Ann Thorac Surg 2008;86:1965-1967. doi:10.1016/j.athoracsur.2008.05.043
© 2008 The Society of Thoracic Surgeons
Case Reports
Surgical Management of Late Complications After Colonic Interposition for Esophageal Atresia
Rishi Dhir, MB, ChB,
Robert P. Sutcliffe, MRCS,
Ashish Rohatgi, FRCS,
Matthew J. Forshaw, FRCS,
Dirk C. Strauss, FCS(SA),
Robert C. Mason, FRCS*
Department of Surgery, St. Thomas' Hospital, London, United Kingdom
Accepted for publication May 15, 2008.
* Address correspondence to Dr Mason, Department of Surgery, St. Thomas' Hospital, Westminster Bridge Road, London, SE1 7EH, United Kingdom (Email: robert.mason{at}gstt.nhs.uk).
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Abstract
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Late complications after colonic interposition for neonatal esophageal atresia may lead to debilitating symptoms, poor quality of life, and malnutrition in young adults with otherwise normal life expectancies. We report our experience with 3 patients who underwent revision surgery more than 20 years after colonic interposition. Revision surgery may relieve symptoms and improve quality of life in selected patients. However, for patients with recurrent symptoms, further reconstructive options may be limited due to the lack of an available conduit, and long-term enteral feeding may be the only option for these patients.
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Introduction
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Colonic interposition is an established treatment for esophageal replacement in children with long gap esophageal atresia [1]. Several centers report superior long-term results using colonic interposition compared with gastric pull-up, and advocate the colon as the preferred conduit for benign conditions, including esophageal atresia, Boerhaave's syndrome, and benign strictures [1]. Children with long-gap esophageal atresia who are otherwise healthy may have a normal life expectancy. Long-term follow-up in this group of patients is necessary, because problems with the graft may present many years after surgery [2, 3]. Worldwide experience of late complications is limited to case reports and small series, and their surgical management presents a major challenge even for experienced esophageal surgeons. We report our experience of 3 patients who presented with late complications more than 20 years after colonic interposition.
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Case Reports
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Patient 1
Patient 1 was diagnosed with a tracheo-esophageal fistula and esophageal atresia as a neonate, which was treated by colonic interposition (ie, isoperistaltic descending and transverse colon) into the left pleural cavity. He was also diagnosed with congenital anal stenosis, which required multiple procedures, including a defunctioning ileostomy at 36 years of age. Two years previously, a proximal esophago-colonic anastomotic stricture developed in the patient, and was dilated. He re-presented at 43 years of age with dysphagia, weight loss, and regurgitation. At endoscopy, he was found to have a redundant loop of colonic conduit and a distal colono-gastric anastomotic stricture. Due to the severity of his symptoms and poor quality of life, he underwent surgical exploration through a left thoraco-abdominal incision. At operation, there was evidence of obstruction at the distal end of the conduit by a fibrotic band, which was divided. There was no evidence of colonic redundancy; therefore the conduit was not revised. Postoperatively, his dysphagia initially improved, but during the subsequent months it gradually recurred, although less severe than preoperatively. He is currently able to tolerate fluids and sufficient oral nutritional supplements to maintain his weight. However, his overall quality of life remains poor, and he has required treatment for depression.
Patient 2
Patient 2 was diagnosed with long-gap esophageal atresia, requiring cervical esophagostomy, decompressive gastrostomy, and feeding jejunostomy 8 days after birth. She underwent delayed reconstruction at the age of 18 months with a colonic interposition (ie, isoperistaltic descending and transverse colon) placed into the left pleural cavity. At 12 years of age, symptoms of vomiting and dysphagia developed, which became progressively worse during the next 12 years. After multiple failed endoscopic dilatations, she remained symptomatic and underwent surgical revision of the conduit at 24 years of age. This was performed at a different institution and no operative details were available. Postoperatively, an anastomotic leak developed that required a prolonged intensive care admission. She was discharged home, but for the next 13 years her dysphagia worsened, which caused her failure to thrive and reduced her quality of life. A barium swallow demonstrated functional hold-up of contrast within a redundant loop of colon proximal to the cologastric junction. Due to the debilitating nature of her symptoms, it was decided to attempt surgical revision of the redundant loop through a left thoraco-abdominal incision. At operation, there was evidence of partial mechanical obstruction of the colonic conduit due to adhesions and herniated caudate lobe of the liver (Fig 1). The adhesions were divided and the caudate lobe was mobilized from the esophageal hiatus. A 20-cm redundant colonic loop was resected and the cologastric anastomosis was refashioned with interrupted 3-0 polyglactin sutures. A small bowel obstruction developed in the patient in the postoperative period that required laparotomy and adhesiolysis. At follow-up, her dysphagia improved, but she continues to require supplemental nutrition through a feeding jejunostomy to maintain weight.
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Fig 1. Preoperative computed tomographic scan of patient 2, which shows herniation of caudate lobe of the liver through the esophageal hiatus (arrow), causing partial obstruction of the colonic conduit.
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Patient 3
Patient 3 was diagnosed with esophageal atresia and underwent colonic interposition (ie, isoperistaltic descending and transverse colon) into the left pleural cavity as a neonate. From 18 to 28 years of age, he had progressive dysphagia develop in association with post-prandial neck swelling and recurrent aspiration pneumonia. A barium swallow and computed tomographic scan demonstrated colonic redundancy, with hold up of contrast at the level of the aortic arch (Fig 2). He underwent surgical revision of his colonic conduit through a left posterolateral thoracotomy. At operation, he was found to have a 10-cm loop of redundant colon that was resected. The conduit was refashioned by a handsewn end-to-end anastomosis. Postoperative recovery was complicated by an anastomotic leak that was managed conservatively with drainage. At follow up, he had made a full recovery and was asymptomatic.
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Fig 2. Barium swallow of patient 3 showing a redundant loop of colonic conduit at the level of the aortic arch.
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Comment
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Late complications after colonic interposition include graft redundancy (4% to 5%), anastomotic stricture (27% to 30%), and adhesional obstruction [4, 5]. Although some patients may be managed by nonsurgical methods, such as endoscopic dilation, surgical revision is required in as many as one fifth of the cases [6]. In patients who undergo revision surgery, the procedure is tailored to each individual case, and may involve adhesiolysis or resection of redundant segments, or both [2–4, 6]. Colonic redundancy is the most common complication that requires surgery [6–8], and it probably occurs due to discrepancy in length between the vascular pedicle and the colonic graft [2, 5]. In time, the colon is susceptible to passive dilatation above points of partial obstruction (eg, thoracic inlet, left main bronchus, diaphragmatic hiatus, or cologastric anastomotic stricture), which leads to progressive redundancy, debilitating symptoms, and malnutrition. Revision surgery for late complications after colonic interposition seems to be successful in the majority of cases [2, 3, 6], although the presence of reporting bias in small series and case reports makes it difficult to determine the true success rate of this procedure.
The management of patients presenting with late complications of colonic interposition is a major challenge to esophageal surgeons, and it requires careful clinical and radiological assessment. It is important to clearly establish the nature and severity of the patient's symptoms and fully explore each patient's expectations. The perioperative risks should be clearly explained, and patients should have a realistic understanding of the possible outcomes, including failure to resolve symptoms. All patients who consider surgery should be thoroughly investigated by contrast swallow, endoscopy, and computed tomography to characterize the full length of colonic graft, including the site and severity of redundant loops, and the presence of any obstructive lesion or stricture. Video fluoroscopy may provide additional information about the functional performance of the graft. Anastomotic strictures may be amenable to endoscopic or radiological dilation, but resistant strictures, particularly in association with redundancy may require surgery. A redundant loop may be completely resected with a colo-colonic anastomosis, or partially resected by excising the anti-mesenteric border with a linear stapler to narrow the lumen. Extrinsic sites of obstruction or adhesions should be corrected. A feeding jejunostomy tube should be inserted to allow early postoperative enteral feeding, and this may become a lifeline for patients whose symptoms persist after surgery.
In our experience, revision surgery after colonic interposition may relieve symptoms and improve quality of life in selected patients in whom the clinical picture closely correlates with endoscopic and radiological findings. However, patients with recurrent symptoms after revision surgery should receive careful counseling about the limitations of further surgery. Global immotility of the colonic graft may contribute to persistent or recurrent symptoms, and the only option for these patients may be long-term enteral feeding to maintain nutrition. Resection of the entire graft and reconstruction may be possible, but these may be limited by availability of a suitable conduit in patients who have often undergone multiple previous operations.
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References
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Abstract
Introduction
