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Ann Thorac Surg 2012;93:905-912. doi:10.1016/j.athoracsur.2011.12.054
© 2012 The Society of Thoracic Surgeons
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Original Articles: General Thoracic

Similar Outcomes After Primary and Secondary Esophagocoloplasty for Caustic Injuries

Mircea Chirica, MDa, Helene Vuarnesson, MDa, Sarah Zohar, PhDb, Matthieu Faron, MDa, Bruno Halimi, MDa, Nicolas Munoz Bongrand, MDa, Pierre Cattan, MD, PhDa,*, Emile Sarfati, MDa

a Department of General, Endocrine and Digestive Surgery, Saint-Louis Hospital, Assistance publique - Hôpitaux de Paris (AP-HP), Université Paris 7 Diderot, Paris, France
b Department of Biostatistics et Medical Informatics, Saint-Louis Hospital, AP-HP; UMR 717 INSERM; Université Paris 7 Diderot, Paris, France

Accepted for publication December 16, 2011.

* Address correspondence to Prof Cattan, Centre Hospitalier Universitaire Saint-Louis, 1 avenue Claude Vellefaux, 75475 Paris Cedex 10, France (Email: pierre.cattan{at}sls.aphp.fr).


   Abstract
Top
 Abstract
Introduction
 Patients and Methods
 Results
 Comment
 References
 
Background: The main purpose of the study was to report a comparative experience with primary and secondary esophagocoloplasty for caustic injuries. Secondary esophagocoloplasty is the main rescue option after graft loss, but data in the literature are scarce.

Methods: The operative characteristics, postoperative course, and functional outcomes of 21 secondary and of 246 primary esophagocoloplasty operations performed for caustic injuries between 1987 and 2006 were compared. Intraoperative events requiring significant changes in the planned operative strategy, such as graft ischemia or necrosis, were recorded. Statistical tests were performed in both cohorts to identify factors predictive of postoperative graft necrosis. Univariate analysis was performed to identify factors predictive of functional failure after secondary esophagocoloplasty.

Results: Operative mortality (5% vs 4%, p = 0.56), morbidity (62% vs 59%, p = 0.96), postoperative graft necrosis (14% vs 7%, p = 0.16), and functional success (68% vs 70%, p = 0.79) rates of the secondary and primary esophagocoloplasty operations were similar. Intraoperative graft ischemia at the time of secondary esophagocoloplasty was significantly associated with the risk of postoperative graft necrosis (p = 0.015) and functional failure (p = 0.046). At the time of primary esophagocoloplasty, intraoperative necrosis of the colon was the only independent predictive factor of postoperative graft necrosis (p < 0.0001).

Conclusions: Secondary esophagocoloplasty is a safe and reliable salvage option after primary graft loss in patients with caustic injuries. Delayed esophagocoloplasty should be considered if intraoperative colon necrosis occurs at the time of primary reconstruction.


   Introduction
Top
 Abstract
 Introduction
Patients and Methods
 Results
 Comment
 References
 
Retrosternal esophagocoloplasty is currently the gold standard to restore digestive continuity after severe caustic esophageal injuries [1–4]. In experienced hands, operative morbidity and mortality rates are low, and most patients eventually achieve a good functional result [1, 2, 4, 5]. Nutritional autonomy after esophagocoloplasty for caustic injuries is conditioned by several factors such as age, control of the underlying psychiatric disease, severity of the initial caustic injuries, delay in reconstruction, need for pharyngeal reconstruction, operative technique, and occurrence of early or late complications [2, 6, 7]. Functional failure after esophageal reconstruction is the result of complex interactions between several of these factors.

The irreversible loss of the colonic graft is a rare cause of functional failure with tremendous consequences for the patient. The main cause for graft loss is the ischemic necrosis of the ascended colon during the early postoperative period. Postoperative graft necrosis has been reported in 4% to 8% of patients after esophagocoloplasty and is typically diagnosed between postoperative days 2 and 7 in a patient who is not doing well without apparent reason [1, 5, 8–14]. Emergency management includes ablation of the necrotic segment and construction of a cervical esophagostomy. Less common conditions that may lead to graft loss include diffuse ischemic stenosis of the coloplasty [2, 15], operative trauma, graft necrosis after incarceration into the pleura [2, 3], and repeat caustic ingestion [2, 16].

Rescue reconstruction with a novel digestive segment is currently the single possible option to restore digestive continuity after the definitive loss of a primary colonic graft [17]. In the particular setting of caustic injuries, esophageal reconstruction using gastric pull-through [18] or more complex procedures, such as supercharged [19] or free jejunal [20] flaps, may be hindered by a history of emergency gastrectomy, bowel resection, or jejunostomy construction. In such critical situations, secondary esophagocoloplasty is the sole option to avoid definitive esophagostomy and lifelong enteral nutrition.

The present study reports our comparative experience with primary and secondary esophagocoloplasty procedures in a high-volume referral center during a 20-year period. The management of intraoperative technical difficulties encountered during the construction of the colonic graft was specifically addressed.


   Patients and Methods
Top
 Abstract
 Introduction
 Patients and Methods
Results
 Comment
 References
 
The Saint-Louis Hospital's Comitée de Protection des Personnes approved the study and waived the need for patient consent.

Patients
Between March 1987 and December 2006, 31 patients with caustic injuries of the esophagus were evaluated at the Saint Louis Hospital in Paris in view of esophageal reconstruction after definitive loss of a primary colonic graft. The study excluded 5 patients who could not be offered rescue reconstruction because of lack of an appropriate esophageal substitute, 3 patients because of difficulty controlling the underlying psychiatric disease, and 2 patients who underwent reconstruction with a gastric tube. Eventually, the data of 21 patients who underwent secondary esophagocoloplasty, defined as salvage esophageal reconstruction with a novel colonic segment, were studied. After retrospective review of the medical records, the operative characteristics, postoperative course, and functional outcome of these 21secondary esophagocoloplasty procedures were compared with those of 246 primary esophagocoloplasty operations for caustic injuries performed during the same period.

The 21 patients (12 men [57%]) who underwent secondary esophagocoloplasty were a median age of 33 years (range, 18 to 74 years). A long-time history of psychiatric disease was recorded at the time of caustic ingestion in 14 patients (67%) who were treated for depression (n = 9) and schizophrenia (n = 5). The corrosive agent was ingested with suicidal intent by 19 patients (90%). The causal agents were caustic soda-based strong alkali in 16 (76%) and strong acids in 5 (24%).

The loss of the primary graft was due to the postoperative ischemic necrosis of the colonic substitute in 13 patients (62%) and to diffuse ischemic stenosis of the coloplasty in 8 (38%). The primary reconstruction operation was performed at our center in 11 patients (52%) and elsewhere in 10 (45%). The graft used for the primary esophagocoloplasty in these patients was the right colon fed by the right colic artery in 15 and the middle colic artery in 2, and the left colon fed by the left colic artery in 4.

During the same period, 246 patients underwent primary esophagocoloplasty for caustic injuries at our center. Data for some of these patients were previously reported in another publication [2], and their operative characteristics and outcomes are presented Table 1.


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  		Table 1 Operative Characteristics and Outcome of Primary and Secondary Esophagocoloplasty Procedures
 
Preoperative Evaluation
Our approach in patients considered for secondary esophagocoloplasty was the same as for the primary reconstruction [2, 6, 8]. Briefly, reconstruction was considered only in psychologically stable patients after careful psychiatric evaluation. All patients underwent a systematic otolaryngology examination to detect pharyngeal injuries, which were systematically treated at the time of esophagocoloplasty. Celiomesenteric arteriography to help the graft choice was not undertaken before primary or secondary esophagocoloplasty. Preoperative colonoscopy was performed in patients aged older than 55 years and in those with a family history of colorectal cancer. Specifically, secondary esophagocoloplasty was considered only in patients in whom thorough analysis of the initial operative reports suggested that another colonic substitute was available; upfront ileoesophagoplasty [12, 21] was not performed in this setting.

Technical Considerations
Our surgical technique of esophagocoloplasty for caustic injuries has been described in detail elsewhere [22], but for the purpose of the present study, some specific technical aspects warrant further discussion.

Primary Esophagocoloplasty
The right colon was used preferentially for primary esophageal reconstruction for caustic injuries [8]. The main arguments justifying this choice include:

1 prevention of pharyngeal reflux by the preservation of the ileocecal valve;
2 congruence of the esophagus and the ileum at the cervical level;
3 construction of an ileocolic anastomosis rather than a colocolic anastomosis at the abdominal level; and
4 possibility of using the left colon as a rescue transplant in case of postoperative right colic transplant necrosis, while the opposite is not always feasible.

Actually, at the time of left coloplasty, the proximal colonic section is usually performed at the right part of the transverse colon, with sacrifice of the middle colic and quite often of the right colic pedicles, rendering uncertain the construction of a rescue right graft. However, the left colic pedicle is usually preserved at the time of right esophagocoloplasty and can be used for construction of a salvage left graft. A first-line left coloplasty was constructed only if the right colon could not be used.

The definitive choice of the colonic segment relied on the intraoperative evaluation of the efficiency of the marginal colic artery after sequential clamping of the main vascular pedicles. Dissection of the vascular pedicles was systematically performed up to their origin to allow preservation of all proximal vascular connections between the main pedicles.

During a 30-minute clamping test, assessment of the graft's viability relied on the general aspect of the colon, the absence of congestion of the distal veins, and the presence of visible distal arterial pulsation. A satisfactory clamping test led to section of the main vascular pedicles, and the colonic segment was ascended up to the neck through a retrosternal tunnel. At this point, the aspect of the graft extremity was reevaluated after a further 15-minute delay, and if satisfactory, the operation was pursued.

Intraoperative vascular incidents that precluded the smooth course of colonic graft construction and led to significant changes in the operative strategy were recorded. Two clinical situations were identified:

First, early intraoperative graft ischemia occurred after interruption of the blood flow through the major vascular pedicles during the clamping test. This led to immediate unclamping of the vascular pedicles and the switch to another colonic segment for graft construction. If the right colon was not suitable for reconstruction, construction of a left isoperistaltic colonic graft using the left colic pedicle was attempted; if this was not feasible, the use of anisoperistaltic left coloplasty was considered (Fig 1). Similarly, construction of a standard right graft was attempted to palliate a deficient upfront left coloplasty (Fig 2). Construction of a long ileal graft using the ileocolic pedicle [12] was attempted whenever the remaining colonic segment could not be used to replace the deficient graft (Fig 3). The ischemic conditioning of the right colonic graft by ligation of the ileocolic artery, followed by a new attempt at graft ascension after a 2-month delay, was undertaken if all the previously described options have been discarded.


Figure 1
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  		Fig 1. If the right colon was unsuitable for esophageal reconstruction, an (A) isoperistaltic or (B) anisoperistaltic left esophagocoloplasty was performed.

 

Figure 2
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  		Fig 2. If the left colon was unsuitable for esophageal reconstruction, a standard right ileocoloplasty was performed.

 

Figure 3
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  		Fig 3. Intraoperative inability to perform a right or left esophagocoloplasty was managed by construction of a long isoperistaltic ileal graft fed by the ileocolic pedicle.

 
Second, late intraoperative graft ischemia occurred after vascular pedicle section and graft ascension to the neck, despite a satisfactory clamping test. Such an event prompted reintegration of the graft into the abdomen, careful repositioning to avoid twist of the feeding pedicle, and packing with warm sponges to palliate vasoconstriction of the feeding artery. A new attempt at graft ascension was undertaken if the colon recovered a normal aspect, and the operation was continued in the absence of recurrent ischemia. Otherwise, the necrotic colon was removed and another colonic segment was chosen for esophageal replacement during the same procedure, following the same steps as described.

Secondary Esophagocoloplasty
Secondary esophagocoloplasty was performed following the same steps. Management of intraoperative graft ischemia or necrosis, or both, during secondary reconstruction was the same as described. Subcutaneous positioning of the graft was considered only if the retrosternal and mediastinal routes could not be used. A senior member of the surgical team systematically performed the secondary esophagocoloplasty.

Postoperative Management
Postoperative management was similar after primary and secondary esophagocoloplasty and has been described in detail elsewhere [2, 6, 8]. Any unexplained deterioration of the patient's condition during the early postoperative period prompted immediate bedside cervicotomy in the intensive care unit to assess graft viability, followed by transfer to the operating room for a complete surgical exploration if doubt persisted. Definitive diagnosis of postoperative graft necrosis led to coloplasty removal and construction of a cervical esophagostomy; no attempt at further reconstruction was made at this point. Patients who experienced postoperative graft necrosis were discharged to facility care units specialized in management of enteral nutrition and psychologic support.

For all other patients, in-office removal of the jejunostomy tube was performed when the daily oral intake exceeded 1500 Kcal and the weight gain and the psychologic condition were stable [2, 6]. Clinical follow-up was conducted every 6 months during the 2 first years and annually thereafter, and psychologic follow-up was pursued indefinitely [2].

Statistical Analysis
Operative mortality was defined as any death occurring before postoperative day (POD) 30 or during the hospital stay. Functional success was defined as ability to remove the jejunostomy and tracheotomy tubes in patients with minimum 6 months of follow-up, after evaluation of digestive and respiratory functions [2, 6]. To allow comparison of functional outcomes between the primary and secondary esophagocoloplasty procedures, the occurrence of postoperative graft necrosis was considered as a functional failure of the procedure, regardless of the patient's final outcome. Technical failure of esophagocoloplasty (primary or secondary) was defined as definitive esophagostoma and lifelong enteral nutrition in the absence of further reconstruction possibilities due to the lack of an appropriate esophageal substitute.

Results are reported as median (range) or as counts (proportion). Quantitative variables were compared by Wilcoxon rank sum tests and qualitative variables by the Fisher exact test. Intraoperative data, postoperative mortality and morbidity rates, and functional outcomes of primary and secondary esophagocoloplasty were compared. For patients undergoing primary esophagocoloplasty, univariate analysis was performed to identify predictors of postoperative graft necrosis. All variables achieving statistical significance at a 0.10 level in the univariate analysis were considered in a logistic regression model. A backward variable selection procedure with a p value cutoff at 0.05 was used to identify the set of independent predictors of graft necrosis. For patients undergoing secondary esophagocoloplasty univariate analysis was performed to identify predictors of graft necrosis and predictors of functional success. Multivariate analysis was not performed in this group due to small sample size.

The validity of the logistic regression models was checked using the Le Cessie and Van Houwelingen [23] goodness-of-fit method. Statistical analyses were performed using R 2.13 software (The R Development Core Team). A test was considered significant if the p value was less than 0.05. All reported p values are two-sided.


   Results
Top
 Abstract
 Introduction
 Patients and Methods
 Results
Comment
 References
 
Secondary Esophagocoloplasty
Operative Data
The median delay between primary and secondary esophagocoloplasty was 7 months (range, 3 months to 2 years). Secondary esophagocoloplasty was eventually completed in all patients in whom it was attempted. A two-stage procedure was required in 2 patients (10%). Secondary reconstruction was attempted with the right colon in 4 patients (19%) and with the left colon in 17 (81%). A right colonic graft fed by the right colic artery was constructed in 2 patients (10%). Inability to use the right colon was managed by construction of an ileal graft using the ileocolic artery in 1 patient (5%). Ischemic conditioning of the right colon by ligation of the ileocolic artery and ascension of a right graft after a 2-month delay was performed in 1 patient (5%). A left esophagocoloplasty was performed in 16 patients (75%) by using the left colic artery in 14, the middle colic artery in 1, and the sigmoid branch of the inferior mesenteric artery in 1. Inability to construct a left colonic graft in 1 patient (5%) was managed by ascension of an ileal graft using the ileocolic artery.

Intraoperative graft ischemia was recorded at the time of secondary reconstruction in 6 patients (29%) and management included anisoperistaltic graft ascension to the neck in 3, construction of an ileal graft in 2, and the ischemic conditioning of the colon in 1. No intraoperative graft necrosis occurred. Two patients (10%) underwent anisoperistaltic left esophagocoloplasty because of insufficient length of the remaining transverse colon after previous ablation of a right graft. In 1 patient, the length of the remaining left colonic segment did not allow construction of a tension-free cervical anastomosis after ascension to the neck. A cervical colostomy was constructed and a two-stage anastomosis was successfully performed through a cervical approach 2 months later.

The graft was positioned subcutaneously in 3 patients (14%) because of extensive retrosternal sclerosis. Pharyngeal reconstruction by colopharyngoplasty was performed in 3 patients (14%). The intestinal continuity was restored by a coloduodenal anastomosis in 8 patients (38%), a Roux-en-Y loop in 8 (38%), and a cologastric anastomosis in 5 (24%). Median operative time was 7.75 hours (range, 2 to 15 hours).

Postoperative Course
One patient (5%) died of pulmonary complications on POD 55. Postoperative complications occurred in 13 patients (62%). The most frequent adverse events were pneumonia, 10 (48%); wound infection, 3 (14%); and cervical fistula, 2 (10%). Postoperative graft necrosis occurred in 3 patients (14%), and no further reconstruction was considered in these patients. Fourteen patients (66%) required intensive care unit stay for a median of 14 days (range, 5 to 55 days). Median hospital length of stay was 49 days (range, 18 to 68 days). Late morbidity occurred in 8 patients (38%) and included cervical anastomotic stenosis in 7 (33%), recurrent nerve palsy in 3 (14%), and colonic redundancy in 1 (5%).

One patient (5%) was lost to follow-up. Functional outcome was evaluated in 19 patients after a median follow-up of 4 years (range, 17 months to 9 years). Functional success was recorded in 13 patients (68%). Occurrence of intraoperative graft ischemia at the time of secondary esophagocoloplasty was the only factor significantly associated with the risk of postoperative graft necrosis (p = 0.015; Table 2) and functional failure (p = 0.046; Table 3). At the end of the follow-up period, 7 patients (33%) had died, 1 (5%) of whom committed suicide.


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  		Table 2 Univariate Analysis of Postoperative Graft Necrosis in 21 Patients Who Underwent Secondary Esophagocoloplasty
 

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  		Table 3 Univariate Analysis of Functional Success in 21 Patients Who Underwent Secondary Esophagocoloplasty
 
Primary Esophagocoloplasty
Technical Difficulties Encountered During Graft Construction
Intraoperative graft ischemia was recorded in 41 of the 246 patients (17%) who underwent primary esophagocoloplasty across the study period. Early ischemia occurred in 20 patients (8%) and was managed by construction of a left isoperistaltic colonic graft in 5, a anisoperistaltic colonic graft in 8, an ileal graft in 5, and by the ischemic conditioning of the right colon in 2. Late ischemia occurred in 21 patients (9%); the graft eventually recovered a normal aspect in 8, and the operation commenced uneventfully. Intraoperative necrosis of the colon developed in 13 patients (5%) and they underwent segmental right (n = 12) and left (n = 1) colectomy. Reconstruction was undertaken in all of them during the same procedure using the left colon in 11 patients (anisoperistaltic in 2) and an ileal graft in 2.

Postoperative Outcomes
Postoperative graft necrosis occurred in 17 patients (7%) after a median delay of 4 days (range, 1 to 10 days). On univariate analysis, ingestion of strong acids (p = 0.004), occurrence of intraoperative necrosis of the colon (p < 0.0001) and construction of a left colonic graft (p = 0.04) were associated with a high risk of postoperative graft necrosis (Table 4). Occurrence of intraoperative colon necrosis was retained as the only independent predictive factor of postoperative graft necrosis (odds ratio, 15.9; 95% confidence interval, 3.6 to 67.6; p < 0.0001) in the multivariate analysis model.


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  		Table 4 Univariate Analysis for Postoperative Graft Necrosis in 246 Patients Who Underwent Primary Esophagocoloplasty
 
Comparison of Primary and Secondary Reconstruction Operations
As a result of our reconstructive policy, a left colonic graft was used more often during secondary esophagocoloplasty and a right graft during primary esophagocoloplasty (p < 0.0001). Anisoperistaltic graft ascension was more frequent at the time of secondary reconstruction (24% vs 4%; p = 0.003). Early intraoperative graft ischemia occurred more often (29% vs 8%, p = 0.009), and the incidence of technical failure was higher (14% vs 3%, p = 0.046) in the secondary reconstruction group. No significant differences were recorded between the secondary and primary esophagocoloplasty operations for operative mortality (5%, vs 4%, p = 0.56), morbidity (62% vs 59%, p = 0.96), graft necrosis (14% vs 7%, p = 0.16), late morbidity (38% vs 53%, p = 0.26), and functional success rates (68% vs 70%; p = 0.79; Table 1).

Efficacy of Technical Maneuvers for the Management of Intraoperative Vascular Incidents
Overall, intraoperative graft ischemia was recorded in 47 patients during esophagocoloplasty (primary and secondary) for caustic injuries. No postoperative graft necrosis occurred in patients with early intraoperative ischemia managed by switch to an isoperistaltic left esophagocoloplasty or in patients with late ischemia who remained free of intraoperative colon necrosis. The postoperative graft necrosis rates after management of early ischemia by anisoperistaltic left esophagoplasty, ileal graft construction, and the ischemic conditioning of the colon were 9%, 14%, and 100%, respectively. The postoperative graft necrosis rate in patients who experienced intraoperative colon necrosis at the time of primary esophagocoloplasty was 46%.


   Comment
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
References
 
The present study reports the main technical aspects, the postoperative course, and the functional outcomes of 21 secondary esophagocoloplasty and 246 primary esophagocoloplasty operations for caustic injuries during a 20-year period. The main finding was that secondary esophagocoloplasty was a feasible, safe, and efficient salvage option for the management of patients with caustic injuries whose primary colonic graft failed. Operative mortality and morbidity, incidence of late complications, and functional success rates were similar after secondary and primary esophagocoloplasty procedures. Moreover, results of secondary esophagocoloplasty were in the range of the 4% to 17% mortality [4, 10, 11, 13, 16, 24, 25], 27% to 73% morbidity [4, 10, 11, 13, 16, 24, 25], and 66% to 92% functional success rates [1, 4, 5, 13, 16] of primary esophagocoloplasty reported in the literature.

The present study addresses the specific issue of intraoperative technical difficulties encountered during esophagocoloplasty for caustic injuries and their management. It looks like common sense to expect additional technical difficulties at the time of secondary esophagocoloplasty as a result of previous major abdominal surgery and a restrained choice of an esophageal substitute. Although the operative mortality, morbidity, and graft necrosis rates of both procedures were similar, the incidence of early intraoperative graft ischemia was higher during secondary esophagocoloplasty. Early ischemia recorded during secondary esophagocoloplasty (but not during primary esophagocoloplasty) resulted in an increased risk of graft necrosis and functional failure.

Alongside significantly increased rates of technical failure after secondary reconstruction, these findings underscore increased difficulties in graft construction and limited intraoperative rescue possibilities at the time of secondary esophagocoloplasty. These assumptions were furthermore supported by indirect markers such as longer operative times and more frequent need for anisoperistaltic ascension and subcutaneous graft positioning.

Early intraoperative ischemia during esophagocoloplasty was the immediate consequence of the anatomic interruption or functional inefficiency of the marginal artery and was readily revealed by the clamping test. When feasible, the immediate switch to a left colonic graft was a safe management alternative for early intraoperative ischemia. In the absence of another available colonic segment, two techniques were used to deal with this condition:

1 The construction of an ileal graft using the ileocolic artery proved a fair rescue option and resulted in an acceptable 14% graft necrosis rate.
2 The ischemic conditioning of the colon was attempted in 3 patients on the basis of promising results of gastric ischemic conditioning for esophageal replacement after esophagectomy for cancer [26, 27]. This technique resulted invariably in postoperative graft necrosis and was rapidly abandoned. Such dismal results may be explained by different patterns of small vessel distribution into the walls of the stomach and colon [28].

Late intraoperative graft ischemia was recorded in 21 patients (9%) and accounted for half of the vascular incidents during primary esophagocoloplasty. Aside more common technical errors, such as torsion of vascular pedicles during retrosternal graft pull-through or misjudgment of graft viability during the clamping test, venous ischemia of the colon has been offered as a possible explanation [3, 4] for the occurrence of late intraoperative graft ischemia. This phenomena was explained by the observation that branching of arteries is usually closer to the colon than the confluence of veins [3]; thus, the "en masse" clamping of the vascular pedicles may interrupt the venous network and lead to venous intraoperative graft ischemia. Successful intraoperative management of late ischemia by graft repositioning did not increase the risks of postoperative graft necrosis.

Conversely, the need to perform colonic resection as a result of intraoperative necrosis of the colon, followed by the construction of another graft, resulted in a 46% postoperative graft necrosis rate, which meant technical failure in this peculiar setting. The present considerations support the use of a two-stage management strategy in the event of intraoperative colon necrosis, including the cessation of the initial procedure after resection of the necrotic colon and followed by delayed secondary reconstruction.

In conclusion, secondary esophagocoloplasty is a reliable salvage option in patients with caustic injuries after failed primary reconstruction due to graft loss. Although operative and functional results were similar to those of primary reconstruction, secondary esophagocoloplasty should be regarded as a difficult, high-risk procedure ideally undertaken by experienced esophageal surgeons. Delayed secondary esophagocoloplasty should be considered for the management of intraoperative colon necrosis at the time of primary reconstruction.


   References
Top
 Abstract
 Introduction
 Patients and Methods
 Results
 Comment
 References
 

  1. Chien KY, Wang PY, Lu KS. Esophagoplasty for corrosive stricture of the esophagus: an analysis of 60 cases Ann Surg 1974;179:510-515.[Medline]
  2. Chirica M, Veyrie N, Munoz-Bongrand N, et al. Late morbidity after colon interposition for corrosive esophageal injury: risk factors, management, and outcome. A 20-years experience. Ann Surg 2010;252:271-280.[Medline]
  3. Gerzic ZB, Knezevic JB, Milicevic MN, Jovanovic BK. Esophagocoloplasty in the management of postcorrosive strictures of the esophagus Ann Surg 1990;211:329-336.[Medline]
  4. Hong PW, Seel DJ, Dietrick RB. The use of colon in the surgical treatment of benign stricture of the esophagus Ann Surg 1964;160:202-209.[Medline]
  5. Wain JC, Wright CD, Kuo EY, et al. Long-segment colon interposition for acquired esophageal disease Ann Thorac Surg 1999;67:313-317discussion 317–8.[Abstract/Free Full Text]
  6. Chirica M, de Chaisemartin C, Goasguen N, et al. Colopharyngoplasty for the treatment of severe pharyngoesophageal caustic injuries: an audit of 58 patients Ann Surg 2007;246:721-727.[Medline]
  7. Lefrancois M, Gaujoux S, Resche-Rigon M, et al. Oesophagogastrectomy and pancreatoduodenectomy for caustic injury Br J Surg 2011;98:983-990.[Medline]
  8. Bothereau H, Munoz-Bongrand N, Lambert B, Montemagno S, Cattan P, Sarfati E. Esophageal reconstruction after caustic injury: is there still a place for right coloplasty? Am J Surg 2007;193:660-664.[Medline]
  9. Cerfolio RJ, Allen MS, Deschamps C, Trastek VF, Pairolero PC. Esophageal replacement by colon interposition Ann Thorac Surg 1995;59:1382-1384.[Abstract/Free Full Text]
  10. DeMeester TR, Johansson KE, Franze I, et al. Indications, surgical technique, and long-term functional results of colon interposition or bypass Ann Surg 1988;208:460-474.[Medline]
  11. Furst H, Hartl WH, Lohe F, Schildberg FW. Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon Ann Surg 2000;231:173-178.[Medline]
  12. Popovici Z. A new philosophy in esophageal reconstruction with colon. Thirty-years experience. Dis Esophagus 2003;16:323-327.[Medline]
  13. Thomas P, Fuentes P, Giudicelli R, Reboud E. Colon interposition for esophageal replacement: current indications and long-term function Ann Thorac Surg 1997;64:757-764.[Abstract/Free Full Text]
  14. Wilkins Jr EW. Long-segment colon substitution for the esophagus Ann Surg 1980;192:722-725.[Medline]
  15. Cheng W, Heitmiller RF, Jones B. Subacute ischemia of the colon esophageal interposition Ann Thorac Surg 1994;57:899-903.[Abstract/Free Full Text]
  16. Knezevic JD, Radovanovic NS, Simic AP, et al. Colon interposition in the treatment of esophageal caustic strictures: 40 years of experience Dis Esophagus 2007;20:530-534.[Medline]
  17. Poghosyan T, Gaujoux S, Sfeir R, Larghero J, Cattan P. Bioartificial oesophagus in the era of tissue engineering J Pediatr Gastroenterol Nutr 2011;52(Suppl 1):S16-S17.[Medline]
  18. Orringer MB, Marshall B, Chang AC, Lee J, Pickens A, Lau CL. Two thousand transhiatal esophagectomies: changing trends, lessons learned Ann Surg 2007;246:363-372discussion 372–4.[Medline]
  19. Poh M, Selber JC, Skoracki R, Walsh GL, Yu P. Technical challenges of total esophageal reconstruction using a supercharged jejunal flap Ann Surg 2011;253:1122-1129.[Medline]
  20. Icard P, Marchand JP, Grossetti D, Houssin D. [Last recourse reconstruction of the cervicothoracic esophagus: the free jejunal transplant] Ann Chir 1989;43:229-231.[Medline]
  21. Hirsch Jr DM, Neville WE. Total esophageal replacement with a segment of ileum J Thorac Cardiovasc Surg 1968;55:211-215.[Medline]
  22. Munoz-Bongrand N, Cortes A, Sarfati E. [Right ileo-coloplasty after total esophagogastrectomy for caustic lesion] J Chir (Paris) 2001;138:349-352.[Medline]
  23. Le Cessie S, Van Houwelingen J. A goodness-of-fit test for binary regression models, based on smoothing methods Biometrics 1991;47:1267-1282.
  24. Davis PA, Law S, Wong J. Colonic interposition after esophagectomy for cancer Arch Surg 2003;138:303-308.[Medline]
  25. 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]
  26. Urschel JD. Esophagogastric anastomotic leaks: the importance of gastric ischemia and therapeutic applications of gastric conditioning J Invest Surg 1998;11:245-250.[Medline]
  27. Holscher AH, Schneider PM, Gutschow C, Schroder W. Laparoscopic ischemic conditioning of the stomach for esophageal replacement Ann Surg 2007;245:241-246.[Medline]
  28. Allison AS, Bloor C, Faux W, et al. The angiographic anatomy of the small arteries and their collaterals in colorectal resections: some insights into anastomotic perfusion Ann Surg 2010;251:1092-1097.[Medline]




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ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
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