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Ann Thorac Surg 1995;59:1382-1384
© 1995 The Society of Thoracic Surgeons

Esophageal Replacement by Colon Interposition

Section of General Thoracic Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota

	Abstract

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Between 1985 and 1993, 32 patients (24 male and 8 female) underwent colon interposition for replacement of the esophagus at the Mayo Clinic. Median age was 58.5 years (range, 1 to 79 years). The colon was used because of an inadequate stomach in 27 patients (84%) and as the conduit of choice in 5 (16%). Esophageal cancer was present in 15 patients (47%). The left colon was used in 20 patients (63%) and the right, in 12 (38%). The colon was placed substernally in 19 patients (59%) and in the esophageal bed in 13 (41%). The operative mortality was 9%; cause of death was ischemic necrosis of right colon conduits in 2 patients and adult respiratory distress syndrome in 1 patient. Major complications occurred in 4 additional patients and included ischemic colitis of a right colon conduit, Roux-en-Y limb obstruction, chylothorax, and an anastomotic leak. Follow-up was complete for all patients and ranged from 15 months to 7 years (median follow-up, 2.3 years). Eleven patients died during follow-up. The cause of death was metastatic esophageal cancer in 9 patients, myocardial infarction in 1 patient, and respiratory failure in 1 patient. At last follow-up, 26 of the 29 operative survivors had little or no difficulty eating. Two patients had dumping symptoms, and 1 patient had severe dysphagia. Seven patients required dilation of the esophagocolonic anastomosis. We conclude that colon interposition for esophageal replacement provides acceptable long-term function; however, early morbidity and mortality are considerable.

	Introduction

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
In 1911, Kelling [1] and Vulliet [2] independently reported use of the colon as a replacement for the esophagus. Since then, many reports have detailed the morbidity and mortality associated with this procedure, including anastomotic stricture and gastric reflux [3–6]. This review summarizes our recent experience with colon interposition for esophageal replacement, evaluates the technique, and describes long-term function.

	Material and Methods

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
From January 1985 to December 1993, 32 consecutive patients underwent esophageal replacement with colon. The record of each patient was reviewed for age, sex, indication for esophageal resection, type of operation, indication for the selected colon conduit, morbidity, and mortality. Patients with esophageal cancer were staged according to the American Joint Committee on Cancer Manual for Staging of Cancer [7]. Hospital mortality was defined as any death occurring prior to hospital discharge or within 30 days of the procedure.

Survival was estimated by the Kaplan-Meier method [8] using the date of operation as the starting point. The influence of variables on survival was analyzed using the log-rank test for discrete variables [9] and the proportional hazards model of Cox for continuous variables [10]. Values of p less than 0.05 were considered significant. Follow-up evaluation was obtained from the most recent office visit, reports from the patient or home physician, or telephone interviews with the patient. The patient's gastrointestinal symptoms were graded as excellent, good, fair, or poor. Results were considered excellent if the patient could eat without any symptoms, good if the patient complained of dysphagia or vomiting less than one time per week, fair if the patient complained of dysphagia or vomiting between one time and four times per week, and poor if patient had more frequent complaints or required repeated dilations at home.

	Results

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
There were 24 male and 8 female patients with a median age of 58.5 years (range, 1 to 79 years). The colon was used because of an inadequate stomach in 27 patients (84%) and as the conduit of choice in 5 (16%). Esophageal carcinoma was present in 15 patients. Eight patients had adenocarcinoma, and 7 had squamous cell cancer. The cancer was in the cervical esophagus in 1 patient, the midesophagus in 5, and the distal esophagus in 9. One patient had preoperative chemotherapy, 3 had preoperative radiotherapy, and 1 had intraoperative irradiation (1,500 cGy). Two patients were in postsurgical stage I, 10 were in stage IIA, 1 was in stage IIB, and 2 were in stage IV. Esophageal atresia was present in 3 and benign stricture, in 2. Twenty-eight patients (88%) had had a previous operation: gastric resection in 12, failed esophagogastrectomy in 11, Nissen fundoplication in 3, and gastrostomy in 2.

Preoperative evaluation included chest roentgenograms and liver function tests in all patients. Thirty-one patients (97%) underwent upper gastrointestinal endoscopy, and 12 (38%) had computed tomography of the chest. Preoperative evaluation of the colon was performed in all patients and included either a barium enema (26 patients) or colonoscopy (6 patients). No patient had any colonic pathology detected. Five patients had preoperative mesenteric arteriography.

The left colon was used in 20 patients (63%) and the right, in 12 (38%). The colon interposition was performed through concomitant abdominal and neck incisions in 20 patients, thoracoabdominal and neck incisions in 10, and abdominal and thoracic incisions in 2. The proximal colonic anastomosis was to the esophagus in 30 patients and to the pharynx in 2. A two-layered anastomosis was performed in 26 patients and a single-layered anastomosis in 6. Two patients had microvascular anastomosis of the ileocolic artery to the carotid artery to supplement the right colon blood supply. Nine patients had a portion of the manubrium, clavicle, or both resected.

The colon was placed substernally in 19 patients and in the esophageal bed in 13. The left colon was isoperistaltic in 18 patients and antiperistaltic in 2. The right colon was isoperistaltic in all 12 patients. The distal colonic anastomosis was to the jejunum in a Roux-en-Y configuration in 18 patients, the posterior stomach in 7, the anterior stomach in 6, and the distal esophagus in 1 patient. A pyloromyotomy was performed in 10 patients. Mean operative time was 8.4 hours (range, 5 to 11.5 hours).

There were three operative deaths (operative mortality, 9.4%). Two of the three deaths occurred in patients with esophageal cancer. Cause of death was right colon necrosis in 2 patients and adult respiratory distress in 1 patient. The first death occurred in a patient who had had a previous Billroth I operation and underwent resection for esophageal cancer. The patient was reexplored on the fourth postoperative day and was found to have a necrotic right colon. A cervical esophagostomy and gastrostomy were performed. The patient died 10 days later of massive hemorrhage from the azygos vein. The second death occurred in a patient who had had a previous gastrectomy and underwent resection for esophageal cancer. Reconstruction was with the right colon and a supplemental ileocolic-carotid artery anastomosis. The patient died on the third postoperative day of peritonitis secondary to a necrotic colon. The last death occurred in a patient who had had a failed Ivor Lewis operation elsewhere and underwent an isoperistaltic left colon interposition at our institution. The patient died of adult respiratory distress syndrome on the ninth postoperative day. Postmortem examination demonstrated no evidence of anastomotic leak or necrosis of the colon.

Seven (24%) of the 29 operative survivors had development of complications: pneumonia, deep venous thrombosis, abdominal wound infection, anastomotic leak, and reoperation (3 patients). The three reoperations were as follows: to ligate the thoracic duct for persistent chylothorax in 1, to lyse adhesions to relieve small-bowel obstruction in 1, and to perform a cervical esophagostomy for an ischemic right colon in 1. This last patient underwent a successful jejunal interposition graft to reestablish gastrointestinal continuity 6 months later. The patient with the anastomotic leak was treated with drainage and hyperalimentation, and the fistula closed spontaneously.

Follow-up was complete for all patients and ranged from 15 months to 7 years (median follow-up, 2.3 years). Eleven patients died during follow-up. Cause of death was metastatic esophageal cancer in 9 patients and myocardial infarction and respiratory failure in 1 patient each. Only 4 of the 15 patients with esophageal cancer are currently alive. The 1-year and 2-year survival for patients with esophageal carcinoma was 53% and 29%, respectively.

Twenty-six (90%) of the 29 operative survivors had little or no difficulty eating. Gastrointestinal function was scored as excellent in 11 patients, good in 15, fair in 2, and poor in 1. Seven patients (24%) required dilation of the esophagocolonic anastomosis. Four patients required one dilation, 1 patient had two, and 1 had three. One patient required multiple self dilations and continues to have difficulty swallowing. There was no correlation between the anastomotic technique and the need of postoperative dilations. Seven patients complained of colonic reflux, and 2 patients had severe dumping symptoms. There was no correlation between conduit used, conduit position, location of gastric anastomosis, and long-term function.

	Comment

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Esophageal replacement by colon is commonly performed for congenital esophageal atresia, less commonly after resection of benign strictures, and only occasionally after resection for esophageal cancer. Colon conduits are used selectively in complicated reoperative circumstances when patients have an inadequate stomach. In children, isoperistaltic colon offers a potential advantage over stomach because of improved somatic growth, better propulsion of solid food, and fewer late complications of esophagitis and stricture [11]. On the other hand, stomach has the disadvantages of long-term gastroesophageal reflux, possible ulceration, and progressive dysfunctional propulsion. Some surgeons argue that the prevalence of gastroesophageal reflux is reduced if the esophagogastric anastomosis is constructed in the high chest or neck rather than the middle of the chest [12]. Nonetheless, some long-term survivors of transhiatal or Ivor Lewis esophagectomy have major gastroesophageal reflux, and colon interposition is occasionally selected to palliate this complication.

Patients undergoing colon interposition require careful preoperative evaluation. There should be no distant metastases, and cardiopulmonary status and nutritional status should be optimized. All patients should undergo evaluation of the colon with either a barium enema or colonoscopy. Colonoscopy offers direct mucosal visualization and the opportunity to perform biopsy of and treat unsuspected lesions. If the patient has had previous lower-extremity claudication or repair of an abdominal aortic aneurysm, mesenteric arteriography is of value in identifying abnormalities of the colonic blood supply, as the inferior mesenteric artery may be occluded. In addition, the marginal artery is highly variable, and several types of colonic arterial supply have been identified [11]. Antegrade cathartics should be given the day before the scheduled procedure to cleanse the colon, or, in the patient with esophageal obstruction, retrograde tap water enemas can be used.

The surgical approach in a patient undergoing colon interposition depends on the level of the esophageal disease and the colon segment selected for transposition. We favor a midline laparotomy with examination of the arterial supply of the colon conduit by palpation, transillumination of the mesentery, and intraoperative Doppler examination if necessary. The marginal artery and the left and right branches of the middle colic arteries are identified. The left colon is our preferred conduit because of its more reliable blood supply, smaller lumen, and easier placement in an isoperistaltic position. After selection of the segment of colon, atraumatic vascular clamps are used to temporarily occlude arterial branches and observe the effect on the colon prior to ligation. The colon is then carefully mobilized from mesenteric attachments so that transposition can be accomplished without tension or arterial compromise. Intravenous fluorescein (1 to 2 g) may be used after mobilization of the colon to determine viability. Adequacy of blood supply to the conduit is also ensured by bleeding visualized at the edges of the transected colon.

We prefer placement of the colon conduit in the esophageal bed because of a more direct route and reduced chance of mesenteric kinking or twisting. If the patient has a stomach, the colon is transposed through the hiatus posterior to the stomach. If the esophageal bed position is not available, a substernal route is our alternative choice. In this case, a portion of the manubrium and a portion of the clavicle are resected to enlarge the thoracic inlet and prevent compression. If the proximal anastomosis is to be made in the neck, the esophagocolonic anastomosis is performed first. Then the distal end of the colon is tailored to the appropriate length, and the cologastric anastomosis is created. We prefer to anastomose the distal colon to the posterior wall of the stomach at the junction of the body and antrum because the colonic mesentery is less rotated in this position and may reduce reflux [11]. Colonic continuity is then reestablished, and a pyloromyotomy is performed to facilitate drainage. If the proximal anastomosis is to be made in the chest, a pyloromyotomy is performed and the cologastric and the colocolonic anastomoses are completed. The proximal colon is placed through the hiatus prior to closure of the abdomen. A thoracotomy is then performed, the colon is carefully brought into the chest to avoid torsion on the mesentery, and the esophagocolonic anastomosis is completed.

Esophageal replacement by colon has major morbidity and mortality. In most series, operative mortality is about 4% to 10% (Table 1). The most devastating complication is ischemic colonic necrosis. In our series, 2 of the 3 patients with ischemia died, and all three ischemic events occurred in right colon conduits. Others [6] have reported similar findings. Thus, we prefer to use the left colon.

	Footnotes

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 
Presented at the Poster Session at the Thirty-first Annual Meeting of The Society of Thoracic Surgeons, Palm Springs, CA, Jan 30-Feb 1, 1995.

Address reprint requests to Dr Allen, Department of Surgery, Mayo Clinic, 200 First St SW, Rochester, MN 55905.

	References

Top Footnotes Abstract Introduction Material and Methods Results Comment References

 

1. Kelling G. Oesophagoplastic mit Hilfe des Querkolon. Zentralbl Chir 1911;38:1209.
2. Vulliet H. De l'oesophagoplastic et des diversos modifications. Sem Med 1911;31:529.
3. Wilkins EW. Long-segment colon substitution for the esophagus. Ann Surg 1980;192:722–5.[Medline]
4. Mansour KA, Hansen HA II, Hersh T, Miller JI Jr, Hatcher CR Jr. Colon interposition for advanced nonmalignant esophageal stricture: experience with 40 patients. Ann Thorac Surg 1981;32:584–91.[Abstract]
5. Curet-Scott MJ, Ferguson MK, Little AG, Skinner DB. Colon interposition for benign esophageal disease. Surgery 1987;102:568–74.[Medline]
6. Gaissert HA, Mathisen DJ, Grillo HC, et al. Short-segment intestinal interposition of the distal esophagus. J Thorac Cardiovasc Surg 1992;106:860–7.[Abstract]
7. Beahrs OH, Henson DE, Hutter RVP, Kennedy BJ, eds. American Joint Committee on Cancer. Manual for staging of cancer. Philadelphia: JB Lippincott, 1992:57–61.
8. Kaplan EL, Meier P. Non-parametric estimation from incomplete observations. J Am Stat Assoc 1958;53:457–81.
9. Peto R, Peto J. Asymptotically efficient rank and invariant procedures. J R Stat Soc [A] 1972;135:185–201.
10. Cox DR. Regression models and life-table (with discussion). J R Stat Soc [B] 1972;34:187–220.
11. Belsey RHR. Replacement of the esophagus with the colon. In: Shields TW, ed. General thoracic surgery. Philadelphia: Lea & Febigee, 1994:1483–91.
12. Orringer MB, Stirling ML. Esophageal resection for achalasia: indications and results. Ann Thorac Surg 1989;47:340–5.[Abstract]

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