EJCTS Click here to go to Siemens website
HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
QUICK SEARCH:   [advanced]


     

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Attila Csekeö
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kotsis, L.
Right arrow Articles by Csekeö, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kotsis, L.
Right arrow Articles by Csekeö, A.
Related Collections
Right arrow Esophagus - other

Eur J Cardiothorac Surg 2002;21:79-83
© 2002 Elsevier Science NL

Late complications of coloesophagoplasty and long-term features of adaptation

Lajos Kotsisa*, Zoltán Krisárb, Károly Orbána, Attila Csekeöa

a Thoracic Surgical Clinic of Semmelweis University, Pihenöút 1, H-1529 Budapest, Hungary
b Department of Surgery, Hospital Oradea, Oradea, Romania

Received 22 February 2001; received in revised form 15 August 2001; accepted 3 October 2001.

* Corresponding author. Tel.: +36-1-391-3239; fax: +36-1-200-2573.


   Abstract
Top
 Abstract
1. Introduction
 2. Materials and methods
 3. Adaptation image
 4. Results
 5. Discussion
 6. Conclusions
 References
 
Objectives: Revisional surgery of late complications after 141 substernal by-pass operations (1962–1990), except three cases with isoperistaltic (except seven with anisoperistaltic) transverse colon grafts for caustic esophageal strictures, are presented. Long-term adaptation of the grafts was investigated with cineradiographical and histochemical methods. Methods: Correction of the ‘pseudodiverticulum’ of the proximal anastomosis as a complication of the standard by-pass procedure (in five patients) was achieved by closure of the esophagus below the anastomosis or by end-to-end reanastomosis. Cervical anastomosis stricture (in seven) was solved either by plasty or resection and a similar reanastomosis. Delayed passage due to an intra-abdominal redundant graft (in five) was managed by abdominal shortening coloplication or by side-to-side gastrocolostomy. Late pyloric obstruction as a cause of gastrocolic reflux required pyloroplasty in two instances. Mixed barium–bread bolus for a cineradiographical transit study and periodic acid Schiff reaction plus Alcian Blue staining for a mucopolysaccharide search were used 8 years after the operations. Results: In all but one case, redo surgery was successful. Characteristic coordinated multihaustral propulsive movement developed in the distal colonic segment, playing a secondary but active role in the final phase of swallowing in isoperistaltic substitution. These grafts were free from gastrocolic reflux. Augmentation of neutral mucopolysaccharide was observed on the surface and in the Lieberkühn glands of colonic mucosa. Conclusions: This experience attests that the majority of late complications following colonic esophageal substitution may be corrected by revisional surgery. The predominantly automatic propulsive movements of the isoperistaltically interposed grafts seem to provide an effective antireflux barrier against the gastrocolic reflux if some technical requirements (high gastric anastomosis, good gastric drainage, etc.) are respected. The graft mucosa showed signs of a positive adaptation. The best functional results were achieved by isoperistaltically interposed left colic transplants, which may be considered as an ideal graft (both technically and functionally) in extensive caustic strictures.

Key Words: Coloesophagoplasty • Isoperistaltic long left colic transplants • Late sequelae • Histochemical and functional adaptation


   1. Introduction
Top
 Abstract
 1. Introduction
2. Materials and methods
 3. Adaptation image
 4. Results
 5. Discussion
 6. Conclusions
 References
 
Late sequelae and the morphofunctional state of esophageal substitutes are two of the most fascinating areas, and this is especially true for coloesophagoplasty.

Although the value of colonic substitution in benign esophageal diseases is generally accepted, the functional assessment of these transplants is controversial, as is the frequency of late complications [1]. Distinguishing between a true functional sequela and a technical failure may produce a real diagnostic problem.

The aim of this study is to present the effectiveness of revisional surgery in late complications after 141 substernal colonic by-pass operations for benign strictures. The underlying adaptation of these grafts was evaluated by cineradiographical and histochemical examinations.


   2. Materials and methods
Top
 Abstract
 1. Introduction
 2. Materials and methods
3. Adaptation image
 4. Results
 5. Discussion
 6. Conclusions
 References
 
Late complications following 141 substernal colonic by-pass operations (1962–1990), except three with isoperistaltic (except seven with anisoperistaltic) long left colon grafts (transverse colon with flexures) for caustic strictures, were detected by periodical clinical and barium meal examinations in the follow-up period (1–27 years).

Twenty-eight patients had a previous or simultaneous limited gastric resection for accompanied gastric outlet obstruction. End-to-side or end-to-end cervical anastomoses and high anterior cologastrostomy have been carried out.

Late complications are summarized in Table 1. ‘Pseudodiverticulum’ of the cervical anastomosis in five patients — as a consequence of the standard by-pass procedure — was encountered in the early period of this experience. Correction was achieved by subanastomotic closure of the esophagus or by end-to-end reanastomosis. Stricture of the proximal anastomosis in seven cases was solved either by plasty (in three) or by resection and a similar reanastomosis through a partial median sternotomy.


View this table:
[in this window]
[in a new window]
  		Table 1. Late sequelae of 141 substernal isoperistaltic by-pass with left colon, 1962–1990a

 
Delayed passage and regurgitation due to subdiaphragmatic graft redundance in five cases were managed either by shortening coloplication (in four) or by side-to-side antrocolostomy. Late pyloric obstruction as a cause of gastrocolic reflux required pyloroplasty in two instances.


   3. Adaptation image
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Adaptation image
4. Results
 5. Discussion
 6. Conclusions
 References
 
The transport activity of the colon transplants was studied cineradiographically after 15 isoperistaltic and four anisoperistaltic interpositions 3–15 years after the operations.

The mucosal biopsies of the grafts (in six patients at 8 years of follow-up) were examined histochemically. The neutral mucopolysaccharides were examined using the periodic acid Schiff (PAS) reaction and sialic acid with Alcian Blue staining (at pH 2.5), and the same staining at pH 1 was used for the mastocytes.

The state of growth of the young patients was controlled periodically with the usual anthropometric methods.


   4. Results
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Adaptation image
 4. Results
5. Discussion
 6. Conclusions
 References
 
In all but one case, the surgical correction of these complications was successful.

The transit time after swallowing the mixed barium–bread bolus was considerably longer than that of normal subjects. The average time was 3 min and 50 s after isoperistaltic interpositions, and 5 min and 15 s in the case of anisoperistaltic interpositions.

Cineradiographically, the passage through the cervical anastomosis and thoracic segment of the isoperistaltic grafts was short (4–11 s), but temporary food retention occurred at the level of the supradiaphragmatic colon segment. For 30–90 s, the cologastric anastomosis remained closed, followed by low-grade multihaustral propulsive contractions in the adjacent colon, aiding food transmission into the stomach. If the orientation of this segment was nearly vertical, this occurred more rapidly, while the shortest transport time was noted in patients with accompanied Billroth I resection. In this group, gastrocolic reflux could not be produced either by the Trendelenburg position or by abdominal compression.

In cases of antiperistaltic interpositions, the passage time was much longer, with evident stasis into the infradiaphragmatic colonic segment. The administration of Prostigmin (0.5 mg i.v.) produced mass contraction without any influence on bolus transit. Clinically, this group of patients suffered from reflux symptoms in 86.5%.

Histochemically (Table 2), the mucosal surface was covered with mucin rich in neutral (PAS positive) mucopolysaccharide. A similar phenomenon was seen throughout the whole depth of the Lieberkühn glands (Fig. 1) and in the production of sialic mucin.


View this table:
[in this window]
[in a new window]
  		Table 2. Late features of mucosal adaptation

 


View larger version (141K):
[in this window]
[in a new window]
  		Fig. 1. PAS reaction showing hyperproduction of neutral mucopolysaccharide in Lieberkühn glands and on the mucosal surface.

 
All young people from the isoperistaltic group had unimpaired growth and weight gain; among them, eight women had complication-free pregnancies.


   5. Discussion
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Adaptation image
 4. Results
 5. Discussion
6. Conclusions
 References
 
It is generally accepted that coloesophagoplasty, with its several technical requirements, is the most delicate modality of esophageal replacement. In the late follow-up period, some technical deficiencies may by confused with late functional defects. Although the incidence of some specific late complications, such as ulcer [2], perforation [3], colo-tracheal fistula [4], gastrocolic reflux [5], and ischemic stenosis [6], seems to decrease in the recent publications, other ones, such as cervical stricture [7], and especially, redundancy of the interposed colon [8], remained as constant graft-related sequelae.

A preliminary comparative study [9] concluded that left colon transplants are less exposed to cervical fistulization and subsequent stricture than other long esophageal substitutes, since the paracolic vascular arcade at this level commonly provides adequate blood supply. The incidence decreased convincingly from 15.9 to 2.5% when, instead of the ileocolon, left colon grafts were replaced [7]. Therefore, for patients with a long life expectancy, these grafts with less frequent proximal anastomotic complications were considered more favorable than gastric tubes [10].

We never resected any part of the thoracic outlet with the intention of avoiding some proximal compression on the graft, but a sufficiently wide substernal tunnel was routinely accomplished with partial division of the sternocleidomastoideus muscle. We mentioned that if the cervical esophagus is moderately narrowed by the postcaustic scarring process, side-to-end esophago- or pharyngocolostomy (with subanastomotic obliteration if it is necessary) is preferable to a standard end-to-end type one. After repeated failed attempts of dilation, plasty or reanastomosis is unavoidable, providing definitive results in this series. For revision of long strictures, enlarged access through a partial sternotomy seems to be the best approach [11].

The transport function of these substitutes is mainly influenced by the intra-intestinal pressure gradient as a result of pharyngeal muscle contraction, gravity, respiratory cycle and intragastric pressure. However, in the final phase of swallowing, based on our own and other [12,13] cineradiographic and preliminary fluoroscopic [14] studies, and especially stimulated manometric [15–17] studies, the multihaustral propulsive contractions which develop on the distal colonic segment provide a secondary force which propels the bolus into the stomach in the isoperistaltic interposition. Recent ambulatory manometric and pH-metry findings [18] have also demonstrated that the normal colonic motility, described by Ritche [19], is not disturbed by the new intrapleural environment. The smaller size transverse colon motility is two and half times stronger than that of other colonic segments. In light of these objective investigations, colonic substitutes may not be considered as passive tubes in the food transport mechanism.

Regardless of the colonic segment used, redundancy of the graft is the most frequent late sequela of such esophageal substitutes. In three of our five patients, intra-abdominal colonic redundance developed in the initial period of this experience. In the later case, a side-to-side antrocolostomy was used which may be considered as a simple and effective procedure [20]. An intraoperatively well-fashioned straight colon segment is the most important measure to avoid this complication (Fig. 2). Only a very short (3–5 cm) colon segment between the nutritive pedicle and future gastric anastomosis should be tailored [11,21]. Nevertheless, the level of the cologastrostomy depends on the length of the mobilized nutritive vascular pedicle.



View larger version (23K):
[in this window]
[in a new window]
  		Fig. 2. Illustration of the intraoperative tailoring procedure during colonic transplantation.

 
A recent important coloesophagoplasty series [8] drew attention to the fact that an intrapleural long segment interposition may be followed by two other types of redundancy — supra-aortic and supradiaphragmatic ones — which required revisional surgery in 15 of 69 such substitutions. A lot of other factors, such as colo-vascular disproportion, which may be corrected by coloplication [11], obstructions along the graft, initial motility disorder, the patient's age and the negative intrathoracic pressure, should also be considered.

Although a similar long colon graft was used in both the above-mentioned and our own series, no intrathoracic graft redundance developed following our substernal transposition series. Others stress that regardless of the interposition route and type of colon segment used, such complications did not occur after straight fashioned grafts [7]. It is possible that for exactly tailored grafts, the substernal pleural tunnel (Fig. 3) could provide secondary but effective protection against the passive intrathoracic dilatation.



View larger version (139K):
[in this window]
[in a new window]
  		Fig. 3. Intact substernal pleural tunnel for well-tailored grafts may provide protection against the passive dilation.

 
Cologastric reflux due to late pyloric obstruction occurred only in two instances, but there was never ulceration of the grafts. Evaluating this positive aspect of such isoperistaltic left colonic substitutes, we mention the following circumstances. (1) All seven technical reflux factors, such as a low or very wide gastric anastomosis, pregastric nutritive graft pedicle, presternal transposition, pylorospasm or antropyloric stenosis and anisoperistaltic interposition [11], should be avoided (Table 3). (2) Even after free colonic transplantation, 50% of the ganglions of the intrinsic neuronal plexus remained intact [22]. In this way, the above-mentioned, predominantly automatic propulsive colonic contractions provide an effective barrier against the reflux episodes. Frequent neutral episodes found at 24 h pH-metry in the distal colonic anastomosis [15] are another argument for this hypothesis. (3) Our histochemical investigations attest adaptation of the colonic mucosa to the new environment by the production of mucus rich in neutral mucopolysaccharide and sialic mucin [23] which enhance the stability of mucopolysaccharides and mucosal resistance.


View this table:
[in this window]
[in a new window]
  		Table 3. Prevention of gastrocolic reflux in coloesophagoplasty

 
On the contrary, antiperistaltic colonic motility was found in our and other studies [24] in the majority of the patients with anisoperistaltic interpositions suffering from reflux and inflammatory mucosal changes [25]. Revisional surgical procedures [11] in instances of gastrocolic reflux are shown in Fig. 4.



View larger version (29K):
[in this window]
[in a new window]
  		Fig. 4. Useful surgical procedures in severe gastrocolic reflux. (1) Vagotomy with pyloroplasty; (2) antrectomy; (3) colonic resection and reimplantation; (4) jejunal interposition; (5) reimplantation in a Roux loop; (6) excision of the ulcer.

 

   6. Conclusions
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Adaptation image
 4. Results
 5. Discussion
 6. Conclusions
References
 
The relatively few late sequelae after substernal colonic esophageal by-pass procedures may be successfully managed surgically. The importance of the interposition modality and technique, and the functional superiority of the isoperistaltic left colic transplants in colonic esophageal replacement are stressed. Due to the secondary but active role in the swallowing mechanism of the stability of transit properties, mucosal adaptation, no or minor detectable reflux, unimpaired growth of young people, these grafts are the best substitution in extensive benign diseases and long life expectancy.


   Footnotes
 
Presented at the 8th European Conference on General Thoracic Surgery of the European Society of Thoracic Surgeons, London, UK, November 1–4, 2000.


   References
Top
 Abstract
 1. Introduction
 2. Materials and methods
 3. Adaptation image
 4. Results
 5. Discussion
 6. Conclusions
 References
 

  1. Postlethwait R.W. Colonic interposition for esophageal substitution. Surg Gynecol Obstet 1983;156:377-383.[Medline]
  2. Malcolm J.A. Occurrence of peptic ulcer in colon used for esophageal replacement. J Thorac Cardiovasc Surg 1968;55:763-772.[Medline]
  3. Bianchi A., Salvans F., Doncel F., Sirvent J.M., Leon A., Ayuso A. Late perforation of a mediastinal oesophagocoloplasty. Br J Surg 1989;76:917-920.[Medline]
  4. Moren González E., Santoyo J.S., Aguierre J.I., Selas P.R., Sanz R.G., Gozales J.S. Tracheo-colic fistula: an exceptional complication after total replacement of an esophagus injured by acid. Hepatogastroenterology 1990;37:212-214.[Medline]
  5. Pompeo E., Nofroni I., Van Raemondonck D., Coosemans W., Van Cleynenbreughel B., Lerut T. Esophagocoloplasty for congenital, benign and malignant diseases. Surgical and long-term functional results. Eur J Cardiothorac Surg 1996;10:561-568.[Abstract]
  6. Gossot D., Lefebred I.F. Ischaemic atrophy of the cervical portion of a substernal colonic transplant: successful reconstruction using a synthetic resorbable tube. Br J Surg 1988;75:801-802.[Medline]
  7. Gerzic Z.B., Knezevic J.B., Milicevic M.N., Jovanovic B.K. Esophagocoloplasty in the management of postcorrosive strictures of the esophagus. Ann Surg 1990;211:329-336.[Medline]
  8. Jeyasingham K., Lerut T., Belsey R.H.R. Functional and mechanical sequelae of colon interposition for benign oesophageal disease. Eur J Cardiothorac Surg 1999;15:327-332.[Abstract/Free Full Text]
  9. Lortat-Jacob I.L., Mailard J.N., Richard C.L.A., Fekete F., Huguier A. Résults de 117 oesophagoplasties. Mem Acad Chir 1968;94:334-346.
  10. Hölscher A.H., Voit H., Butterman G., Siewert J.R. Function of the intrathoracic stomach as esophageal replacement. World J Surg 1988;12:835-844.[Medline]
  11. Kotsis L., Krisár Z., Imre J., Csikos M. Complications of oesophagoplasty with isoperistaltic transverse colon. Scand J Thorac Cardiovasc Surg 1983;17:317-321.[Medline]
  12. Othersen H.B., Clatworthy H.W. Functional evaluation of esophageal replacement in children. J Thorac Cardiovasc Surg 1967;53:55-63.[Medline]
  13. Sieber A.M., Siebert W.K. Colon transplant as esophageal replacement: cineradiographic and manometric evaluation in children. Ann Surg 1968;168:116-122.[Medline]
  14. Hanna E.A., Harrison A.W., Derrick J.H. Comparative function of visceral esophageal substitutes by cinefluoroscopy. Ann Thorac Surg 1967;3:173-176.[Medline]
  15. Clark J., Moraldi A., Moossa A.R., Hall A.W., DeMeester T.R., Skinner D.B. Functional evaluation of the interposed colon as an esophageal substitute. Ann Surg 1976;183:93-100.[Medline]
  16. Benages A., Moreno-Ossett E., Paris F., Ridocci M.T., Blasco E., Pastor J., Tarazona V., Molina R., Mora F. Motor activity after colon replacement of esophagus. J Thorac Cardiovasc Surg 1981;82:335-340.[Abstract]
  17. Moreno-Osset E., Ridocci M.T., Paris F., Mora F., Garcia-Zarza A., Molina R., Pastor J., Benages A. Motor activity of esophageal substitute (stomach, jejunal, and colon segments). Ann Thorac Surg 1986;41:515-519.[Abstract]
  18. Peppas G., Payne H.R., Jeyasingham K. Ambulatory motility patterns of the transposed short segment colon. Gut 1993;34:1572-1575.[Abstract/Free Full Text]
  19. Ritchie J.A. Colonic motor activity and bowel function. Part I. Normal movement of contents. Gut 1968;9:442-456.[Free Full Text]
  20. 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]
  21. Thomas P., Fuentes P., Giudicelli R., Reboud E. Colon interposition for esophageal replacement: current indication and long-term function. Ann Thorac Surg 1997;64:757-764.[Abstract/Free Full Text]
  22. Nakayama K. New reconstructive method after radical removal of carcinoma of cervical esophagus. Free autografts of intestine. Asian Med J 1967;10:1-51.
  23. Eleftheriadis E., Kotzampassi K. Long-term microscopic findings after colon esophagoplasty. Am J Gastroenterol 1992;87:929.[Medline]
  24. Hanna E.A., Harrison A.W., Derrick J.R. Long-term results of visceral esophageal substitutes. Ann Thorac Surg 1967;3:111-118.[Medline]
  25. Isolauri J., Helin H., Markkula H. Colon interposition for esophageal disease: histologic findings of colonic mucosa after a follow-up of 5 months to 15 years. Am J Gastroenterol 1991;86:277-280.[Medline]



This article has been cited by other articles:


Home page
 Ann. Thorac. Surg.Home page
B. Tuncozgur, M. C. Savas, A. F. Isik, A. Sarimehmetoglu, M. Sanli, and L. Elbeyli
Removal of Metallic Stent by Using Polyflex Stent in Esophago-Colic Anastomotic Stricture
Ann. Thorac. Surg., November 1, 2006; 82(5): 1913 - 1914.
[Abstract] [Full Text] [PDF]

Home page
 J. Thorac. Cardiovasc. Surg.Home page
J.-H. Zhou, Y.-G. Jiang, R.-W. Wang, Y.-D. Lin, T.-Q. Gong, Y.-P. Zhao, Z. Ma, and Q.-Y. Tan
Management of corrosive esophageal burns in 149 cases
J. Thorac. Cardiovasc. Surg., August 1, 2005; 130(2): 449 - 455.
[Abstract] [Full Text] [PDF]

This Article
Right arrow Abstract Freely available
Right arrow Full Text (PDF)
Right arrow Alert me when this article is cited
Right arrow Alert me if a correction is posted
Right arrow Citation Map
Services
Right arrow Email this article to a friend
Right arrow Similar articles in this journal
Right arrow Similar articles in PubMed
Right arrow Alert me to new issues of the journal
Right arrow Add to Personal Folders
Right arrow Download to citation manager
Right arrow Author home page(s):
Attila Csekeö
Right arrow Permission Requests
Citing Articles
Right arrow Citing Articles via HighWire
Right arrow Citing Articles via Google Scholar
Google Scholar
Right arrow Articles by Kotsis, L.
Right arrow Articles by Csekeö, A.
Right arrow Search for Related Content
PubMed
Right arrow PubMed Citation
Right arrow Articles by Kotsis, L.
Right arrow Articles by Csekeö, A.
Related Collections
Right arrow Esophagus - other

HOME HELP FEEDBACK SUBSCRIPTIONS ARCHIVE SEARCH TABLE OF CONTENTS
ANN THORAC SURG ASIAN CARDIOVASC THORAC ANN EUR J CARDIOTHORAC SURG
J THORAC CARDIOVASC SURG ICVTS ALL CTSNet JOURNALS