Colon interposition for esophageal replacement: current indications and long-term function

Pedunculated gastric tube interposition in an esophageal cancer patient with prepyloric adenocarcinoma

Gastric carcinoma is one of the malignancies that are most frequently associated with esophageal carcinoma. We describe herein our device for advanced esophageal cancer associated with early gastric cancer in the antrum. A 57-year-old man presenting with dysphagia and upper abdominal pain was admitted to our hospital. Preoperative examinations revealed locally advanced squamous cell carcinoma (SCC) of the middle thoracic esophagus (T3N0M0 Stage IIA) and mucosal signet-ring cell carcinoma of the gastric antrum (T1N0M0 Stage IA). Although the gastric tumor appeared to be an intramucosal carcinoma, its margin was obscure, so endoscopic en-bloc resection was considered inadequate. We chose surgical resection of the gastric tumor as well as the esophageal SCC after neoadjuvant chemotherapy with 5-fluorouracil and cisplatin for advanced esophageal cancer. Following transthoracic esophagectomy with three-field lymph node dissection, the gastric carcinoma was removed by gastric antrectomy, which preserved the right gastroepiploic vessels, and a pedunculated short gastric tube was used as the esophageal substitute. Twenty-eight months after the surgery, the patient is well with no evidence of cancer recurrence. Because it minimizes surgical stress and organ sacrifice, gastric tube interposition is a potentially useful technique for esophageal cancer associated with localized early gastric cancer.

Late morbidity after colon interposition for corrosive esophageal injury: risk factors, management, and outcome. A 20-years experience

OBJECTIVE

The aim of this study was to report our experience in the management of late morbidity after colonic interposition for caustic injury and to assess the influence of coloplasty dysfunction on patient outcome.

SUMMARY BACKGROUND DATA

Reports on coloplasty dysfunction after colon interposition for corrosive esophageal injuries are scarce in the literature. Dysfunction of the colonic substitute might jeopardize an already fragile functional result, and appropriate management can improve outcome.

METHODS

Long-term follow-up (>6 months) was conducted in 223 patients (125 men; median age, 35 years) who underwent colonic interposition for caustic injuries between 1987 and 2006. Statistical tests were performed on this cohort to identify risk factors for late morbidity and functional outcome. During the same period, 28 patients who underwent colon interposition for caustic injury in another center were referred for treatment of coloplasty dysfunction. Data from these patients were used together with those of our patients to describe specific coloplasty-related complications and their management.

RESULTS

With a median follow-up of 5 years (range: 6 months-20 years), late complications were recorded in 125 (55%) of our patients (stenosis 36%, reflux 11%, redundancy 5%). A delay in reconstruction <6 months (P = 0.03) and absence of thoracic inlet enlargement (P = 0.002) were independent predictive factors for cervical anastomotic stenosis. Functional failure was recorded in 52 patients (23%) and was associated with a delay in reconstruction <6 months (P = 0.009) and emergency tracheotomy (P = 0.002). Coloplasty dysfunction was responsible for half of the recorded failures. Revision surgery for coloplasty dysfunction was performed in 96 patients (68 local, 28 referred) with an overall 70% success rate.

CONCLUSIONS

Late complications occurred in half of the patients after colonic interposition for corrosive injuries and accounted for half of the functional failures. Prolonged surgical follow-up and appropriate management of coloplasty dysfunction are key factors for long-term success after esophageal reconstruction for caustic injuries.

Laparoscopically assisted esophagectomy and colon interposition for esophageal replacement in children: preliminary results of a novel technique

BACKGROUND

Colonic interposition is one of the surgical options in children when esophageal replacement is necessary, especially when the stomach is not suitable as a conduit. Conventional open surgery and blind mediastinal dissections present reasonable morbidity, which can be reduced by videosurgery. The authors present novel techniques and the preliminary results of the first series of laparoscopically assisted esophagectomies and colonic interpositions (LECIN) in children.

METHODS

Five children aged 19 months to 4 years underwent LECIN. Indications were complicated esophageal atresia and severe caustic esophagitis. The patients were operated on laparoscopically using 3 ports, including the gastrostomy site. Transhiatal esophagectomy was carried out, followed by pyloroplasty and mobilization of the transverse colon maintaining a double blood supply from the left pedicle. The stomach at the gastrostomy site was freed and closed in 3 cases. The colon was exteriorized through this 2- to 3-cm site or through the umbilicus, and the conduit was fashioned extracorporeally, including the colocolic and gastrocolic anastomosis. The colon was pulled up along the retromediastinal tunnel for the coloesophageal anastomosis through a cervical incision.

RESULTS

Operative times ranged from 3 to 4.3 hours; there were no conversions and no complications related to laparoscopy. There were no cardiorespiratory problems, and 4 were extubated immediately after operation. Feedings could be started by day 3 to 4. Postoperative complications included atelectasis (1), pneumonia (1), and cervical stenosis because of persistent fibrotic esophagus, requiring cervical revision (1). One needed dilatations for mild dysphagia. After a follow-up period of 10 to 29 months, all patients are asymptomatic, gaining weight, and feeding well.

CONCLUSIONS

These preliminary data suggest that LECIN is feasible and can be safely performed with very low morbidity in children. Further studies with larger series and follow-up are expected.

Anatomically based comparison of the different transthoracic routes for colon ascension after total esogastrectomy

Colon interposition is the method of choice to restore the digestive tract after esogastrectomy. The aim of this study was to compare the length of the four available routes for colon transposition (posterior mediastinum route, transpleural route, substernal route and subcutaneous route) and to achieve a specific evaluation of the transpleural route. Our study was conducted with anatomical (dissection) and radiological (2D CT scan reconstructions) protocols. For both, the posterior mediastinum route was always the shortest way and the subcutaneous route was always the longest. For the anatomical results, the transpleural route and the substernal route were similar in terms of length and for the radiological study, the transpleural route was shorter than the substernal route (P < 0.001) and shorter than the subcutaneous route (P < 0.001). We demonstrated that the transpleural route was acceptable for colon transposition in term of length, and could be an alternative when the substernal route is unavailable.

Operative outcome of colon interposition in the treatment of esophageal cancer: a 20-year experience

BACKGROUND

In patients with esophageal cancer and a history of gastric surgery, colonic interposition is the treatment of choice. Our aim was to review our experience with this technique and to identify possible predictors of the clinical outcome.

METHODS

Between 1986 and 2006, 43 patients underwent esophageal reconstruction accomplished by colon interposition in our surgical department. Data from these patients were collected consecutively and reviewed retrospectively.

RESULTS

Colon interposition was performed isoperistaltically in 15 patients and was performed in 28 patients anisoperistaltically. In 18 patients, the right colon was used for interposition, whereas in 25 patients, the left colon was used. The mean survival time was 23+/-29 months. Artificial ventilation more than 24h, tumor differentiation grade III, the presence of major complications, and the presence of multivisceral resection had a significant negative influence on the operative outcome of colon interposition for esophageal replacement.

CONCLUSION

Colon interposition for esophageal replacement provides a satisfactory operative outcome with high complication rates. Therefore, it should be reserved as a treatment of second choice for cases in which the stomach is not available.

Corrosive injury to the GI tract in adults: a practical approach

Corrosive injury to the GI tract still poses great challenges with regards to the initial evaluation triage, as well as the optimization of medical management. Although relatively uncommon in the adult population, these injuries can cause significant morbidity and serious sequelae of complications, such as esophageal strictures and cancer. Prompt recognition of the process and aggressive measures towards the stabilization of the patient are key to a favorable outcome.

Chemical injuries of the oesophagus: aetiopathological issues in Nigeria

Background

Chemical injuries of the oesophagus occur worldwide. There is paucity of information on aetiopathological profile of chemical injuries of the oesophagus in Nigeria.

Aim

The aim of the study was to determine the aetiopathological pattern of chemical injuries of the oesophagus in Nigeria.

Materials and methods

This is a multi-centre hospital based study in Lagos metropolis spanning a period of 10 years.

The patients' bio data, substances ingested, sources of corrosives, reasons for ingesting corrosives and patients' mental state were recorded.

Results

In all, there were 78 patients (61 Males, 17 Females). The offending agents were acids in 55.1% of cases and it was accidental ingestion in 62 patients. The highest incidence of 57.6% was found in the middle 1/3 of the oesophagus.

Conclusion

Accidental ingestion of acids is the commonest cause of oesophageal injuries in Nigeria. The incidence of severe strictures necessitating oesophageal substitution could be reduced if early management of corrosive oesophagitis improves in Nigeria.

Structural modifications of colonic transplant in plastic repair of the esophagus

Structural changes in the colonic transplant were studied after esophagoplasty, carried out for post-burn cicatricial strictures of the esophagus. It was shown that artificial esophagus was liable to hypotony and deformation in delayed periods after reconstructive interventions. Regeneratory and adaptive reactions in the mucosa underlie its restructuring, while under pathological conditions proliferative catarrhal changes predominated in the artificial esophagus. The leading pathomorphological characteristics of the colonic transplant are epithelial degeneration, active, sometimes unbalanced proliferation, hyperplasia and hypersecretion of goblet cells, lymphoplasmacytic infiltration of the stroma paralleled by slight sclerosis. Modifications of the ultrastructural organization of cell populations in the Lieberkuhn crypts are determined by the intensity of pathological processes and are aimed at realization of the cytoprotective potential of the transplant mucosa.

The esophageal remnant after gastric interposition

Gastric interposition is usually considered the reconstruction of choice following esophageal resection. However, a number of reports show that esophagectomy followed by a gastric transplant is associated with poor quality of life and significant reflux esophagitis in the esophageal remnant. The aim of this work is to review the factors affecting the mucosa of the esophageal remnant when using the stomach. A Medline was conducted. Additional references and search pathways were sourced from the references of reviewed articles. Reflux disease is considered an unavoidable consequence of esophageal resection followed by gastric interposition. Mucosal damage from acid and bile exposure in the esophageal remnant affects approximatively 50% of these patients. There is usually no correlation between symptoms and the presence of mucosal damage in the remaining esophagus. Endoscopy and endoscopic biopsies are the only reliable methods to document the status of the mucosa. When present, reflux esophagitis shows a progression from inflammation to erosions and to the development of columnar lined metaplasia. Esophageal and gastric function, gastric drainage operation, level of the anastomosis, route of reconstruction, and patients' position after the operation have all been shown to influence the severity and extent of damage in the esophageal remnant. Prevention and treatment of esophagitis in the remaining esophagus are discussed. When the stomach is used as a substitute to reconstruct the esophagus whether for malignant or benign conditions, an in vivo model of reflux diseases is created. Studies using this model may help clarify molecular and cellular events that lead to irreversible insult on the esophageal mucosa. Improvement to the reconstruction itself must be sought to favor better results with the gastric transplant.

[Second time esophageal reconstruction surgery: coloplasty and gastroplasty]

OBJECTIVE

To analyze the morbidity and mortality of second time esophageal reconstruction in an Esophagogastric Unit.

PATIENTS AND METHOD

Second time esophageal reconstruction surgery with coloplasty and gastroplasty was performed on 20 patients, from January 2001 to October 2006. The morbidity and mortality of each technique has been analyzed retrospectively.

RESULTS

The mean age of the 16 males and 4 women operated on was 54.3 +/- 17.5 years. The diagnoses at the first surgery were: 7 caustic ingestions, 7 Boerhaave syndrome, 3 iatrogenic perforations, 1 tracheal-esophageal fistula, 1 esophageal-jejunal dehiscence and 1 necrosis of the gastroplasty after transhiatal oesophagectomy. There were 14 (70%) right coloplasties, 4 (20%) left coloplasties and 2 (10%) gastroplasties with gastric conditioning. In 11 of the 20 patients gastroplasty was ruled out due to gastrectomy (8 cases) or previous gastric surgery (3 cases). It was noted on analyzing the morbidity: pleural effusion (65%), respiratory failure (45%), atelectasis (35%) and cervical anastomosis dehiscence (35%). Five patients were re-intervened: 3 due to intra-abdominal sepsis and 2 due to hemoperitoneum. Mortality was 10% (2 cases). In subsequent follow up there was 5% (1 case) of stenosis of the anastomosis.

CONCLUSIONS

Esophageal reconstruction technique which in specialist units has an acceptable mortality rate (10%) and an insignificant morbidity. Coloplasty was the technique most used on these patients.

Surgical management of colonic redundancy following esophageal replacement

Colonic redundancy is the most common late complication following esophageal replacement by colonic interposition. Redundancy in the colonic graft leads to mechanical dysfunction of the neo-conduit, causing disabling symptoms that may develop decades after the original surgery. When symptoms caused by food retention in the colonic loop occur, surgical correction may be necessary to improve quality of life and to prevent complications such as aspiration if lifestyle modifications fail. We describe two cases where remedial surgery was performed for redundancy in interposed colonic grafts. Particularly attention is given to preoperative work-up and surgical technique. The literature is reviewed for the etiology, clinical features and management options of this condition. These cases illustrate a successful surgical technique for correcting this complication.

Intestinal interposition for benign esophageal disease

Various options exist for intestinal interposition for benign, but debilitating, end-stage esophageal disorders. Principally, the stomach, colon, or jejunum is used for esophageal replacement. Much debate exists regarding the ideal esophageal replacement option. The conduit choice must be tailored to the individual patient. Unlike malignant processes, the conduit choice for benign disorders must be sufficiently durable and functional. Colonic interposition meets both criteria. However, this operative procedure's technical difficulty increases the complexity of this already challenging clinical problem, as seemingly small errors in judgment and technique can significantly impact graft viability and long-term function. Using a gastric tube also provides durability and functionality, but with an operative procedure that is less technically demanding. A minimally invasive laparoscopic transhiatal esophagectomy offers the patient even more benefit in terms of shorter operative times and intensive care unit and recovery periods. However, the advent of surgical robotic technology augments these benefits even further. Robotic technology arms the surgeon with improved dexterity and three-dimensional visualization. These revolutionary improvements allow the surgeon to overcome many of the operative limitations that exist with the open and minimally invasive approaches to esophagectomy, thus potentially offering patients reduced morbidity and mortality rates.

Esophageal reconstruction after caustic injury: is there still a place for right coloplasty?

BACKGROUND

Through a systematic policy of using the right colon as an esophageal substitute, the authors analyze the reliability of this transplant for reconstruction after digestive caustic injury.

METHODS

From 1995 to 2005, a right coloplasty was attempted in 81 patients after total esophagogastrectomy (n = 57) or for esophageal stricture (n = 24).

RESULTS

The use of the right colon was not possible in 10 patients (12%) because of insufficient blood supply. In addition, postoperative right colic graft necrosis occurred in 5 patients. Cervical fistula occurred in 25 patients (31%). Opening of the thoracic inlet was associated with a lower rate of this complication (P = .04). At the end of the follow-up, 71 patients (88%) recovered oral feeding.

CONCLUSION

Attempt to use the right colon as an esophageal substitute failed in 18% of the patients. Despite high rates of cervical complications, in part linked to the peculiar setting of caustic injury, functional results remains satisfactory.

Surgical outcome of colon interposition by the posterior mediastinal route for thoracic esophageal cancer

BACKGROUND

For thoracic esophageal cancer patients with a history of gastrectomy, esophageal reconstruction using segments of colon was often accomplished using the anterior mediastinal route to avoid fatal complications related to colon necrosis. Our aim was to review our experience with reconstruction by the posterior mediastinal route and assess the surgical outcomes.

METHODS

Between 1989 and August 2006, 34 esophageal cancer patients at Akita University Hospital underwent esophageal reconstruction accomplished by colon interposition by the posterior mediastinal route. Data from these patients were reviewed.

RESULTS

Colon conduits consisted of left colon segments in 4 patients and right colon segments in 30. The grafts were supplied with blood by the left colonic artery in 13 patients, the middle colonic artery in 20, and the right colonic artery in 1. The esophagocolic (pharyngocolic) anastomosis was located in the neck in 33 patients (97%) and in the thorax in 1. No patient died during the initial hospital stay. There were no instances of colon necrosis. An anastomotic fistula occurred in 3 patients (9%). Proximal anastomotic strictures occurred in 2 patients (6%). No late graft redundancies resulting in significant dysphagia occurred. Reductions in body weight did not differ from those seen when the gastric tube was used for reconstruction, and alimentary function was good after surgery. The 1-, 2-, 3-, and 5-year survival rates were 66%, 52%, 48%, and 48%, respectively.

CONCLUSIONS

Colon interposition by the posterior mediastinal route provides a good outcome and is considered the route of first choice.

Evaluation of decellularized esophagus as a scaffold for cultured esophageal epithelial cells

Recently, decellularized tissue has been reported to have the potential to regenerate a variety of tissues. However, the optimal protocol for a decellularized esophagus has not been studied. Here, we investigated the effect of different decellularization protocols on the histology and biocompatibility of decellularized esophagi in view of future applications to tissue engineering. The esophageal mucosal epithelium (EP) from 4-week-old Wistar rats was enzymatically dissociated and cultured with growth-arrested feeder cells. Two methods for decellularization using deoxycholic acid (DEOX) or Triton X-100 (TRITON) were compared on esophagi from adult Wistar rats. Those treated with DEOX showed superior mechanical properties, maintenance of extracellular matrix, and lower DNA content than those treated with TRITON. To evaluate the biocompatibility of the scaffold, cultured (passage 3) esophageal epithelial cells were seeded inside the decellularized esophagus and cultured for 7 days. The cells seeded onto the decellularized esophagus were examined histologically and immunocytochemically. Esophageal epithelial cells were stratified into three to four cellular layers in vitro inside the decellularized esophagus, to show polarity. The results from immunocytochemistry indicated that the seeded epithelial cells expressed characteristic marker proteins for native esophageal EP. Decellularized esophagus showed suitable compatibility as a scaffold material for esophageal tissue engineering.

A new technique for substernal colon transposition with a breast dissector: report of 39 cases

This paper investigates the effectiveness of the breast dissector to create a substernal space for oesophageal reconstruction. The surgeon must be extremely careful while dissecting the tissue below the sternum in order to avoid pneumothorax. The endoscopically assisted preparation of the substernal route is safe but it requires appropriate training. A retrospective study on 68 patients who underwent oesophageal reconstruction was done analysing the patients' records. In 39 cases, the breast dissector was used. In 29 cases, the substernal tunnel was created with hand dissection only. All 68 colon segments were successfully transferred in the two groups of patients. In all 39 the cases where the breast dissector was used no pneumothorax followed. In 10 (34%) patients of the control group pneumothorax occurred. Concluding, no more pneumothorax has occurred during the substernal oesophageal reconstruction since we started using the breast dissector.

Esophageal conduit necrosis

A cumulative review of the prevalence of esophageal conduit necrosis is summarized in Table 4. The spectrum of conduit ischemia is broad and includes cases in which there is anastomotic leak or stricture as well as cases in which there is frank graft necrosis. Many of the studies that the authors reviewed do not specify the exact nature of postoperative ischemic complications or how they are defined. Therefore, postoperative conduit ischemia is reported globally. Based on the authors' review, average rates of ischemic complications for stomach, colon, and jejunum are 3.2%, 5.1%, and 4.2%, respectively. Results for colon and jejunum include results for both long- and short-segment grafting. Most reports that compare outcomes using different esophageal conduits demonstrate findings similar to the authors'. Davis and colleagues compared results with colon versus gastric conduit esophageal reconstruction. They found that operative mortality, anastomotic leaks, and conduit ischemia rates were all lower for the stomach than for the colon. Specifically, ischemia of the stomach conduit was 0.5%, compared with 2.4% for the colon conduit. Moorehead and Wong, in a large series of 760 esophagectomy patients in whom the stomach, colon, or jejunum was used for reconstruction, demonstrated that the stomach had the lowest incidence of conduit ischemia (1%), followed by jejunum (11.3%), then colon (13.3%). Some of the factors they identified as correlating with the risk of ischemia include length of conduit, technique of stomach graft preparation, whether anastomosis is in the neck or chest, and route of passage of the conduit. Mansour and colleagues compared their results using bowel interposition (either colon or jejunum) to reconstruct the resected esophagus. The authors report an overall mortality of 5.9%, and 3% conduit ischemia. All ischemia was noted in the colon conduits harvested from the left side. No ischemic complications were noted from jejunal segments. Briel and colleagues compared stomach versus colon conduit use after esophagectomy. They note an overall incidence of ischemia of 9.2%. In their series, the incidence of ischemia for stomach and colon was 10.4% and 7.4%, respectively. Anastomotic leak and stricture rates, both thought to be sequelae of ischemia, also were lower for colon conduit use than for stomach conduit. Multivariate analysis identified patient comorbidities as the only independent risk factor for conduit ischemia. The authors use their findings to support the preferential use of colon conduits rather than stomach conduits. The incidence of colon conduit ischemia (7.4%) is directly in line with all other published results, including the cumulative review by the authors of this article, whereas the rate of stomach conduit ischemia (10.4%) is considerable higher than in most other studies. Esophageal conduit necrosis is an uncommon but disastrous complication of esophageal surgery. Careful selection of patients for surgery, preoperative evaluation of the proposed conduit, and meticulous operative technique are the best defenses against conduit ischemia. Postoperatively, surgeons should have a high index of suspicion for this complication. Unexplained tachycardia, respiratory failure, leukocytosis, or any evidence for graft or anastomotic leak should prompt a search for conduit ischemia. The diagnosis is made by contrast esophagography, endoscopy, or direct operative inspection. There is no documented salvage technique once ischemia is identified. Treatment for mild cases may be supportive, with or without management of anastomotic leak. More severe cases of necrosis require débridement and conduit take-down with proximal esophageal diversion and placement of enteral feeding tubes. Reconstruction can be planned for later if possible. The majority of the data demonstrates that risk of ischemia is related to conduit type, length of conduit, comorbidities, and operative technique. The stomach has the lowest reported incidence of conduit ischemia, followed by the jejunum, and colon. In the future, methods to predict conduit ischemia more accurately at the time of surgery may further reduce the incidence of this disastrous complication.

Management of corrosive esophageal burns in 149 cases

OBJECTIVES

We sought to present our experience in the management of esophageal burns.

METHODS

From April 1976 through October 2003, 149 patients with corrosive esophageal burns were included in this study. Treatment modalities consisted of modified intraluminal stenting in 28, colon interposition in 71, gastric transposition in 25, repair of cervical stricture with platysma myocutaneous flap in 17, and miscellaneous operations in 12 patients. Eleven of these patients underwent the above procedures twice at our institute. The remaining 7 patients were treated with conservative therapy.

RESULTS

Twenty-three patients recovered from intraluminal stenting, and 5 experienced stricture after stent removal. One of the 5 patients with failed stents responded to bougienage, and the remaining 4 patients required esophageal reconstruction later. Of the 71 colon interpositions, 5 patients died postoperatively, and complications consisted of proximal anastomotic fistula in 17, anastomotic stenosis in 6, and abdominal incision dehiscence in 2 patients. Postoperative complications in the 25 patients with gastric transpositions comprised anastomotic stricture in 2 patients and empyema in 1 patient. There was a cervical leak in 1 of the 17 patients undergoing the repair of cervical esophageal or anastomotic stricture with a platysma myocutaneous flap. One of the patients in the group undergoing 12 miscellaneous procedures died 8 months after surgical intervention. All the survivors currently eat regular diets.

CONCLUSIONS

Intraluminal stenting can prevent the formation of caustic esophageal stricture. The location of the cicatricial esophagus dictates whether to perform concomitant esophagectomy during esophageal reconstruction. Platysma myocutaneous flap repair is an excellent method for the treatment of severe cervical esophageal or anastomotic stricture.

Surgical treatment of giant esophageal leiomyoma

AIM: To summarize the operative experiences for giant leiomyoma of esophagus.

METHODS: Eight cases of giant esophageal leiomyoma (GEL) whose tumors were bigger than 10 cm were treated surgically in our department from June 1980 to March 2004. All of these cases received barium swallow roentgenography and esophagoscopy. Leiomyoma located in upper thirds of the esophagus in one case, middle thirds of the esophagus in five cases, lower thirds of the esophagus in two cases. Resection of tumors was performed successfully in all of these cases. Operative methods included transthoracic extramucosal enucleation and buttressing the muscular defect with pedicled great omental flap (one case), esophagectomy and esophago-gastrostomy above the arch of aorta (three cases), total esophagectomy and esophageal replacement with colon (four cases). Histological examination confirmed that all of these cases were leiomyoma.

RESULTS: All of the eight patients recovered approvingly with no mortality and resumed normal diet after operation. Vomiting during meals occurred in one patient with esophagogastrostomy, and remained 1 mo. Reflux esophagitis occurred in one patient with esophago-gastrostomy and was alleviated with medication. Thoracic colon syndrome (TCS) occurred in one patient with colon replacement at 15 mo postoperatively. No recurrence occurred in follow-up from 6 mo to 8 years.

CONCLUSION: Surgical treatment for GEL is both safe and effective. The choices of operative methods mainly depend on the location and range of lesions. We prefer to treat GEL via esophagectomy combined with esophago-gastrostomy or esophagus replacement with colon. The long-time quality of life is better in the latter.

[Reinterventions for complication and defect of coloesophagoplasty]

AIM OF THE STUDY

To report a series of 17 patients operated for a complication oesophagocoloplasty, with evaluation of therapeutic modalities, and both early and distant results.

MATERIALS AND METHOD

From 1985 to 2003, 17 patients with a mean age of 50 years (range: 23-76) were reoperated after coloplasty pediculated on left superior colic vessels. Initial diseases were caustic ingestion (N=7), cancer (N=6), oesophageal perforation (N=2), gastric lymphoma (N=1) and oesotracheal fistula (N=1). Coloplasty has been performed as a first-intent procedure in 13 cases and as a second-intent procedure after failure of a previous operation in 4 cases. Nine patients were initially operated in another center and were subsequently referred in our unit. Complications needing reoperation were graft necrosis in 8 cases (47%) and stricture in 9 cases (53%). All patients with necrosis were reoperated within the 10 first postoperative days.

RESULTS

Necroses were treated by complete (N=5) or partial (N=3) resection of the coloplasty. Strictures were treated by resection-reanastomosis (N=3), right ileocoloplasty (N=2), colic stricturoplasty (N=2), a free antebrachial flap (N=1) and a tubulized latissimus dorsi myocutaneous pedicled flap (N=1). The 30-day mortality rate was 12% (N=2) and the overall morbidity rate was 66%. All deaths occurred after reoperation for necrosis. Eleven patients (65%) kept or recovered digestive continuity (including the 9 with stenosis) and 8 (73%) eat normally. Four patients with transplant necrosis died before reestablishment. Four patients operated for necrosis died before restoration of digestive continuity and 2 patients are still awaiting restoration.

CONCLUSION

Use of colon as an oesophageal substitute is risky. Reoperations for stenosis allows satisfactory oral feeding, while reoperation for necrosis is associated with both high early mortality and a low rate of restoration or digestive continuity. This later requires a range of complex surgical procedures.

Quality of life after colon interposition by necessity for esophageal cancer replacement

BACKGROUND

After esophagectomy for cancer, the first choice for reconstruction of the gastrointestinal continuity is by gastric tube. When this is not feasible, a reconstruction by colon interposition can be performed. The aim of this study was to assess the quality of life in patients at least 6 months after esophageal cancer resection and colon interposition without signs of recurrent disease. The results were compared with previously published data of patients after esophageal cancer resection and gastric tube reconstruction.

PATIENTS AND METHODS

Between January 1993 and January 2002, 36 patients underwent esophageal cancer resection and gastrointestinal reconstruction by colon interposition. A one-time Quality of Life assessment was carried out in 14 patients who were still disease free after a median follow-up of 21 months (mean 35, range 7-97). The patients were visited at home and asked to fill in questionnaires which consisted of the Short Form-36 (SF-36) Health Survey to assess general quality of life, an adapted Rotterdam Symptom Checklist to assess disease-specific quality of life, a visual analogue scale, and an additional questionnaire concerning other specific effects of the operation.

RESULTS

All 14 patients returned the completed set of questionnaires. Compared to the previously published results of patients after gastric tube reconstruction patients with a colon interposition scored significantly (P < or = 0.05) lower in five of the eight subscales of the SF-36 questionnaire (i.e. general health, physical role, vitality, social functioning, and mental health). The most frequent symptoms measured by the Rotterdam Symptom Checklist were early satiety after a meal, dysphagia, diarrhea, loss of sexual interest, and fatigue. Six patients could not independently run their housekeeping and four patients still needed artificial enteral nutrition.

CONCLUSION

Based on the SF-36 questionnaire, patients after colon interposition by necessity have a poor general quality of life. Even long after the operation they have a broad spectrum of persisting symptoms. Prior to surgery, patients should be informed about the disabling long-term functional outcome of a colon interposition.

Surgical treatment of oesophageal cancer

Various reconstructive conduits and routes of reconstruction have an impact on operative morbidity and foregut function in patients undergoing oesophagectomy. Advantages of a fundus rotation gastroplasty are the better blood supply and the greater length of the gastric tube and its possible impact on anastomotic complications. For a subgroup of patients with oesophageal carcinoma limited to the lamina propria vagal-sparing oesophagectomy seems to be a good alternative in terms of quality of life to preserve gastric secretory, motor, and reservoir function. Posterior mediastinal reconstruction is usually preferred when complete resection (R0) has been accomplished. Anterior mediastinal reconstruction may secondary prevent dysphagia after incomplete resections due to tumour recurrence (R0, R1). However, for all presently available surgical approaches in the treatment of oesophageal cancer qualified studies (prospective randomised) are needed. In addition, randomized trials are needed to identify the specific subgroups of patients who benefit from neoadjuvant or adjuvant radiochemotherapy.

[Surgery for oesophageal cancer: current controversies]

Any attempt to define the present role of surgery in the treatment of oesophageal cancer should integrate the dramatic changes that occurred within this disease over the last 2 decades: major shift in the histologic type of tumours, improved staging methods, spectacular reduction of operative risks, standardization of oncologic principles focusing on the completeness of resection, and development of multimodality therapeutic strategies. Surgery has still a pivotal role. Esophagectomy should be performed by trained surgeons in high-volume institutions. Radical surgery with en-bloc resection and 2 fields lymphadenectomy, should be encouraged in low-risk patients with subcarinal tumors. Although multimodality treatment strategy is commonly applied for locally advanced disease, few data support its superiority over surgical resection alone, followed by adjuvant therapy when appropriate. One may thus hypothesize that the risk/benefit ratio of such strategies is probably optimal in case of early stage tumors, and future studies may further clarify this issue. Conversely, locally advanced tumors, particularly those located in the upper mediastinum and the neck, may be managed alternatively without surgery. However, surgery remains an important tool to ensure optimal palliation of dysphagia, to achieve local control, and finally to improve quality of life. In that way, video-assisted techniques and/or trans hiatal approaches aiming to minimize the surgical insult may have a place in the treatment of patients who have substantially responded to induction therapy. Tumors located close to the pharyngo-oesophageal junction are best managed with chemotherapy and radiotherapy. Finally, salvage surgery may be considered in highly selected patients in case of non-response or local relapse without distant metastases.

Management of long-term failure after colon interposition for benign disease

PURPOSE

To assess causes and treatment of late failures of colon interposition.

METHODS

We reviewed the charts of 6 patients who underwent one or more revisions of a colonic interposition at a mean of 16 years after colon interposition (CI).

RESULTS

Symptoms of problems with the CI were dysphagia (67%), regurgitation (67%), pneumonia (40%), and chest pain (33%). Findings that accounted for failure were colonic redundancy (67%), and gastrocolonic reflux (50%). Approach was resection of redundant colon or management of reflux. Four patients underwent segmental resection of the colon preserving blood supply. Three patients had gastric resection or diversion of bile and acid for management of reflux. Treatment was successful in all patients.

CONCLUSION

Late failure of colon interposition is secondary to conduit redundancy and severe reflux. Resection of redundant colon will correct colonic redundancy. Gastric resection or diversion of bile and acid corrects gastrocolonic reflux.

Does the interponat affect outcome after esophagectomy for cancer?

Clinical decision-making in esophageal cancer surgery is a process of balancing the risks of treatment against potential benefits, such as survival and quality of life. Various options are available for esophageal reconstruction. While these reconstructive options do not directly have an impact on cancer survival, they do affect operative morbidity and long-term quality of life. The affect of various interponats (reconstructive conduits) and routes of reconstruction on operative morbidity and foregut function is reviewed. Gastric interponats are preferred for esophageal reconstruction because of their reliable vascularity and the relative simplicity of the reconstructive operation. Colon interponats supposedly provide better long-term function as an esophageal substitute (unproven), but at the cost of increased operative complexity and morbidity. Colon interposition is therefore reserved for situations in which gastric transposition is not feasible. Both posterior and anterior mediastinal routes of gastric interponat reconstruction are acceptable (meta-analysis of randomized controlled trials). Posterior mediastinal reconstruction is usually preferred when a complete (R0) resection has been accomplished. Anterior mediastinal reconstruction may prevent secondary dysphagia after incomplete (R1, R2) resections.

German experience with colon interposition grafting as an esophageal substitute

Preliminary results of a questionnaire survey showed that gastric transposition is the technique of choice in Germany to restore alimentary continuity after esophageal resection. Experience with colon interposition grafting is low. Only 13% of all centers perform this technique. Despite this limited experience, there appears to be no difference in the complication rate between gastric pull-through procedures and colon interpositions. A modification of established colon interposition techniques is possible when the right colon is used if it is prepared in such a way that the left colonic artery is the blood supplying vessel. This modified technique may be simpler to perform than previous procedures for creating a colon interposition graft and may also facilitate esophageal replacement using colon interposition grafting.

Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery

BACKGROUND

Anastomotic leak after gastrointestinal surgery is an important postoperative event that leads to significant morbidity and mortality. Postoperative leak rates are frequently used as an indicator of the quality of surgical care provided. Comparison of rates between and within institutions depends on the use of standard definitions and methods of measurement of anastomotic leak. The aim of this study was to review the definition and measurement of anastomotic leak after oesophagogastric, hepatopancreaticobiliary and lower gastrointestinal surgery.

METHODS

A systematic review was undertaken of the published literature. Searches were carried out on five bibliographical databases (Medline, Embase, The Cochrane Library, Cumulative Index for Nursing and Allied Health Literature and HealthSTAR) for English language articles published between 1993 and 1999. Articles were critically appraised by two independent reviewers and data on definition and measurement of anastomotic leak were extracted.

RESULTS

Ninety-seven studies were reviewed and a total of 56 separate definitions of anastomotic leak were identified at three sites: upper gastrointestinal (13 definitions), hepatopancreaticobiliary (14) and lower gastrointestinal (29). The majority of studies used a combination of clinical features and radiological investigations to define and detect anastomotic leak.

CONCLUSION

There is no universally accepted definition of anastomotic leak at any site. The definitions and values used to measure anastomotic failure vary extensively and preclude accurate comparison of rates between studies and institutions.

Colon interposition for esophageal replacement: isoperistaltic or antiperistaltic? Experimental results

BACKGROUND

Isoperistaltic colon is preferred to antiperistaltic colon for esophageal replacement, but experimental data do not exist to support this practice.

METHODS

In 7 dogs a 20 cm long colon loop was interposed between the skin and the small bowel, isoperistaltically in 3 dogs and antiperistaltically in 4 dogs. Three months later five strain-gauges were implanted and evacuation was investigated by motility testing, barium studies, and scintigraphy.

RESULTS

Motility recording showed normal colon motility in the excluded loops. Quiescent states (duration 40.2 +/- 13.6 minutes) were followed by contractile states (duration 7.5 +/- 2.4 minutes, frequency 3.3 +/- 0.6 per minute). The main peristaltic direction of isoperistaltic loops was isoperistaltic, and the main peristaltic direction of antiperistaltic loops was antiperistaltic. Evacuation took place exclusively during the contractile status. Half time emptying was more rapid in isoperistaltic loops (35 +/- 11 vs 69 +/- 16 minutes). The content of antiperistaltic loops was held back by antiperistaltic activity. Application of oatmeal porridge into the loops shortened the quiescent status from 40.2 to 13.2 +/- 4.8 minutes.

CONCLUSIONS

The colon graft for esophageal replacement is an active system. Food is stored during the quiescent states and evacuated during the contractile states. The original peristaltic direction is preserved so that retroperistalsis in antiperistaltic loops may lead to patient discomfort and pulmonary complications.

Limited resection for early adenocarcinoma in Barrett's esophagus

OBJECTIVE

To assess the extent of disease in patients with pT1 esophageal adenocarcinoma and to evaluate the feasibility and outcomes of a limited surgical approach.

SUMMARY BACKGROUND DATA

Radical esophagectomy with systematic lymphadenectomy is widely advocated as the treatment of choice in patients with early adenocarcinoma of the distal esophagus. This approach, however, is associated with substantial complications and long-term side effects. The extent of resection necessary to achieve cure in such patients is not clear.

METHODS

Seventy-one patients with pT1 adenocarcinoma of the distal esophagus underwent transmediastinal or transthoracic esophagectomy with two-field lymphadenectomy. Twenty-four patients with uT1N0 tumors underwent a limited resection of the distal esophagus and esophagogastric junction, regional lymphadenectomy, and reconstruction by interposition of an isoperistaltic pedicled jejunal segment. The two groups were compared for extent and multicentricity of the primary tumor and associated high-grade dysplasia, pattern of lymph node metastases, complications, deaths, and outcome of surgical treatment.

RESULTS

Multicentric tumor growth or associated high-grade dysplasia was observed in 60.6% of the resection specimens. Complete resection of the tumor and the entire segment with intestinal metaplasia was achieved in all patients, irrespective of the surgical approach. Patients undergoing limited resection had fewer complications. Lymph node metastases or micrometastases were present in none of the 38 patients with tumors limited to the mucosa (pT1a) versus 10 of the 56 (17.9%) patients with tumors invading the submucosa (pT1b). Distant lymph node metastases occurred only in patients with more than three positive regional lymph nodes. Lymph node metastases were prognostic, but the pT1a/pT1b category and the surgical approach were not. The mean Gastrointestinal Quality of Life Index after limited resection did not differ from that of healthy controls: 20 of the 24 patients were completely asymptomatic.

CONCLUSIONS

In patients with early adenocarcinoma in the distal esophagus, resection of the distal esophagus and esophagogastric junction, with regional lymphadenectomy and jejunal interposition, is an attractive limited surgical alternative to radical esophagectomy.

Gastroesophageal junction adenocarcinoma

The incidence rate of adenocarcinoma of the esophagogastric junction (AEG) is increasing in association with the epidemiologic rise in distal esophageal adenocarcinoma and gastric cardial (AEG type III) tumors. The overall survival rate is poor in most patients with AEG because lymph node or visceral metastases are frequently present at the time patients become symptomatic. A few patients are identified early in the disease because of screening for gastroesophageal reflux and Barrett's esophagus. Early stage AEG (T1N0 or T2NO, carcinoma in situ, or severe dysplasia ) can in many instances be cured with surgery alone. Ablative treatments for early stage AEG, including endoscopic fulguration by cautery and laser or photodynamic therapy, are investigational at this time. Locoregionally advanced AEG (T3, T4, N1, or M1a ) without distant systemic metastases (M1b) has a poor overall survival rate with surgery alone or definitive chemotherapy and radiation therapy without surgery. Analysis of the use of multimodality treatment strategies for locoregionally advanced AEG types I and II have demonstrated improved survival rates in two small phase III trials with preoperative concurrent chemoradiotherapy followed by surgical resection. In contrast, three small phase III trials with preoperative concurrent or sequential chemoradiotherapy in patients with predominantly squamous cell carcinoma did not demonstrate any clear survival advantage. Additionally, a randomized phase III study evaluating preoperative chemotherapy without radiation therapy in esophageal cancer (predominantly adenocarcinoma) has demonstrated no survival benefit. In light of these results, additional large randomized phase III studies are needed to confirm the potential benefit of preoperative concurrent chemoradiotherapy. At the present time, preoperative chemoradiotherapy remains investigational. For locoregionally advanced gastric adenocarcinoma, including AEG type III, postoperative concurrent 5-fluorouracil (5-FU)-based chemoradiotherapy is associated with improved survival as demonstrated in a recently completed random assignment trial (INT 0116). As a result, surgery with postoperative chemoradiotherapy has recently become the standard of care for patients with AJCC stage II and III gastric adenocarcinoma (including patients with AEG type III). Metastatic AEG (M1b) should be treated with palliative chemotherapy (in good performance patients) or supportive care (poor performance) in asymptomatic patients. Radiation therapy and endoscopic stent placement (expandable wire mesh) can be used to palliate dysphagia in patients with M1b disease. The development of expandable stents and improved radiotherapy has obviated surgical bypass to palliate patients with symptomatic, metastatic AEG.

Revisional surgery after colon interposition for benign oesophageal disease

Although the short-term results of colon interposition for replacement of the oesophagus in part or as a whole are known to be satisfactory, there have been several reports of functional problems associated with total replacement in the long-term follow-up of patients. We have retrospectively studied patients who have required revisional surgery for anatomical and functional sequelae over a 7- to 38-year period. Although the short-segment colon interpositions have been relatively trouble free, several mechanical and functional problems requiring revisional surgery have been encountered in the long-term follow-up of patients who underwent long-segment colon interposition.

Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon

OBJECTIVE

To describe the technique and results of an alternative colon interposition procedure in which the ascending and transverse colon is used as graft, but that still relies on the left colonic artery for blood supply.

SUMMARY BACKGROUND DATA

The standard procedure to obtain a left colon interposition graft requires ligation of the middle colic artery and mobilization of the left and right flexure. This approach carries a risk because preparation of the left flexure may damage arterial or venous collaterals located at this site that are crucial for graft perfusion.

METHODS

The authors modified the standard technique so that mobilization of the left flexure is no longer necessary. To obtain a colon interposition graft that is long enough, the ascending colon was included into the graft by ligating the middle and the right colic artery. The left colic artery remained the blood-supplying vessel. From January 1997 to June 1998, 15 patients underwent modified colon interposition with a cervical anastomosis (12 esophagectomies, 3 esophagogastrectomies).

RESULTS

In all cases, intraoperative blood supply from the left colic artery to the proximal ascending colon was sufficient. After surgery, four major complications occurred (27%). Endoscopy demonstrated a vital graft in all patients. In one patient a leakage of the cervical anastomosis was observed. One patient died of herpes pneumonia. Postoperative artificial ventilation was required for an average of 2.8 +/- 4.6 days, the average intensive care unit stay was 6.9+/-4.5 days, and the average total hospital stay was 24.1 +/- 15.1 days.

CONCLUSION

An intact left colic artery, including its collaterals at the splenic flexure, supplies sufficient blood to the proximal ascending colon after central ligation of the middle and right colic artery. Even without mobilization of the left flexure, a sufficient graft length can be obtained. Preliminary complication rates with the use of this technique for colon interposition are in the range of those found for the standard colon interposition technique. These modifications may represent an alternative to established procedures for creating a colon interposition graft.

Esophagectomy with gastric reconstruction for achalasia

PURPOSE

Achalasia is a degenerative esophageal disorder that may result in esophageal failure necessitating resection for restoration of gastrointestinal function. This study evaluates a protocol of esophageal resection and gastric reconstruction for end-stage achalasia.

METHODS

Hospital records, radiographic studies, and resection specimens of patients undergoing esophagectomy and gastric reconstruction were reviewed. Patient outcome was defined by an evaluation of symptoms (early satiety, dysphagia, regurgitation, and reflux), dietary restrictions, and ability to maintain or gain weight. Preoperative, operative, and postoperative variables and pathologic features in the resection specimens were analyzed to determine predictors of outcome.

RESULTS

In a 10-year period, 32 patients underwent esophagectomy with gastric reconstruction for achalasia; 30 (94%) underwent elective surgery and 2 (6%), emergency surgery. No postoperative deaths occurred. Of 29 patients completing telephone interviews, 24 (83%) had no or mild dysphagia; 21 (72%), no or mild regurgitation; 20 (69%), no or mild reflux; and 19 (66%), no or mild early satiety. Twenty-four (83%) patients had no or minimal dietary restrictions; 26 (90%) had no or minimal social dietary restrictions. Postoperative weight was not different from preoperative weight. Of 30 patients, 26 (87%) felt better after esophagectomy and 25 (83%) would have the operation again. There were few predictors of outcome. Younger patients were more likely to have dysphagia ( P =.03).

CONCLUSIONS

Esophagectomy with gastric reconstruction relieves preoperative dysphasia and regurgitation in the majority of patients. Dietary function and weight maintenance are excellent, attesting to the durability of the procedure in patients with end-stage achalasia.

Functional and mechanical sequelae of colon interposition for benign oesophageal disease

OBJECTIVE

In an attempt to estimate the incidence and severity of the functional and mechanical problems associated with colon interposition for benign oesophageal disease, a retrospective analysis of a single centre experience was undertaken.

METHODS

Between 1961 and 1990, a total of 365 patients who survived the postoperative stay in hospital were followed up over 7-38 years and form the basis for this study. Upper gastro intestinal symptoms in these patients were investigated clinically, radiologically, endoscopically and in the oesophageal laboratory. Mechanical and functional abnormalities requiring surgical intervention for relief of symptoms were documented.

RESULTS

There were two late presentations of colo bronchial fistulae, two instances of persistent colo cutaneous fistulae, three cases of diaphragmatic herniation and two adenocarcinomata of the colo gastric junction in the patients with short segment colon interposition. Amongst the long segment colon interposition patients there was one hiatal obstruction, two thoracic inlet delays associated with pseudo diverticulosis and one hiatal obstruction. One other patient presented with an adenocarcinoma of the intrathoracic colon. There were four patients requiring revision of the cervical oesophago colic anastomosis, two of them on recurrent occasions. The remaining sequelae were functional and were associated with increasing redundancy of the colonic segments at different levels. There were 17 such patients, two of whom developed significant redundancy at two different levels.

CONCLUSIONS

Although the patients with short segment colon interposition developed predominantly avoidable iatrogenic complications, those undergoing long segment colon interposition developed functional sequelae requiring re-operations in later life.

Cancer of the esophagus and cardia: does age influence treatment selection and surgical outcomes?

BACKGROUND

Some physicians believe that an aggressive surgical approach for the management of cancer of the esophagus and cardia is unwise in elderly patients because of allegedly higher rates of mortality and morbidity and lower rates of survival than those associated with younger patients. We have long advocated an aggressive surgical approach regardless of the patient's age and have reviewed our experience to determine whether age was a factor influencing treatment and outcomes.

STUDY DESIGN

From January 1, 1970 to January 1, 1997, 505 patients with cancer of the esophagus or cardia underwent operations by one surgical team using standard surgical techniques. One hundred forty-seven patients (29.1%) were 70 years of age or older and 358 patients (70.9%) were under 70 years of age. Their records and clinicopathologic features were reviewed and compared.

RESULTS

The two groups were similar regarding the location of tumors. Tumor cell types were similar except for adenocarcinomas in Barrett's esophagus, which were less common in the older group (15.6% versus 24%; p=0.046). Surgical procedures were similar, as were the rates of resectability and the percentages of R0 resections. The hospital mortality rate was higher in the elderly patients but not significantly so, and the rates of major and minor complications combined were comparable. The differences in postresection pathologic staging were not significant. Satisfactory palliation of dysphagia was comparable between the groups, as were actuarial 5-year survival rates (24.1% of the elderly patients versus 22.4% of the younger patients).

CONCLUSIONS

Age should not be a limiting factor in using an aggressive surgical approach for the management of cancer of the esophagus or cardia in patients aged 70 years or older. Such an approach can be performed as safely as in younger patients, with comparable rates of palliation and survival.