| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
|
|
|
|||||||
|
|||||||||
a Division of Thoracic Surgery, Massachusetts General Hospital and Harvard Medical School, 55 Fruit Street, Blake 1570, Boston, MA, United States
b Division of Plastic and Reconstructive Surgery, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
Received 16 September 2007; received in revised form 31 March 2008; accepted 2 April 2008.
* Corresponding author. Tel.: +1 617 726 6826; fax: +1 617 7267667. (Email: pdedelva{at}partners.org).
 |
Abstract |
|---|
 Top Abstract 1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
Key Words: Esophagectomy • Esophageal replacement • Colon interposition
|
1. Introduction |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
Colon interposition dysfunction requiring operative intervention may be acute or chronic and often devastating. The most serious complications are leaks and conduit necrosis. Surviving patients are often left with a loss of intestinal continuity and require complex procedures to re-establish a swallowing conduit. Other patients develop insidious swallowing dysfunction that often can be attributed to a specific anatomical etiology. Operative techniques can be used to re-establish swallowing function and preserve the conduit.
There is limited experience in the literature on the operative management of failed colon interposition. We have collected our experience regarding these complex problems to recognize commonalities in etiology and describe our operative strategies. Many of these repairs represent unique solutions tailored to the anatomical defects resulting in conduit dysfunction but also provide general operative guidelines for the management of the most common etiologies of failed colon interposition.
|
2. Materials and methods |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
2.1 Selected operative techniques
Several unique operative techniques have been used to address the common problems leading to failed colon bypass. Below are descriptions of some useful techniques.
2.1.1 Boxcar resection
A boxcar resection or segmental colonic resection is most often performed to correct redundancy of the substernal colon bypass (Fig. 1
). It involves resection of the redundant or strictured segment of colon and primary anastomosis. Exposure is achieved by median sternotomy. Great care must be taken to avoid injury to the conduit and vascular pedicle. The use of the oscillating sternal saw is helpful. Careful dissection of the conduit away from the back of the sternum is required, much as one would do for re-operative mediastinal surgery. The plane of dissection remains on the surface of the conduit. Early identification of the vascular pedicle is essential and may be aided by the use of a Doppler probe. The marginal artery is often hypertrophied, making identification and dissection easier. Once the abnormal segment of colon is isolated, great care is exercised to preserve the vascular pedicle. The dissection remains on the free space between the conduit and the marginal artery. Individual segmental arteries are ligated close to the wall of the colon. The redundant loop is resected and an end-to-end anastomosis is performed.
|
|
Prefabrication of a muscle flap is the process by which enhanced flow and dilatation of the main vascular pedicle is created by the disruption of the collateral blood supply. This enhanced vascularity of the main pedicle augments perfusion and favors healing of the anastomosis between the neo-esophagus and the intestinal tract. For the pectoralis major graft, it involves ligation of the superior and lateral vascular bundles and preservation of the perforators from the internal thoracic artery. Prelamination is the application of a split-thickness skin graft sutured over the pectoralis flap to function later as a neo-esophageal mucosa.
The second stage involves elevation of the pectoralis muscle and tubularization to create a lumen lined with skin graft. The myocutaneous tube is sutured to the proximal gastrointestinal tract using a two-layer technique. The third stage of the reconstruction involves creating a pedicled jejunal limb and anastomosis to the distal end of the tubularized pectoralis muscle flap. This reconstruction may replace the entire esophagus. An interval of several weeks between each stage of the reconstruction allows for healing and maturation of the myocutaneous flap prior to creation of the anastomoses and protects the patient from the consequences of leakage in the event of early graft failure.
|
3. Results |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
|
|
3.2 Intractable stricture
Eleven symptomatic and intractable strictures required operative intervention in 10 patients. Seven of the 10 patients had lye stricture (n
= 5) or radiation therapy (n
= 2) and one developed a stricture following the conservative management of a cervical anastomotic leak. One patient with extensive lye injury developed strictures of the cervical and cologastric anastomoses. The cologastrostomy was revised with a good outcome, and the esophagocolonic stricture was initially managed with dilatation but 13 years later required stricturoplasty. An ischemic segmental stricture in one patient at the level of the carina was managed with a boxcar resection. The remaining seven patients were managed by stricturoplasty or revision of the esophagocolonic anastomosis. Swallowing was restored in 9 of 10 patients. One patient with severe pharyngeal stenosis from lye injury could not be palliated despite revision of the pharyngocolostomy, dilatation and pharyngeal stenting.
3.3 Loss of intestinal continuity
Seven patients underwent eight operations for loss of intestinal continuity as a consequence graft necrosis. Four patients had total loss of the conduit. Two were reconstructed with gastric conduit and one patient was reconstructed with a right colon graft following a failed left colon bypass. One patient with loss of gastric and colon conduits was reconstructed with a proximal prefabricated pectoralis major flap and a distal Roux-en-Y limb. Three patients had partial loss of the conduit. One patient had reconstruction of a blind cervical colon pouch following a segmental ischemic perforation by mobilization of the remaining conduit and reanastomosis. The repair leaked, but was managed successfully with local drainage. In one patient with segmental necrosis of the colon graft, reconstruction was attempted with a free jejunal graft. The free graft failed, but a later myocutaneous flap succeeded. One patient with proximal colon graft necrosis and a failed deltopectoral flap at an outside institution was reconstructed by mobilization of the remnant distal colon, proximal myocutaneous flap and primary anastomosis. Intestinal continuity and swallowing function was restored in all seven patients.
3.4 Anastomotic fistula
Five patients with leaks developed chronic fistulae. Repair was achieved by revision of a proximal anastomosis (n
= 2) or primary repair and buttress with local muscle (n
= 3). One patient had proximal conduit necrosis following revision of an anastomosis. A free jejunal interposition was used for reconstruction. Swallowing was restored in all patients.
3.5 Conduit obstruction
Five patients underwent six individualized operations for obstructed interposition. A non-functioning colonic substitute following surgery for scleroderma managed with long colonic myotomy, vagotomy and pyloroplasty had a poor outcome. The colon bypass was taken down and continuity reconstructed with stomach. Disease progression affected the remaining intestinal tract and led to dependence on parenteral nutrition. A second patient had migration of the colon bypass from the retro-sternal position to the posterior mediastinum with resultant dysphagia and obstruction. Repositioning of the graft to the anterior mediastinum relieved the obstruction. A third patient presented with an obstructed conduit at the hiatus and a small bowel obstruction secondary to an internal hernia through the colonic mesenteric defect. A lysis of adhesion, partial resection of the hiatus and closure of the trap relieved the obstruction. The fourth patient with obstruction secondary to sternal compression resolved with a lower hemi-sternectomy. The fifth patient had an obstructing marginal ulcer at the cologastrostomy and was revised with a completion gastrectomy and coloduodenostomy. Swallowing was restored in all five patients.
3.6 Reflux esophagitis/colitis
Three patients required operative intervention for esophagitis and bile reflux colitis. A patient with a congenital tracheoesophageal fistula managed by colon bypass developed reflux esophagitis of the remnant esophagus and required a completion esophagectomy. Another patient with bile reflux colitis was managed with a Roux-en-Y biliary diversion. One patient with odynophagia and peptic ulceration of the conduit underwent a revision of the distal anastomosis. Symptoms and peptic ulcerations persisted and required graft removal and reconstruction with a gastric conduit. Swallowing was restored in all three patients.
3.7 Outcome
There were no operative deaths. Swallowing function was restored in 32 of the 35 patients (91%). Three failures included a patient with progressive scleroderma, persistent aspiration following revision for redundancy and persistent pharyngeal stenosis secondary to lye injury. Four patients required five re-operations after a failed revision at our institution. Swallowing was restored in three of the four patients.
|
4. Discussion |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
Belsey's group reported on the need for revision surgery after colon interposition for benign disease in 29 out of 365 patients [6]. Most complications occurred in patients with long-segment colon bypass (27 out of 29). Repair of redundant segments was the most common long-term complication followed by revision of esophagocolonic anastomosis for intractable stricture. Demeester and colleagues reported on 20 cases of revision operations in 92 patients with colon bypass for benign and malignant disease [2]. Failed colon bypass and redundancy were the most common indications for operative intervention. Currett-Scott and colleagues reported a re-operative rate of 37.5% with strictures and redundancy being the most common indications [5]. They also confirmed a higher incidence of long-term complications in long-segment colon interposition. Kotsis and colleagues reported 19 re-operations in 141 colon interpositions for corrosive injury [9].
Loss of the colon graft is a devastating complication best prevented by careful preparation of the colon conduit when it is first constructed. The use of preoperative mesenteric angiogram is standard at our institution [3,4]. This serves to identify anomalous and atherosclerotic vasculature that might compromise viability or limit length and avoids an unexpected intraoperative discovery of an unusable conduit. We prefer the left colon based on the ascending branch of the left colic artery because of its reliable blood supply. We routinely test clamp collateral vessels to be certain of viability. Adequate length must be determined. This frequently entails preserving the middle colic artery and its right and left branches and allows use of the colon to the hepatic flexure. The venous and arterial pedicles are carefully handled and placed in such a way to avoid any compression. It is important to adequately dissect the substernal path and the thoracic inlet to avoid compression. It may be necessary to remove a plate of manubrium, clavicle and first rib to create enough space. It is best to avoid entry in the pleural space or excessive dissection when creating the substernal tunnel as this helps reduce the risk of future conduit redundancy. We believe that the use of these strategies helps to reduce the incidence of failed colon interposition.
The management of loss of intestinal continuity is a formidable challenge because the colon is often chosen if the stomach is not a suitable conduit or to reconstruct defects high in the cervical esophagus or pharynx. Therefore, reconstructive options are often limited. Prior to reconstruction, the following factors should be considered: location and length of intestinal defect, prior reconstructive attempts, prior thoracic and abdominal surgery and how much remaining colon conduit remains. Several lessons can be learned from our experience.
It is helpful to preserve as much viable colon as possible during the acute management of conduit necrosis. Although there can be necrosis of the entire graft, often the distal end is compromised and the remaining graft can be salvaged. It is easier to bridge a small gap than to replace the entire length of the conduit. Preservation of conduit may allow for mobilization and simple re-anastomosis. If anastomosis is not possible, small gaps can be reconstructed with free jejunum proximally or Roux-en-Y limb distally.
Before reconstruction is considered, sepsis should be completely controlled, the bed of the conduit should be free of inflammation and the patient should be nutritionally resuscitated. A thorough understanding of the patient's anatomy is crucial to a successful operative plan. Review of the previous operative records and a clear understanding of the vascular supply of the conduit are required. Endoscopies from the mouth and when available, retrograde through a gastrostomy, may provide valuable information about the remaining conduit. We have found that in selected cases, angiography can provide not only valuable information about the location and status of the vascular pedicle, but also may delineate how much graft length is available.
Before undertaking reconstruction, the surgeon should explore all options for reconstruction and have flexibility to conform to the patient's anatomy. Several of our patients were reconstructed with a stomach conduit after failed colon bypass. It is helpful to consult with a reconstructive surgeon regarding the option of free jejunal transfers or myocutaneous flaps. Flexibility, creativity and a thorough understanding of the patient anatomical defects are the keys to re-establishing swallowing function after failed colon interposition.
Redundancy of the colon conduit is a common indication for revision surgery. Jeyasingham and colleagues have reported on 15 patients with this problem [7]. All had undergone long-segment interposition. Most cases occurred in the chest and abdomen with a few cases of cervical redundancy. Management included resection and primary anastomosis or cologastric diversion. Most cases in our series occurred years after the initial operation but some occurred within months. Certainly some cases of redundancy are due to the length of colon conduit constructed at the primary operation. Demeester advocates performing the esophagocolonic anastomosis first and careful measurement of the conduit to create a straight course [2]. The conduit is fastened to one side of the hiatus and the distal anastomosis is created. We believe these measures do minimize acute redundancy. Nevertheless, all patients develop some degree of redundancy in the long term. It is the development of dysphagia and regurgitation that requires operative intervention.
A barium swallow and endoscopy are crucial in selecting an operative plan. The location of the redundancy will help to define the approach. Exposure must be excellent to preserve the vascular pedicle. The segmental blood supply of the colon through its main pedicle affords tremendous flexibility in operative options. Segmental or boxcar resections are possible if the dissection plane is maintained in proximity to the wall of the colon with preservation of the main vascular pedicle. Redundant segments can be excised and the colon re-anastomosed. In our series, there were no anastomotic leaks or loss of the conduit with boxcar resection. When redundancy is in proximity to an anastomosis, resection and re-anastomosis with preservation of the vascular pedicle is often the simplest repair. More complex methods of repair have been described, but in our experience they are seldom necessary. Dilated proximal colon conduit will empty again when a straight course is constructed to relieve obstruction and allow for gravitational drainage.
Benign strictures are well known complications of colon bypass. Most can be successfully managed with dilatation and a few require long term, serial dilatation. Wain et al. reported an incidence of 24 out of 50 patients with dilatable strictures [3]. Half of patients with anastomotic strictures had caustic injuries of the esophagus. Two of the 24 patients subsequently required surgical revision. Curret-Scott and colleagues reported an incidence of seven intractable strictures in a series of 53 patients with colon bypass for benign disease. Jeyasingham and colleagues reported eight revisions for stenosis in 365 patients [6]. Demeester reported four anastomotic revisions in 92 patients [2]. Most strictures occur at the esophagocolonic anastomosis. The presumed mechanisms include distal graft ischemia, scarring secondary to anastomotic leaks and, in patients with lye injury, the proximal anastomosis is often fashioned in injured and fibrosed tissue. In this series, anastomotic strictures were seen in nine patients, with seven having exposure to lye or radiation for head and neck or esophageal cancer.
The management of these strictures by reanastomosis can be challenging because of dense scar tissue or the anastomosis may need to be refashioned in the hypopharynx or base of the tongue. It is important to remember that all colon interpositions in time will develop some degree of redundancy. Careful lysis of adhesions with preservation of the vascular pedicle may allow resection of the stricture and re-anastomosis. This has been our approach for long or densely fibrotic strictures. In cases of short stenoses, stricturoplasty may be the simplest alternative to manage the obstruction. We used stricturoplasty in 4 out of 10 cases of anastomotic stricture with excellent functional results. Short and soft focal strictures are ideal for this repair.
We have also noted segmental ischemic strictures of the colon. One patient in our series was managed with a boxcar resection and colocolostomy with a good outcome. Presently we have another patient with a similar segmental ischemic stricture in the mid colon that requires dilatation every three months. The patient has deferred a surgical repair. These strictures are ideally managed with a limited boxcar resection and preservation of the remaining conduit.
Reflux colitis and esophagitis can be prevented when the colon interposition is constructed. Demeester advocates preservation of at least 10 cm of intra-abdominal colon bypass and fashioning the cologastric anastomosis on the posterior wall of the stomach at a point one-third the distance between the top of the fundus to the pylorus [2]. We create the cologastrostomy using a similar technique and have found a low incidence of reflux symptoms requiring revision.
There are several limitations in our study design. Our series is not inclusive of all complications known to occur after colon bypass. Colonic fistulas, perforated diverticulitis, pseudodiverticulum and colon cancer have been reported [9–12]. Retrospective data analysis of highly selected patients introduces several biases to our results and analysis. This is a single institution, tertiary care experience at a center with expertise in esophageal surgery. The case series encompasses a diverse group of patients with varying indications for esophageal replacement and spanning 40 years. Our results may not be applicable to all patients or hospital settings.
Revision surgery following colon interposition is possible and safe. Careful evaluation of all possible reconstruction possibilities and precise attention to operative detail allows reconstruction of the gastrointestinal tract and restored swallowing in most patients.
|
Appendix A |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
Dr T. Lerut (Leuven, Belgium): Just to start off the discussion. You gave us the number of reinterventions. But what was the total number of coloplasties that were performed in the department in the same time period so that we have a more precise idea about the overall late complication rate.
Dr de Delva: This series was inclusive of patients that had their primary colon interposition at our institution as well as patients that were referred from other institutions. Out of the total series, 24 total coloplasties were performed at Mass General, and during the same time period about 150 colon interpositions were performed at our institution. So about a 16% reoperation rate in our institution.
Dr Lerut: Which I think is probably reflecting the incidence in other centers of experience.
Dr R. Santosham (Chennai, India): In the case in which you used a skin tube, you said you used a skin tube, with a skin color in the inside. We have also used them and what we find is hair growth. Growth of hair also interferes with swallowing, that's one point.
And second thing, how do you manage the pharyngocoloplasties in your center? You said that persistent swallowing difficulty. This is a very big problem in our country, and how do you manage these pharyngeal obstructions?
Dr de Delva: Regarding the first question, I think that our new practice has been to use a split-thickness skin graft. And in the split-thickness skin graft I think that we would avoid a lot of the hair growth that can occur. So I think that may be one solution to that problem. It also creates a much thinner, sort of neomucosa as opposed to using a true skin tube that has all layers and can be relatively thick. So I think using split thickness helps in that regard re-creating the more natural anatomy of the mucosa.
Dr D. Mathisen: And I would say that that kind of depends on the problem. Clearly in people who have had lye strictures, using the native esophagus sometimes is not available, and you do it laterally or you actually do it to the pharynx. And I think in those patients they are notoriously difficult when you’ve had a lye stricture, not only in preserving the patency, but also to allow them to swallow without aspiration. And in that very small subset of patients, it is quite difficult and sometimes always very individualized as exactly how you do it.
And if the question is how you do it, all of our anastomoses are done in two layers. So whatever anastomosis we do, it's always done with two layers, interrupted sutures.
Dr Santosham: Do you approach the pharynx in the side and put the esophagus? Because it interferes with swallowing most of the time and they aspirate. These are the very difficult problems that we face. And they may suffer restenosis also.
Dr Mathisen: You’re absolutely right. And one of the failures was in just such a patient. So in patients who have had lye strictures, I think that is certainly a worry when you do this. And what we do is we do it to the side of the pharynx. We generally incise and make a linear incision rather than cutting out a doughnut, if you will, from the pharynx. And some in which they have re-strictured and some even though it is patent, they have a problem with long-term swallowing. So those patients are quite a challenge.
Dr P. Rajesh (Birmingham, United Kingdom): Can I ask the presenter as to how he would access for your redundant colon reoperations? Because sometimes you get what we call a sigmoid esophagus and it's either in the left or the right chest. How do you decide which side of the chest you’re going to open before you do your procedures?
Dr de Delva: The majority of our patients had their colon interposition placed in the substernal tunnel. And so our practice has been to do a redo sternotomy, very carefully, to re-access the conduit, carefully identify the vascular pedicle, and then do the resection. If we need to extend it into the abdomen, then that can be done through a midline laparotomy. But our standard practice is to very carefully reopen the sternotomy, much as you would do with a reoperative cardiac field.
|
Footnotes |
|---|
Presented at the 21st Annual Meeting of the European Association for Cardio-thoracic Surgery, Geneva, Switzerland, September 16–19, 2007. |
References |
|---|
|
TopAbstract1. Introduction2. Materials and methods3. Results4. DiscussionAppendix AReferences |
|---|
This article has been cited by other articles:
|
|
 |
|
  P. A. Thomas, A. Gilardoni, D. Trousse, X. B. D'Journo, J.-P. Avaro, C. Doddoli, R. Giudicelli, and P. Fuentes Colon interposition for oesophageal replacement MMCTS, June 3, 2009; 2009(0603): 2956. [Abstract] [Full Text] [PDF]
|
|
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| 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 |
