic artery (MCA) based ICG was attempted. Intraoperatively, prior to graft harvest, a trial clamping of the collateral blood supply produced an ischemic change and the procedure was abandoned. Postoperative angiography showed absence of any communication between the MCA and the right colic artery (Fig 1). The patient was referred to our center.
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Fig 1. The superior mesenteric arteriography of the patient showing compromised mesocolon with sparse communication between the middle colic artery (white arrow) and right colic artery (black arrowhead). The right colic artery (black arrow) branched from the ileocolic artery.
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In our center, an isoperistaltic esophageal substitute approximately 40 cm in length ICG vascularized by ICA, was interposed through the retrosternal route. Intraoperatively, adequacy of the perfusion of the graft was tested by careful trial clamping of the collateral at the root level of the right colic artery and MCA. The right colic artery was first divided and the ICG was harvested by dividing the ascending colon and ileum, 15 cm above and 25 cm below the ileocecal valve, respectively. An end-to-end esophagoileostomy, end-to-side colojejunostomy and end-to-side ileo-transverse-colostomy were performed. The hepatic flexure was removed for possible compromised perfusion. Surgical findings and procedures are illustrated in Figure 2. On postoperative day 11, oral intake was gradually resumed and the patient was discharged uneventfully on postoperative day 21. Subsequent follow-up at 2 years showed no dysphagia or other sequelae.
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Fig 2. The operative diagram showing ileocolic graft (ICG) pedicled on ileocolic artery with a 25-cm long ileum and 15-cm colon. (A) Compromised mesocolon, the division of the ileum, ascending and transverse colon are marked in dotted lines. (B) The complete surgical result, showing ICG through the retrosternal route with neck end-to-end esophagoileostomy, end-to-side colojejunostomy, and ileocolostomy.
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Comment
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Several kinds of esophageal substitutes are used for esophageal reconstruction, including the gastric tube and grafts using the colon, jejunal, and free revascularized gastrointestine. The stomach remains the first choice of esophageal substitute due to its reliable blood supply and simple applicability with a single anastomosis [1], whereas colon interposition, introduced by Kelling and Vuillet almost a century ago, provides fewer lethal anastomotic problems and progressive improvement of propulsive function [2]. In addition, the left colon was preferable to the right due to its smaller caliber, better propulsive function to solids, and relatively more reliable blood supply.
In most cases of corrosive injury, finding a good esophageal substitute for reconstruction is difficult. The stomach is inevitably destroyed, and mesentery within the territory of the MCA is often injured and compromised by intraabdominal dissemination of the caustics and direct contact thermal injury. Under these circumstances, an ICG, first introduced by Dor and colleagues [3] in 1963, proved to be a practical option. In our literature review, anatomical variations of superior mesenteric artery (SMA) were often described. According to Garcia-Ruiz and colleagues [4], the blood supply of the ascending colon mainly originates from a branch emanating from the ICA (66%), followed by the MCA (23.3 %), or even, less frequently, a direct branch of the superior mesenteric artery (10.7%). Therefore, ICA is probably the only constant branch of the superior mesenteric artery to the right colon and could be the preferred alternative vascular pedicle for ICG interposition. The left colon was not used in this case due to shorter graft length measured from splenic flexure and beyond, compared to the ICG.
We found four key points of importance concerning the harvesting of the graft: (1) the root of ICA should be dissected high to its bifurcation from the superior mesenteric artery because it is the center of graft’s rotation; (2) marginal vascular communication between the cecum and ileum must be carefully verified; (3) the harvested ileal portion of the ICA-based ICG should be longer compared with MCA-based graft owing to the shorter well-perfused right colon; and (4) the graft’s perfusion evaluation with simple intraoperative trial clamping of the collateral vessel at the root level for unexpected variation in vascularity to avoid disastrous graft failure [5]. Surgeons should adopt versatile and flexible policy towards esophagocoloplasty rather than adhering to the classic single approach.
For esophageal reconstruction in corrosive injury with compromised mesocolon, ICG interposition vascularized by ICA provide a valuable alternative.
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References
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- Urschel JD. Does the interponat affect outcome after esophagectomy for cancer? Dis Esophagus 2001;14:124-130.[Medline]
- Renzulli P, Joeris A, Strobel O, et al. Colon interposition for esophageal replacement: a single-center experience Langenbecks Arch Surg 2004;389:128-133.[Medline]
- Dor J, Houel J, Richelme H, Dor V, Malmejac CI. Esophagoplasty with ileocecum Ann Chir Thorac Cardiovasc 1964;3:787-797.
- Garcia-Ruiz A, Milsom JW, Ludwig KA, Marchesa P. Right colonic arterial anatomyImplications for laparoscopic surgery. Dise Colon Rectum 1996;39:906-911.
- Huttl TP, Wichmann MW, Geiger TK, Schildberg FW, Furst H. Techniques and results of esophageal cancer surgery in Germany Langenbecks Arch Surg 2002;387:125-129.[Medline]
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Abstract
Introduction
