Total laparoscopic abdominal aortic aneurysm repair with reimplantation of the inferior mesenteric artery

We performed a total laparoscopic reimplantation of the inferior mesenteric artery (IMA) during laparoscopic infrarenal aortic aneurysm repair. The postoperative course was uneventful, and angiograms showed a patent IMA after reimplantation. To our knowledge, total laparoscopic reimplantation of the IMA in human beings has not previously been described.

Laparoscopic transperitoneal clipping of the inferior mesenteric artery for the management of type II endoleak after endovascular repair of an aneurysm

We report the case of a high risk patient with an abdominal infrarenal aortic aneurysm (AAA) who was treated by endovascular technique and the subsequent management of a type II endoleak by the laparoscopic approach. In this case, a 74-year-old woman with a 6-cm infrarenal AAA underwent endovascular repair using a bifurcated stent-graft device. Surveillance CT scan showed a persistent type II endoleak at 1 week and 3 months after the operation. Angiography confirmed retrograde flow from the inferior mesenteric artery (IMA). Attempted transarterial embolization of the IMA via the superior mesenteric artery was not successful. Laparoscopic transperitoneal IMA clipping was performed. Subsequent aortic duplex scan and CT scan confirmed complete elimination of the type II endoleak. We conclude that a combination of endovascular and laparoscopic procedures can be used to manage AAA successfully.

Ligation of the inferior mesenteric artery in the surgery of rectal cancer: anatomical considerations

BACKGROUND

No agreement has been found in the literature concerning the safest point of ligation of the inferior mesenteric artery (ima) in order to avoid nerve damage during the surgery of rectal cancer.

STUDY DESIGN

The distance between the origin of the ima and the left paraortic trunk was measured, as was the distance between the left paraortic trunk and the origin of the left colic artery (lca). The measurements were carried out on 20 cadavers and during 22 operations for rectal cancer.

RESULTS

The left paraortic trunk always runs posterior to the ima: its distance from the origin of the ima is on average 1.2 cm; the distance of the left paraortic trunk from the origin of the lca is on average 0.4 cm. The point at which the ima and the left paraortic trunk cross varies greatly, but it is never near the origin of the ima.

CONCLUSIONS

From an anatomical point of view the safest point of ligation of the ima is at its origin. At this point, the left paraortic trunk never runs; so there isn't any risk to damage the nerve involving it during the ligation of the artery.

Preserving the Superior Rectal Artery in Laparoscopic Sigmoid Resection for Complete Rectal Prolapse

Sigmoid resection is indicated in the treatment of complete rectal prolapse (CRP) in patients with prolonged colorectal transit time (CTT). Its use, however, has been limited because of fear of anastomotic leakage. This study challenges the current practice of dividing the mesorectum by prospectively evaluating the impact of sparing the superior rectal artery (SRA) on leak rates after laparoscopic sigmoid resection (LSR) for CRP. During a 30-month period, data on 33 selected patients with CRP were prospectively collected. Three patients were withdrawn from the analysis, as they had neither resection nor anastomosis. Twenty-nine women and 1 man (median age 55 range 21-83 years) underwent LSR with preservation of SRA for a median CRP of 8 (3-15) cm. There were 20 ASA I and 10 ASA II patients. Ten patients had undergone previous surgery. Four patients complained of dyschezia, whereas incontinence was present in 26 patients. Anal ultrasound showed isolated internal sphincter defects in 2 patients. Four young adults (21-32 years) had normal CTT, whereas 26 older patients had a median CTT of 5(4-6) days. Defecography demonstrated 10 enteroceles, two sigmoidoceles, and one rectal hernia through the levator ani muscle. Mortality was nil. Median operating room time was 180 (120-330) min, suprapubic incision length 5(3-7) cm, estimated blood loss 150 (50-500) mL, specimen length 20 (12-45) cm, solid food resumption 3(1-6) days, and length of stay 4.5(2-7) days. Thirty-day complications were not related to anastomosing and occurred in 20% of the patients. Median follow-up was 34.1 (18-48) months. One patient had a recurrence. Although the evidence provided by the present study suggests that sparing SRA has a favorable impact on anastomotic leak rates, these nonrandomized results need further evaluation. The division of the mesorectum at the rectosigmoid junction seems not necessary, and its sparing should therefore be considered as it may contain anastomotic leak rates.

Surgical technique influences bowel function after low anterior resection and sigmoid colectomy

BACKGROUND/AIMS

Since June 1996, we have changed surgical strategies to preserve the pelvic autonomic nerve and abandon high ligation of the inferior mesenteric artery. The aim of this study was to clarify the influence of this surgical technique on subjective bowel function of patients with low anterior resection and sigmoid colectomy for cancer.

METHODOLOGY

Forty-eight patients who underwent low anterior resection or sigmoid colectomy for cancer during June 1996 and February 2000 replied to the questionnaire which consisted of eight categories of bowel symptoms. Subjective bowel function and operative data of these patients were compared with those obtained from 84 patients with low anterior resection or sigmoid colectomy during April 1984 and May 1996.

RESULTS

When recent series were compared with previous series, the frequency of bowel movement at night (21% vs. 60%, p < 0.01) and patient's own judgment as fair or poor (0% vs. 29%, p < 0.01) was decreased in patients with low anterior resection; whereas the frequency of defecation > 2 per day (5% vs. 34%, p < 0.01), difficulty in emptying (32% vs. 71%, p < 0.01), and incomplete evacuation (32% vs. 66%, p < 0.05) was decreased in patients with sigmoid colectomy. Patient judged as poor bowel function was less frequent in the recent group after low anterior resection (25% vs. 71%, p < 0.01) and sigmoid colectomy (18% vs. 42%, p < 0.05) compared with the previous group. Operative data including volume of blood loss, frequency of transfusion, and length of resected specimen were also different between the two groups.

CONCLUSIONS

Surgical technique had a significant impact on bowel function following low anterior resection and sigmoid colectomy for cancer. When high ligation of the inferior mesenteric artery is abandoned and the pelvic autonomic nerve is preserved by careful technique, postoperative bowel dysfunction in patients with rectosigmoid colon cancer can be minimized.

Surgical intervention for acute intestinal ischemia: experience in a community teaching hospital

The aim of this study was to evaluate the current management of acute mesenteric ischemia secondary to thrombotic or embolic occlusion of visceral vessels in a community teaching hospital. Between October 1997 and July 2000, a review of all hospital discharges revealed 83 patients with a discharge diagnosis of "acute vascular insufficiency-intestine." Among these 83 patients, 22 cases of acute mesenteric ischemia were confirmed. Management of these 22 patients was divided into 2 groups for analysis. In Group A, 14 patients were aggressively treated with visceral angiography (n=10), visceral artery bypass (n=8), visceral embolectomy (n=4), and bowel resection (n=7). In 8 of 14 of these patients, surgical intervention occurred in less than 24 hours from presentation. In Group B, 8 patients were managed with supportive care because of advanced age (mean age = 86 +/- 7 years), comorbid conditions, or patient and family preference. Postoperative morbidity in Group A consisted of cardiac events (n=3), pulmonary insufficiency (n=5), and prolonged gastrointestinal tract dysfunction (n=3). Twelve of 14 patients in Group A survived and were discharged, whereas only 2 of 8 patients in Group B survived and were discharged from the hospital. Although the literature suggests that there can be a significant delay in the diagnosis and treatment of acute mesenteric ischemia, the early recognition and aggressive treatment of acute mesenteric ischemia resulted in a good survival rate. Supportive management of very elderly and debilitated patients needs to be considered on a case-by-case basis. Although the outlook for such patients is dismal, survivors are possible as demonstrated by this series.

[Diagnosis and surgical treatment of ischemic lesions of the viscera in elderly patients with aorto-femoral atherosclerosis]

During the period from 1991 to 2000 161 patients with atherosclerosis of the aortic-femoral zone, aged over 60, underwent scheduled treatment in the vascular surgery department of the clinical regional hospital of the city of Yaroslavl. In 62 (38.5%) patients different pathology of the visceral arteries was revealed according to the diagnostic analysis. The chronic ischemic abdomen disease of the sub- and decompensated degree was revealed in 28 (45.2%) patients which had multiple lesions of the abdomen aorta visceral branches. 53 patients underwent different surgery. Postoperative hospital mortality rate was 9.4%. Good results were obtained in 79.2% of cases. There are many variants of reconstruction operative treatment of such disorders, but in patients aged over 70 the most appropriate one was the aortic-femoral reconstruction with a renewal of blood circulation in one, maximum two, affected visceral arteries. Today the priority is given to implantation of the beginning of arteria mesenterica inferior into the prosthesis and also to the aortic- or prosthesis-visceral autovein as grafting.

[Collateral circulation of the left colon: historic considerations and actual clinical significance]

INTRODUCTION

The arterial communication between the superior and inferior mesenteric arteries is important in surgery of the colon and aorta.

METHODS

The anastomosis between the median colic artery (ACM) and the superior colic artery (AMS) was studied on 52 cadavers (32 female, 20 male). The length of the artery was measured using a flexible scale, and its diameter was determined at three different locations (origin, middle, end).

RESULTS

The median lengths of the arteries were: 6.8 cm (range 3.9-9.7) for ACM, 12.2 cm (range 7-17.4) for ACS, and 23 cm (range 13.6-34.2) for margin artery. The median diameters were: 3.4 mm (range 2.7-4.1) for ACM, 3.1 mm (range 2.1-4.1) for ACS, and 2.7 mm (range 2-3.4) for margin artery. In 9.6% of the cadavers ( n=5), additional anastomoses between the AMS and inferior mesenteric arteries were proven. In 90.4% ( n=47), only margin arteries were found.

SUMMARY

The low incidence of an additional communication (Riolan's arch) and possible additional impairment of the blood supply should be taken into account during operation.

Ovarian Artery: Angiographic Appearance, Embolization and Relevance to Uterine Fibroid Embolization

PURPOSE

To describe the angiographic appearance of the ovarian artery and its main variations that may be relevant to uterine fibroid embolization.

METHODS

The flush aortograms of 294 women who had been treated by uterine artery embolization for fibroids were reviewed. Significant arterial supply to the fibroid, and the origin and diameter of identified ovarian arteries were recorded. In patients with additional embolization of the ovarian artery, the follow-up evaluation also included hormonal levels and Doppler imaging of the ovaries.

RESULTS

A total of 75 ovarian arteries were identified in 59 women (bilaterally in 16 women and unilaterally in 43 women). All ovarian arteries originated from the aorta below the level of the renal arteries with a characteristic tortuous course. Fifteen women had at least one enlarged ovarian artery supplying the fibroids. Fourteen women (14/15, 93%) presented at least one of the following factors: prior pelvic surgery, tubo-ovarian pathology or large fundal fibroids.

CONCLUSION

We advocate the use of flush aortography in women with prior tubo-ovarian pathology or surgery or in cases of large fundal fibroids. In the case of an ovarian artery supply to the fibroids, superselective catheterization and embolization of the ovarian artery should be considered.

[Prevention of ischemic colitis following aortic reconstruction: personal experience of the role of transmural oximetry in the decision for inferior mesenteric artery reimplantation]

BACKGROUND

The colonic ischemic necrosis is one of the most serious complication in the surgical reconstruction of abdominal aorta aneurysm (AAA) due to surgical inappropriate binding of the inferior mesenteric artery (IMA).

METHODS

A retrospective analyzed of a group of 118 infrarenal AAA surgically treated is presented.

RESULTS

The most common cause of ischemic colitis (75% of cases) is the surgical binding of an opened IMA or its failed reimplantation.

CONCLUSIONS

In this paper according to their personal experience and the literature data, the authors outline a diagnostic behaviour to select the patients needing the reimplantation of IMA; they suggest to complete the pre operative information with an instrumental evaluation during the surgical treatment.

[Unusual revascularization in acute mesenteric ischemia (a case report and review of the literature)]

Acute-on-chronic mesenteric ischemia is rare, symptomatic manifestation of arteriosclerosis, and there are important gaps in our knowledge and recognition of this potentially lethal condition. Careful exploration of anamnestic history and angiography remain cornerstones of early diagnosis. Prognosis crucially depends on rapid diagnosis and surgical management, to prevent, or at least to minimize bowel infarction. Delay in surgical intervention is associated with increasing mortality that is still high and varies from 60 to 100%. The prognosis dramatically improves if revascularization can be achieved prior to intestinal infarction. Patients surviving extended intestinal resection may develop short gut syndrome. Case rapport of acute-on-chronic mesenteric ischemia with extraordinary approach for superior mesenteric artery revascularisation is described. Literature review is presented.

Technical consideration in the management of chronic mesenteric ischemia

Our aging population may result in a rise in the prevalence of chronic mesenteric ischemia. This report reviews our contemporary experience with a tailored surgical approach to chronic mesenteric ischemia. The medical records of 17 patients operated on for chronic mesenteric ischemia were retrospectively reviewed. Symptom-free survival and long-term patency documented by duplex scanning when available were also analyzed. Sixteen patients ranging in age from 32 to 80 years were included in the study. Seventy-five per cent of the patients were female. The most common preoperative complaints were postprandial abdominal pain and weight loss. Revascularization was tailored to the arterial anatomy and included bypass to the superior mesenteric artery (SMA) alone (eight), bypass to the celiac artery and SMA (six), SMA reimplantation onto the aorta (one), SMA/inferior mesenteric artery reimplantation (one), and transaortic endarterectomy of the celiac artery/SMA (one). Bypass conduits included Dacron (eight), saphenous vein (four), and polytetrafluoroethylene (two). Bypass grafts originated from the supraceliac aorta in 12 patients; the remaining bypass originated from the left limb of an aortofemoral graft. There was one perioperative death (mortality 5.6%). Follow-up duplex scans at a mean of 34 months (range 1-114) showed no graft thromboses. We conclude that a variety of surgical techniques can provide durable relief of mesenteric ischemia. A tailored approach to revascularization optimizes patency and provides long-term symptom-free survival.

[Clinical analysis of colon ischemia complicating with operated abdominal aortic aneurysm]

OBJECTIVE To investigate the etiology, prevention and treatment of colon ischemia after operation for abdominal aortic aneurysm (AAA). METHOD Seven of 140 cases complicated with colon ischemia who had received AAA operation were analyzed retrospectively. RESULTS Three cases underwent emergency operation. The seven cases were subjected to removal of AAA, implantation of prosthesis, and ligation of the inferior mesenteric artery. Two cases had the ligation of the bilateral internal iliac artery (IIA). Epilateral IIA was ligated in 2 cases. Bowel resection was carried out in 3 cases, 1 of which received reconstruction of the inferior mesenteric artery (IMA). Three cases received conservative therapy, but died from multiply organ failure. CONCLUSION Correct prevention and management of colon ischemia can effectively reduce the operative morbidity of AAA patients.

Pediatric splanchnic arterial occlusive disease: clinical relevance and operative treatment

OBJECTIVE

Splanchnic arterial occlusive disease is rare in childhood. The purpose of this study was to review the clinical relevance and operative treatment of these lesions in a unique experience from a single institution.

METHODS

Seventeen children (11 boys and 6 girls) from 2 years to 17 years in age with critical narrowings of the celiac artery (CA) and superior mesenteric artery (SMA) underwent treatment at the University of Michigan from 1974 to 2000. Etiologic factors included embryologic fusion abnormalities of the fetal aortae during formation of the splanchnic arteries (n = 15), inflammatory aortoarteritis (n = 1), and radiation-induced arterial fibrosis (n = 1). Individual lesions included CA occlusions (n = 6) and stenoses (n = 7), SMA occlusions (n = 3) and stenoses (n = 11), and inferior mesenteric artery stenosis (n = 1). Fourteen children had abdominal aortic coarctations, and 15 had renal artery stenoses. Two patients had postprandial abdominal discomfort and food aversion, consistent with intestinal angina. Small stature affected five others, perhaps attributable to severe renovascular hypertension and failure to thrive. Ten children underwent intestinal revascularization, at the time of an aortoplasty or thoracoabdominal bypass for aortic coarctation (n = 7) or at the time of renal artery revascularization (n = 8). Primary splanchnic revascularization procedures included SMA-aortic implantation (n = 3), aorto-SMA and CA bypass with an internal iliac artery graft (n = 3) or a saphenous vein graft (n = 1), CA-aortic implantation at a stenotic SMA origin (n = 2), and CA and SMA intimectomy (n = 1). Secondary operations included SMA-aortic implantation (n = 2).

RESULTS

All 10 children who underwent splanchnic revascularization have thrived, gained weight, and are free of abdominal pain, with follow-up periods averaging 9 years. No intestinal ischemic manifestations occurred in the seven children who did not undergo operation.

CONCLUSION

Pediatric splanchnic arterial occlusive disease is a rare illness appropriately treated with operation in properly selected children.

Inferior mesenteric artery reimplantation does not guarantee colon viability in aortic surgery

Reimplantation of the inferior mesenteric artery (IMA) at the time of aortic surgery has been advocated to prevent colon ischemia in patients deemed to have inadequate perfusion of the left colon. The purpose of this study was to determine whether IMA reimplantation is globally protective against colon necrosis. We reviewed the medical records of all patients who were diagnosed with colon ischemia after aortic surgery during a 10-year period. Cases were indexed from the institution's operative database and from the vascular morbidity and mortality registry. Ten patients (eight men, two women; mean age 71 +/- 9 years) were identified during the study period. Five patients (50%) underwent successful IMA reimplantation for inadequate Doppler signals on the antimesenteric border of the sigmoid colon. Five other patients (50%) did not undergo IMA reimplantation because they were deemed to have adequate colon perfusion. Transmural colon necrosis occurred in 6 of the 10 study patients, 4 of whom had IMA reimplantation. Five of the six patients had intraoperative hypotension. Three of the four patients with colon ischemia presenting less than 24 hours after aortic revascularization survived (mortality 25%), but both patients with late colon ischemia died of multisystem organ failure (mortality 100%). Four patients developed mucosal ischemia and did not undergo colectomy. Only one of these had IMA reimplantation. Colon ischemia was detected more than 1 week postoperatively in three patients. All four patients were treated with supportive therapy and antibiotics, and all four survived to discharge after a mean length of stay of 14 +/- 10 days. These data show that IMA reimplantation does not ensure colon viability in aortic surgery. Transmural colon necrosis tends to present sooner than mucosal ischemia and may be attributable to nonanatomic variables such as intraoperative hypotension. Although transmural necrosis is a highly morbid complication after aortic surgery, timely colectomy may lead to survival in some patients.

[Surgical treatment of aneurysms of unpaired visceral branches of the abdominal aorta]

Aneurysms of unpaired visceral branches of the abdominal aorta are rare diseases but they are dangerous for life. Russian Research Center of Surgery RAMS has an experience of diagnosis and surgical treatment of 23 patients with aneurysms of the celiac trunk (2), superior mesenteric artery (4), inferior mesenteric artery (1), hepatic artery (4), splenic artery (7), gastroduodenal artery (2), inferior pancreatoduodenal artery (1), multiple aneurysms of celiac trunk and superior mesenteric artery (2). 21 of 23 patients were operated. 20 patients were discharged with complete recovery. 1 (4.8%) patient died due to gastroduodenal bleeding 4 months after surgery. The results show that patients with aneurysms of unpaired visceral branches of abdominal aorta require surgical treatment.

Treatment of type 2 endoleaks after endovascular repair of abdominal aortic aneurysms: comparison of transarterial and translumbar techniques

OBJECTIVE

The exact significance of collateral endoleaks is unknown and a topic of great debate. Because of this uncertainty, some physicians choose to watch and wait while others aggressively treat these leaks. The purpose of this investigation was the evaluation of the efficacy of the two techniques used in the treatment of collateral endoleaks that occur after endovascular aneurysm repair.

METHODS

Patients with 33 angiographically proven type 2 endoleaks underwent treatment with either transarterial inferior mesenteric artery embolization (n = 20) or direct translumbar embolization (n = 13) during an 18-month period. Embolization success was defined as resolution of endoleak on all subsequent computed tomography angiogram results. The likelihood of embolization failure between the two treatments was expressed as a risk ratio and was compared with Fisher exact test.

RESULTS

Sixteen of 20 transarterial inferior mesenteric artery embolizations (80%) failed with recanalization of the original endoleak cavity over time. A single failure (8%) in the direct translumbar embolization group occurred in a patient in whom a new attachment site leak developed. The remaining 12 translumbar endoleak embolizations (92%) were successful and durable, with a median follow-up period of 254 days. The patients who underwent transarterial inferior mesenteric artery embolization were significantly more likely to have persistent endoleak than were the patients who underwent treatment with direct translumbar embolization (risk ratio, 4.6; 95% confidence interval, 1.9 to 11.2; P =.0001).

CONCLUSION

The transarterial embolization of inferior mesenteric arteries for the repair of type 2 endoleaks is ineffective and should not be performed. Direct translumbar embolization of the endoleak is effective in the elimination of type 2 leaks and should be the therapy of choice when aggressive endoleak management is indicated.

Mesenteric revascularization in a contaminated abdomen: a case report

The management of acute mesenteric ischemia in the contaminated abdomen may require the use of an autogenous graft to achieve mesenteric revascularization. The authors present a case of an ischemic small bowel perforation in a 62-year-old-woman whose preoperative angiogram demonstrated occlusion of the celiac, superior mesenteric, and inferior mesenteric arteries. Vein mapping of the right greater saphenous vein demonstrated a dual saphenous system whose individual diameters were more than 4 millimeters. Exploratory laparotomy revealed a diffusely ischemic small bowel and liver, as well as abdominal sepsis from the perforated small bowel. Revascularization was accomplished by using saphenous vein in a nonreversed orientation as a bifurcated conduit from the supraceliac aorta to the hepatic and superior mesenteric arteries. Following revascularization, the liver and small bowel immediately regained a normal perfused appearance and the perforated segment of small bowel was resected and reanastomosed. She returned for a follow-up clinic visit 5 months later and was found to have an asymptomatic 6 cm aneurysm involving the proximal mesenteric vein bypass. The aneurysmal aspect of the vein bypass was replaced with a polytetrafluoroethylene interposition graft originating from the supraceliac aorta. On follow-up 3 months later, her aortomesenteric bypass is patent without aneurysmal recurrence, and she is clinically asymptomatic from any symptoms of mesenteric ischemia.

[Accessory retrograde aneurysmal aortic lumen supplying the inferior mesenteric artery]

We report the case of a patient with infrarenal abdominal aortic aneurysm with mural thrombus covering the ostium of a patent inferior mesenteric artery (IMA). The IMA was supplied via flow from an accessory aneurysmal lumen within the mural thrombus that filled retrogradely from the aorta. This unusual pattern, associated with calcifications within the thrombus, raised the possibility of chronic aortic dissection.

Retroperitoneal endoscopic ligation of lumbar and inferior mesenteric arteries as a treatment of persistent endoleak after endoluminal aortic aneurysm repair

A 74-year-old man receiving long-term anticoagulation therapy for intermittent atrial fibrillation had a type II endoleak after endovascular abdominal aortic aneurysm repair. During an 8-month follow-up, the endoleak persisted, and the aneurysm failed to decrease in diameter. By means of a left flank retroperitoneal endoscopic surgical approach, the aneurysm was dissected free, and the lumbar arteries emanating from the aneurysm, as well as the inferior mesenteric artery, were ligated with titanium clips. A postoperative spiral computed tomography scan depicted one pair of unclipped lumbar arteries just proximal to the aortic bifurcation. After immediate reoperation with the same approach, complete thrombosis of the aneurysm sac was radiographically confirmed.

Postoperative splanchnic perfusion following the reconstruction of thoracoabdominal aortic aneurysm involving abdominal visceral branches. Report of a case

A 58-year-old man with thoracoabdominal aortic aneurysm involving visceral arteries underwent graft replacement of the thoracoabdominal aorta and associated reconstruction of abdominal visceral branches. Femoro-femoral extracorporeal bypass, intermittent selective visceral arterial perfusion and a staging cross-clamping method of the aorta were utilized at surgery. The total cross-clamping time of the aorta was 165 minutes. The patient's postoperative course was uneventful with no incidence of hepatic and renal failure or paraplegia. Although postoperative systemic blood pressure and cardiac output recovered to normal values within 7 hrs after the release of aortic clamping, it took 18 hrs for hepatic venous hemoglobin oxygen saturation (ShvO2) to recover. Base excess in arterial blood, lactic acid in arterial and hepatic venous blood, and ketone body ratio in arterial blood (AKBR) and hepatic venous blood (HVKBR) recovered to within normal ranges after 18 hrs of the release of aortic clamping. ShvO2 monitoring is a simple and may be a useful parameter in evaluating postoperative splanchnic perfusion and predicting abdominal organ failure at the time of thoracoabdominal aortic reconstruction involving visceral arteries.

[Esophageal replacement by interposition of pedicled ascending colon flap supplied by the inferior mesenteric artery]

OBJECTIVE

Colon interposition for esophageal replacement is indicated in patients with benign esophageal disease, in patients who require an esophago gastrectomy for a potential cure and in patients in whom the stomach is no longer available for replacement because of preceding surgery.

METHODS

In 30 patients we performed colon interposition grafts for esophageal replacement using a modified technique. This technique includes ligation of the middle and right colic artery, thereby creating an interposition graft of the whole ascending colon which receives blood exclusively from the left colic artery. The main advantage of this procedure is the length of the interposition graft. Preparation of the left colic flexure is no longer required. Nineteen patients had an esophagectomy, 11 patients an esophago-gastrectomy.

RESULTS

Minor complications in this unselected patient group occurred six times (20%), and major complications were observed in seven patients (23.3%). Frequency of anastomotic leakage amounted to 13.3%, hospital mortality to 10%.

CONCLUSION

Frequency of postoperative complications and hospital mortality of patients in whom a modified colon interposition was done is comparable with published data of unselected patient groups, which had either a standard colon interposition graft for esophageal replacement or a gastric pull-through procedure.