Clinical outcome and quality of life after gastric and distal esophagus replacement with an ileocolon interposition

Nutritional benefit of remnant gastric preservation in patients with esophageal cancer undergoing radical esophagectomy and ileo-colon interposition

Background

This retrospective study aimed to investigate the short-term surgical outcomes and nutritional status of ileo-colon interposition in patients with esophageal cancer who could not undergo gastric tube reconstruction.

Methods

Sixty-four patients underwent subtotal esophagectomy with reconstruction using ileo-colon interposition for esophageal cancer at the Wakayama Medical University Hospital between January 2001 and July 2020. Using propensity scores to strictly balance the significant variables, we compared treatment outcomes.

Results

Before matching, 18 patients had cologastrostomy and 46 patients had colojejunostomy. After matching, we enrolled 34 patients (n = 17 in cologastrostomy group, n = 17 in colojejunostomy group). Median operation time in the cologastrostomy group was significantly shorter than that in the colojejunostomy group (499 min vs. 586 min; P = 0.013). Perforation of the colon graft was observed in three patients (7%) and colon graft necrosis was observed in one patient (2%) in the gastrojejunostomy group. Median body weight change 1 year after surgery in the cologastrostomy group was significantly less than that of the colojejunostomy group (92.9% vs. 88.5%; P = 0.038). Further, median serum total protein level 1 year after surgery in the cologastrostomy group was significantly higher than that of the colojejunostomy group (7.0 g/dL vs. 6.6 g/dL, P = 0.030).

Conclusions

Subtotal esophagectomy with reconstruction using ileo-colon interposition is a safe and feasible procedure for the patients with esophageal cancer in whom gastric tubes cannot be used. Cologastrostomy with preservation of the remnant stomach had benefits in the surgical outcomes and the postoperative nutritional status.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01704-x.

Ileocolic Interposition as a Gastric Substitute in Patients with Total Gastrectomy; Case Series and Literature Review

Background: The standard method for reconstruction after total gastrectomy is Roux-en-Y reconstruction, which has several negative points such as malabsorption. The most important reasons for weight loss in these patients are reserval insufficiency and reduction of food-digestive juice blending. We suggest that the creation of a food reserve with a natural conduit by ileocolic interposition may help the patient to have more normal diet habits and prevent severe weight loss. Methods: The study enrolled 8 patients with proximal gastric cancer, who underwent total gastrectomy with omentectomy and D2 lymphadenectomy. Then, the ileocolic segment with its vasculature was prepared and the anastomosis was done like right colon interposition between esophagus and duodenum. Intraoperative and postoperative events and also nutritional conditions were recorded. Results: Among 8 patients enrolled in the study, not an intraoperative bad event nor anastomotic site leakage, abscess formation, or other significant post-operative complication were seen. Except for the first two patients, the rest did not suffer from dysphagia. None of the patients suffered from delayed, chronic, or uncontrolled vomiting. All patients experienced weight loss postoperatively but after 2 months, they gained weight. Barium examination and also upper endoscopy revealed that the patients had normal reserval volume, no evidence of erosion or ulceration, no evidence of biliary esophagitis or reflux, and absence of tumor relapse. Conclusions: Because of the nutritional benefits of ileocolic interposition after total gastrectomy in gastric cancer treatment, it can be used as an acceptable alternative method of reconstruction in a subgroup of selected patients.

Peculiarities of intra-thoracic colon interposition-eso-coloplasty: indications, surgical management and outcomes

Stomach is the usual organ of choice for oesophageal replacement. Gastric pull-up is a standardized, fast and secure procedure, requiring only one anastomosis and usually performed with mini-invasive techniques. Colon is used when the stomach is not available, for tumours of the upper oesophagus or the hypopharynx, for benign or paediatric diseases. It is a complex surgery requiring a specific pre-operative management, three or four anastomoses, and a careful choice of the route of reconstruction. Early post-operative complications, such as anastomotic leakage, are frequent. Long-term outcomes are marked by strictures of the anastomosis and redundancy, but the reported quality of life of the patients is good. Eso-coloplasty remains a safe and feasible alternative to gastric pull-up for oesophageal replacement, for specific indications.

European perspective in Thoracic surgery-eso-coloplasty: when and how?

Colon interposition has been used since the beginning of the 20(th) century as a substitute for esophageal replacement. Colon interposition is mainly chosen as a second line treatment when the stomach cannot be used, when the stomach has to be resected for oncological or technical reasons, or when the stomach is deliberately kept intact for benign diseases in young patients with long-life expectancy. During the surgery the vascularization of the colon must be carefully assessed, as well as the type of the graft (right or left colon), the length of the graft, the surgical approach and the route of the reconstruction. Early complications such as graft necrosis or anastomotic leaks, and late complications such as redundancy depend on the quality of the initial surgery. Despite a complex and time-consuming procedure requiring at least three or four digestive anastomoses, reported long term functional outcomes of colon interposition are good, with an acceptable operative risk. Thus, in very selected indications, colon interposition could be seen as a valuable alternative for esophageal replacement when stomach cannot be considered. This review aims at briefly defining "when" and "how" to perform a coloplasty through demonstrative videos.

Reconstituição do trato digestivo após falha de esofagogastro ou esofagocolo anastomose

RACIONAL: Disfagia grave ou mesmo afagia pode ocorrer após esofagectomia secundária à necrose do órgão ascendido com estenose severa ou separação completa dos cotos. Ruptura catastrófica esofágica ou gástrica impulsiona a decisão de "desconectar" o esôfago, a fim de evitar graves complicações sépticas. As operações utilizadas para restabelecer a descontinuidade do esôfago não são padronizadas e reoperações para restabelecimento do trânsito digestivo superior são um verdadeiro desafio. MÉTODOS: Este é estudo retrospectivo da experiência dos autores durante 17 anos incluindo 18 pacientes, 14 previamente submetidos à esofagectomia e quatro esofagogastrectomia. Eles foram operados com o fim de restabelecer o trato digestivo superior. RESULTADOS: Refazer esofagogastro anastomose foi possível em 12 pacientes, 10 por meio da abordagem cervical e combinando esternotomia em quatro, a fim de realizar a nova anastomose. Em cinco pacientes esofagocolo anastomose foi novamente realizada. Interposição de enxerto livre de jejuno foi realizada em um paciente. As complicações ocorreram em 10 pacientes (55,5%): deiscência anastomótica em três, estenose em quatro, condrite esternal em dois e abscesso cervical em um. Não se observou mortalidade. CONCLUSÃO: Existem diferentes opções cirúrgicas para o tratamento desta situação clínica difícil e arriscada; deve ser tratada com procedimentos adaptados de acordo com o segmento anatômico disponível para ser usado, escolhendo o procedimento mais conservador.

The role of ultrasound and computed tomography in the evaluation of subcutaneous esophageal bypass in a dysphagic patient

Several conditions require subcutaneous colon bypass surgery in the esophageal diseases treatment. Esophageal reconstructions are high risk procedures because of their morbidity and mortality rate. Cervical anastomotic strictures, colon transplant redundancy, recurrent dysphagia, intestinal obstruction, regurgitation, and aspiration are the most frequent late complications. The patient assessment should be performed with noninvasive methods in order to prevent long-term complications. We report the use of ultrasound (US) and computed tomography (CT) for evaluating a dysphagic patient, after subcutaneous esophageal bypass. A thorax and upper abdomen contrast media CT study with volume rendering reconstruction was performed in order to evaluate late post operative complications. In addition a US examination, performed after CT scan, was used for the assessment of the colonic wall and its vascularization. The subcutaneous esophageal bypass allowed for an effective ultrasound evaluation with no additional discomfort for the patient. ultrasonography has been shown effective in the esophageal bypass follow up, when subcutaneous colon bypass surgery was performed. The ultrasonography evaluation, also thanks to a Doppler flowmetry, allowed completing the patient assessment without additional invasive procedures or contrast. Thus it may be performed as a first level evaluation or in the follow up of subcutaneous esophageal bypass patients.

Esophageal reconstruction using the terminal ileum and right colon in esophageal cancer surgery

PURPOSE

To evaluate the outcomes of colon interposition based on our surgical experience.

METHODS

We reviewed data from 40 patients who underwent esophagectomy with colon interposition using the terminal ileum and right colon, to treat esophageal cancer, between January 1990 and December 2009.

RESULTS

Transthoracic esophagectomy, transhiatal esophagectomy, and pharyngolaryngoesophagectomy were performed in 31 (77.5%), 8 (20.0%), and 1 (2.5%) patients, respectively. The routes of the colon interposition were posterior mediastinal in 30 (75.0%) patients, retrosternal in 5 (12.5%), and subcutaneous in 5 (12.5%). The median operative time was 450 min (range 320-760 min) and the median blood loss was 755 ml (range 180-3,000 ml). Overall postoperative morbidity involved 18 (45.0%) patients and included esophagoileostomy leakage in 7 (17.5%; minor, n = 4; major, n = 3) and necrosis of the colon conduit in 2 (5%) patients. The 30- and 90-day mortality rates were 0 and 2.5%, respectively. The 1-, 3-, and 5-year survival rates were 80, 66, and 66%, respectively.

CONCLUSIONS

Our surgical outcomes were acceptable in relation to other published results and the prognosis was favorable. Thus, esophageal reconstruction using the ileum and right colon is useful for patients with esophageal cancer for whom the stomach is not available. We currently perform colon interposition with microvascular anastomoses for grafts via the subcutaneous route to increase the safety of this operation.

Esophageal reconstruction with colon tissue

The present best practice for performing esophageal reconstruction using colon tissue was investigated in this review. The left colon has advantages in that it has less variation in blood supply and a smaller diameter than the right colon; however, the rate of graft necrosis is higher for the left colon. Additional microvascular anastomosis, which is unnecessary in most cases, may be able to resolve these issues. The colon graft should be reconstructed in an isoperistaltic fashion whenever possible in order to prevent regurgitation and improve food transit. The posterior mediastinum has the advantage of being the shortest route, but it also has the major disadvantage that graft necrosis can be severe or fatal if it occurs. In palliative or advanced cases, a retrosternal or subcutaneous route is preferred, because the posterior mediastinum is a tumor bed. However, in these cases partial excision of the manubrium and the left clavicula should be considered to release compression of the graft at the thoracic inlet. Consequently, the selection of the colon graft should be flexible and be based on the inspection of blood supply and the length needed, and thereafter microvessel anastomosis should be added in cases where graft ischemia might occur.

Colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer

BACKGROUND

The purpose of this retrospective study was to investigate the feasibility of colon interposition procedures after esophagectomy with extended lymphadenectomy.

METHODS

Between 1990 and 2008, 95 consecutive patients underwent colon interposition after esophagectomy with extended lymphadenectomy for esophageal cancer in our Institution. We reviewed clinical data and long-term survival, and also investigated the association between anastomotic leakage and clinicopathologic findings.

RESULTS

We applied three-field lymphadenectomy to 71 patients and two-field to 24 patients, by a right thoracotomy. Ninety-two patients underwent reconstruction by a retrosternal route, and a posterior mediastinal route was applied to only three patients. We performed hand-sewn anastomosis in the neck in all cases. Three patients required microvascular surgery. Sixty-one patients (64%) experienced postoperative morbidity, most commonly pulmonary complications. Anastomotic leakage occurred in 12 patients (13%). No colon conduit necrosis was detected. Overall mortality, including hospital mortality, was 5.3%. Dysphagia (39%) and diarrhea (38%) were common and stricture was low (6%) after discharge. The overall 5-year survival rate was 43%. During the latter period (1998 to 2008), when ileocolon grafts evolved as the primary choice for interposition, the rate of leakage decreased from 17% (1990 to 1997) to 5.4%. No mortality was recorded during the latter period.

CONCLUSIONS

Results from this study demonstrate that colon interposition after esophagectomy with extended lymphadenectomy is feasible and can have a favorable outcome.

Donor-site morbidity after free ileocolon flap transfer for esophageal and voice reconstruction

BACKGROUND

Radical excision of advanced hypopharyngeal and laryngeal tumors usually compromises both swallowing and speech. Among the available reconstruction methods, the free ileocolon flap allows rehabilitation of both functions in one stage. The donor-site morbidity of this flap has not been addressed in head and neck cancer patients.

METHODS

A retrospective study was conducted in 34 patients between April of 2003 and December of 2007 to investigate donor-site morbidity in patients undergoing reconstruction with free ileocolon flaps. Complications such as diarrhea, upper gastrointestinal tract distress, bowel leak, abscess, or hernia formation were evaluated. Significant association of diarrhea and upper gastrointestinal distress, previous abdominal operations, systemic diseases, primary versus secondary reconstruction, flap length, and postoperative chemotherapy were subsequently evaluated. Differences were considered significant for values of p <or= 0.05.

RESULTS

There were no perioperative or postoperative deaths. Nineteen patients (56 percent) experienced temporary diarrhea. In all but two patients, diarrhea discontinued by 4 months. Chemotherapy was significantly associated with diarrhea (p < 0.01). Colchicine, terbinafine, and heroin withdrawal episodically caused diarrhea but statistical conclusions could not be drawn. Six patients (18 percent) suffered from upper gastrointestinal tract problems (gastroduodenal ulcer, erosive gastritis, and minor bleeding), probably because of insufficient gastric protection.

CONCLUSIONS

The free ileocolon flap proved to be a reliable method when simultaneous restoration of swallowing and speech was required, with donor-site morbidity comparable to that of the other intestinal flaps.

Ileocecal valve as substitute for the missing pyloric sphincter after partial distal gastrectomy

OBJECTIVES

Accelerated gastric emptying (including dumping syndrome) occurs frequently after gastric resections, largely resulting from rapid entry of meal contents into the small intestine. The authors hypothesized that an ileocecal segment used as an interpositional graft placed between the remaining part of the stomach and the small intestine would slow down food transit and thus replace pyloric function.

METHODS

Thirty Göttingen minipigs were randomized into three groups. Group 1: partial gastrectomy and Roux-en-Y reconstruction; Group 2: partial gastrectomy and ileocecal interpositional graft; and Group 3: sham laparotomy. Gastric emptying in the nonsedated animals was quantified using radioscintigraphy at 3 and 6 months postoperatively. The animals ingested 300 grams of soft food containing 99mTc labeled resin- pellets using a technique previously described. Data were analyzed using ANOVA.

RESULTS

Three months postoperatively, the ileocecal group had a significantly prolonged gastric emptying time compared with the Roux-en-Y group, but gastric emptying time was also significantly faster compared to the control group (sham laparotomy). After 6 months no significant difference was seen between the ileocecal group and the controls, while emptying rates were still significantly faster in the Roux-en-Y group.

CONCLUSIONS

Reconstruction of the gastric reservoir with an ileocecal segment largely restores gastric emptying patterns of food in minipigs. Six months postoperatively, gastric emptying time is similar to that of controls, and significantly slower when compared with the group with Roux-en-Y reconstruction. These results suggest that the ileocecal interposition graft could offer specific advantages over current reconstruction procedures.