Colon interposition for oesophageal replacement

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.

[Delayed coloesophagoplasty in difficult clinical situations]

AIM

To improve immediate and long-term results of delayed coloesophagoplasty in cancer patients.

MATERIAL AND METHODS

We presented three case reports of coloesophagoplasty in difficult clinical situations including technical impossibility of primary plasty, extraordinary anesthetic situation, transplant necrosis after primary plasty.

RESULTS

Gastrointestinal tract integrity was restored in all cases and patients returned to nutrition per os, that provided good quality of life and compensated nutritional deficiencies. Only one patient had bleeding in postoperative period that required relaparotomy. There were no postoperative complications in two other patients.

CONCLUSION

Delayed coloesophagoplasty should be performed in all patients who underwent esophagogastrectomy if progression of primary disease is absent. Graft placement and colic segment are chosen individually. However left half of colon with retrosternal location of transplant is preferable for plasty.

Surgical Management of Benign Coloesophageal Stricture: a Novel Technique

Benign coloesophageal anastomotic stricture in postoperative colon bypass patients suffering from the corrosive stricture of the upper esophagus is a challenging problem. Failure of repeated endoscopic balloon dilatation makes way for revisional operative techniques like free jejunal grafts or interposition skin tube based on radial vessels. The situation arising from the morbidity of such reconstructive procedures, at times, becomes more complex than the stricture itself [1]. This clinical scenario has compelled us to innovate with a much simpler technique using buccal mucosal graft (BMG) to manage these strictures. Currently, the utility of BMG is mostly limited to urethral reconstruction. Overtime, it has become an ideal urethral substitute. Here, we present a case series of five patients who have been subjected to coloesophagoplasty with BMG and have demonstrated excellent results. With a median follow-up of 13 months, all patients have fully recovered and are taking solid and liquid foods satisfactorily. Thus, the option of coloesophagoplasty with BMG should always be kept in consideration while planning a revision surgery for a small-segment benign coloesophageal anastomotic stricture in the corrosive injury of the esophagus, considering the ease and excellent outcome.