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Colonic replacement for the treatment of caustic esophageal strictures in children
Colonic R e p l a c e m e n t for the Treatment of Caustic E s o p h a g e a l Strictures in Children By H01yaZ. GLindo~du, F. Cahit Tanyel, Nebil B0yOkpamuk~u, and Akg0n Hi~s6nmez Ankara, Turkey 9 Caustic esophageal stricture is one of the most common indications for esophageal replacement in children. During a 13-year period between 1976 and 1989, colonic replacement was performed in 50 patients for the treatment of caustic esophageal strictures at the Department of Pediatric Surgery of Hacettepe University Children's Hospital. A retrospective clinical study was undertaken to discuss the indications and results of colonic replacement. The 50 children, 34 of whom were male (68%) and 16 of whom were female (32%) with 27 patients (54%) under 6 years of age, were evaluated retrospectively. Indications for operation included 21 (42%1 who could not swallow saliva and had total or nearly total obliteration of lumen involving more than 3 cm of an esophageal segment at admittance, and 16 (32%| who had difficulty in swallowing within a 1-month period following the last dilation after completion of a 1-year dilation program. A further 13 (26%) had bleeding and difficulties during dilations, after experiencing an esophageal perforation. The right colon was used in 48 and the left in the remaining 2 patients. Patients were followed for at least 1 year following replacement. Growth was excellent in all but one patient who had redundant colon and showed growth retardation. There was one postoperative late death because of massive bleeding from ulceration of the transplanted colon. The other 49 patients were available for accurate follow-up. The results were good, 46 (92%) were able to eat everything, while occasional dysphagia in 3 (6%) required dilation after operation. Colon conduit provides an excellent substitute for esophagus in pediatric patients. The operation had a low rate of major complications, most of which could be corrected to give satisfactory long-term results. Copyright 9 1992 by W.B. Saunders Company INDEX WORDS: Esophageal replacement; esophageal stricture, caustic.
THOUGH THE indications have not been clearly efined, some of the strictures resulting from chemical injuries necessitate esophageal replacement for treatment. 1-5Successful outcome following replacement by colon and reversed gastric tubes has been reported in children. 6,7 However, the colon is generally accepted as the more appropriate substitute. 8,9 Use of the colon for replacing the esophagus allows the stomach to be left in its normal position. In this regard it has definite advantages over transplanting the stomach to the thoracic cavity. A retrospective clinical study was undertaken to evaluate the indications and results of colonic replacement in the treatment of caustic esophageal strictures in children. MATERIALS AND METHODS During a I3-year period between 1976 and 1989, 50 children underwent colonic replacement for the treatment of caustic esophJournal of Pediatric Surgery, Vol 27, No 6 (June), 1992: pp 771-774
ageal strictures in the Department of Pediatric Surgery of Hacettepe University Children's Hospital. The ages of patients varied between 1 and 8 years. Twenty-seven patients (54%) were under 6 years of age; 34 were male (68%) and 16 were female (32%). The strictures were caused by lye in 45 patients, by acids in 2 patients, and by other alkalies in the remaining 3 patients. All the patients were admitted after the strictures had developed complications. Colonic replacement as an initial treatment was only performed in patients who could not swallow saliva and had total or near-total obliteration of the lumen involving more than 3 cm of an esophageal segment. The decision to carry out colonic replacement as a succeeding mode of treatment was made in patients who had difficulties during swallowing meat and bread within a month period following the last dilation after the completion of 1-year dilation program. Patients who had previously experienced an esophageal perforation had colonic replacement if bleeding and difficulties developed during further dilations. All the patients had a gastrostomy for feeding or dilation or both. Preoperative esophagograms were obtained. Once the need for colonic replacement was ascertained a barium enema was performed, to evaluate the anatomic appearance of the colon. Interposition with the colonic segment on a pedicle of the midcolic vessels was uniformly performed in single stage by one of the two most senior authors (N.B., A.H.). Right colon was used in 48 and left in the remaining 2 patients. We have used the right colon and terminal ileum for the transplant in most instances, but some prefer the left colon. When the right colon is used, the loop is brought up in an isoperistaltic fashion. If the left colon is used, the loop is antiperistaltic. This appears to make very little difference in the function of the transplant, and both seem equally satisfactory. Substernal tunneling for the colon transplant was carried out. Abdominal entry is usually made through a high midline or paramedian incision. All the attachments of the cecum, terminal ileum, right colon, hepatic flexure, and the right side of the transverse colon are completely mobilized, leaving only the mesocoIon in place at this stage of the procedure. When the colon is elevated the various arteries can be readily identified by transillumination. The inspected transplant uses the middle colic artery as the blood supply for the entire transplant, sacrificing the right colic and ileocolic arteries. Circulation through the marginal artery is usually adequate for the transplant. The right colic artery is carefully isolated and temporary occlusion is maintained for 15 to 20 minutes. During this time the appendix can be removed and preparation of the terminal ileum for division is completed. At the end of the period of temporary occlusion the marginal vessels must be very carefully inspected for the presence of pulsations and the color of the colon is noted. If the
From the Department of Pediatric Surgery Hacettepe University Children's Hospital, Ankara, Turkey. Date accepted:April 16, 1991. Address reprint requests to Hidya Z. Giindo~du, MD, Hacettepe ~ocuk Hastanesi, ~ocuk CerrahisiAna Bilim Dah, Sthhiye, Ankara 06100, Turkey. Copyright 9 1992 by W.B. Saunders Company 0022-3468/92/2706-0025503.00/0 771
GLINDO(3DU ET AL
772 Table 1. Indications for Colonic Replacement
Table 3. Early Postoperative Complications
No. of Patients
(%)
21
(42)
2
(4)
Total or nearly total obliteration of lumen which involves an esophageal segment longer than 3 cm and causes difficulty in swallowing saliva Difficulties and bleeding during dilating a patient who has previously experienced an esophageal perforation Difficulties in swallowing meat and bread within 1 month following last dilation after the completion of 1-year chronic dilation program, Bleeding and difficulties during further dilations
Leak at the cervical anastomosis Mild pneumonia Necrosis of a segment of the transplant Wound infection in abdominal incision
No. of Patients
(%)
25 25 1 2
(50) (50) (2) (4)
Indications for colonic replacement are shown in Table 1. The most common operative complication was pneumothorax. Because of the retrosternal blunt
dissection during transplantation other operative complications were venous congestion at the cervical end of colon, hematoma in the cervical anastomosis and redundancy of the replaced colon (Table 2). A patient with redundant colon had difficultyin swallowing and necessitated partial resection of transplant 1 year after the replacement. Early postoperative complications were leak at the cervical esophagocolic anastomosis, mild pneumonia, necrosis of the cervical end of the colonic segment, and wound infection in the abdominal incision (Table 3). The patient with necrosis of the cervical end of colonic segment had undergone another replacement procedure. Late complications of colonic replacement were stricture at the cervical anastomosis, dumping symptoms, intermittent nocturnal regurgitation, and upper gastrointestinal bleeding (Table 4). Strictures of the cervical anastomosis were relieved with i to 3 dilations in 10 patients and 4 to 12 dilations in 8. The remaining 4 patients required over 12 dilations for relief. Strictures of the cervical anastomosis were significantly higher in patients whose esophageal strictures involved the cervical esophagus (P < .05) (Table 5). All of the cervical anastomotic strictures were encountered in patients who had anastomotic leak during the early postoperative period. In 50 patients follow-up was available for more than 1 year. Clinical appraisal of these patients are shown in Table 6. Patients who were entirely asymptomatic and could eat anything they wished were classified as excellent. Those who had no dysphagia but needed to chew their food carefully were classified as good. Patients who required repeated dilation or who had same dysphagia were classified as fair. Except for one late death due to massive bleeding from the ulceration of transplanted colon, all patients had a satisfactory oral intake and none had a persistent salivary fistula.
Table 2. Operative Complications
Table 4. Postoperative Late Complications
Total
16 11
(32) (22)
50
(100)
colon remains pink and there are good pulsations in the marginal arteries, the right colic artery is divided close to its origin from the superior mesenteric. The terminal ileum is divided, leaving adequate blood supply through segmental vessels. Careful division of the mesentery then leaves the right side of the transverse colon, the ascending colon, and the terminal ileum with its main blood supply on a pedicle from the midcolic artery. The continuity of the intestinal tract is restored by end-to-end ileotransverse colostomy. Experience has shown that the middle colic artery pedicle of the transplant should be passed behind the stomach, because in several instances the pressure of the middle colic artery when brought up anteriorly causes compression of the pyloric end of the stomach with resulting obstruction. This maneuver must be carefully carried out to prevent torsion of the middle colic artery and its vein. A curved incision is then made in the neck. The sternocleidomastoid muscle and carotid sheath are retracted laterally and the esophageal space entered. The anterior attachment of the diaphram to the lover margin of the sternum is divided through the abdominal incision. By sharp and blunt dissection with the fingers, a tunnel can be made retrosternally. Care is taken to avoid entering the pleural cavities, although this is not always possible; if a pneumothorax results, this is corrected either by needle aspiration or an intercostal catheter immediately postoperatively. The colon transplant with the terminal ileum, if used, is then brought up through the substernal tunnel. The distal end of the transplant is anostomosed to the anterior wall of the stomach with two layers of sutures. The anastomosis between the esophagus and the ileum or cecum may be performed at this stage. Then the procedure is terminated by suturing the esophagus and the terminal ileum to the skin margins of the cervical incision and routine closure of the abdominal incision. Pyloroplasty is not routinely performed and the strictured esophagus is left in situ. Patients were followed for at least I year following replacement. RESULTS
Pneumothorax Venous congestion Cervical hematoma Redundancy in replaced colon
No. of Patients
(%)
18 17 4 4
(36) (34) (8) (8)
Stricture at the cervical anastomosis Dumping symptoms Intermittent nocturnal regurgitation Upper gastrointestinal bleeding
No. of Patients
(%)
22 12 7 4
(44) (24) (14) (8)
COLONIC REPLACEMENT OF CAUSTIC STRICTURES
773
Table 5. The Relation of Stricture of Cervical Anastomosis With Caustic Esophageal Strictures Involved Cervical Esophagus
Table 6. Long-Term Results (1 to 13 years) in 50 Patients No. of
CervicalAnastomotic Stricture
Results
Cervical Esophageal Segment
Yes
No
Total
Involved
20
10
30
Not involved Total
2 22
18 28
20 50
40 (80) 5 (10)
Fair Late death
4 (8) 1 (2)
Total
DISCUSSION
The colon is preferred as an esophageal replacement as it is more resistant to peptic ulceration because of its mucus production. 1~ True peristalsis does not occur in the intact colon and emptying of the transplanted colon is effected primarily by gravity and strong mass peristaltis. ~3,14 The indications of esophageal substitution for the treatment of caustic strictures are controversial. Although some authors suggest replacement as an initial mode of treatment, ~5-~7others reserve this for persisting dilations. 18a9 However, opinions about how long to persist with dilations are not uniform and the suggested time intervals vary between 3 and 12 months. 2~ Daly and Cardona described the indications to be complete stenosis with failure to establish a lumen, marked irregularity and pocketing of the esophagus, severe reaction and mediastinitis as a result of dilation, presence of a fistula, inability to maintain a lumen above 40F bougie, and inability or refusal of the patient to undergo repeated dilations. 23 Although we persisted with dilations in the patients with marked irregularity and pocketing of the esophagus, our other indications have been in accord with Daly and Cardona's. Proximal anastomotic leak is the most common early complication in reconstruction of the esophagus from colon, the incidence ranging as high as 70% in one series. 24 Leakage of anastomosis in the neck was reported to occur in as many as 25% of cases. 24 We encountered 25 leaks in 50 patients (50%); however, all these leaks closed spontaneously. Incidence of anastomotic stricture has been described as being 15% to 100% in reported series. ~,2,7,14 It usually
Patients (%)
Excellent Good
50 (100)
occurred at the proximal esophageal anastomosis but could develop in the gastric anastomosis. Stricture of the cervical anastomosis often resolves with time and long-term dilation is rarely necessary. Late strictures developed in 23 patients and this was more than in Shiller's series. 14 We encountered 23 strictures in 50 patients; 22 were cervical (44%) and 1 was gastric (2%) anastomotic stricture. After operation 10 patients needed no more than 3 dilations but 2 patients needed repeated dilations for normal swallowing. At the end of this review we found that in 50 patients, 46 (92%) could swallow well, 3 of them needed repeated dilation, one gastric anastomotic stricture needed operative revision, and one patient died in another medical center because of massive bleeding from an ulceration site of the transplanted colon. After long-term follow-up ranging from 1 to 13 years, we saw that the children with esophageal substitution for lye strictures usually return to the previously established growth curve according to their nutritional status and we did not see malignancy of the transposed colon segment. Late major complications included mild dysphagia, intermittent nocturnal regurgitation, dumping after meals that could be corrected conservatively, and one cologastric anastomotic stricture that required operative correction. " Colonic interposition is our choice of treatment for caustic esophageal strictures in some selected children and provides excellent results if surgeons give sufficient attention to the demonstration of a good blood supply and protection of the vessels. Complications can be corrected and give satisfactory long-term results.
REFERENCES 1. Anderson KD: Esophageal substitution, in Holder TM, Ashcraft KW (eds): Pediatric Surgery. Philadelphia, PA, Saunders, 1980, pp 284-291 2. Azar H, Cripsin AR, Waterston DS: Esophageal replacement with transverse colon in infants and children. J Pediatr Surg 6:3-9, 1971 3. Berkowita WP, Raper CL, Spector G J, et al: Surgical management of severe lye burns of the esophagus by colon interposition. Ann Otol Rhinol Laryngol 84:576-582, 1975 4. Blanchard H, Roy CC, Perrealut G, et al: Retrosternal
esophageal replacement in 18 children. Can J Surg 15:137-145, 1972 5. Hendren WM, Hendren WG: Colon Interposition for esophagus in children. J Pediatr Surg 20:1985 6. Anderson KD, Randolph JG: Gastric tube interposition: A satisfactory alternative to the colon for esophageal replacement in children. Ann Thorac Surg 25:521-525, 1970 7. Ein SH, Shandling B, Simpson JS, et al: Fourteen years of gastric tubes. J Pediatr Surg 13:638-641, 1978 8. Sherman CD, Waterston D J: Oesophageal reconstruction in children using colon. Arch Dis Child 32:11-16, 1957
774
9. Rodgers BM, Talbert JL, Moazam F, et al: Functional and metabolic evaluation of colon replacement of the esophagus in children. J Pediatr Surg 13:35-39, 1978 10. Schechter JJ, Sequitz RH: The colon as replacement for the esophagus: Its resistance to reflux or gastric juice. Wis Med J 38:677-690, 1959 11. Sirak HD, Clatworthy HW, Elliot DW: An evolution of jejunal and colonic transplants in experimental esophagitis. Surgery 36:399-405, 1954 12. Longino LA, Wolley MJ, Gross RE: Esophageal replacement in infants and children with the use of a segment of colon. JAMA 171:1187-1192, 1959 13. Othersen HB, Clatworthy HW: Functional evaluation of esophageal replacement in children. J Thorac Cardiovasc Surg 53:55-62, 1967 14. Schiller M, Frye TR, Boles ET: Evaluation of colonic replacement of the esophagus in children. J Pediatr Surg 6:753 760, 1971 15. Burford TH, Webb WR, Ackerman L: Caustic burns of the esophagus and their surgical management. A clinico-experimental correlation. Ann Surg 138:453-460, 1953
GONDOGDU ET AL
16. Imre J, Kopp M: Arguments against long-term conservative treatment of esophageal strictures due to corrosive burns. Thorax 27:594-598, 1972 17. Oakes DD, Sherck JP, Mark JBD: Lye ingestion. Clinical patterns and therapeutic implications. J Thorac Cardiovasc Surg 83:194-204, 1982 18. Hailer JA, Andrews HG, White JJ, et al: Pathophysiology and management of acute corrosive burns of the esophagus. Results of treatment in 285 children. J Pediatr Surg 6:578-584, 1974 19. Postlethwait RW: Chemical burns of the esophagus. Surg Clin North Am 63:915-924, 1983 20. Fyfe AHB, Auldist AW: Corrosive ingestion in children. Z Kinderchir 39:229-233, 1984 21. Symbas PN, Vlasis SE, Hatcher CR: Esophagitis secondary to ingestion of caustic material. Ann Thorac Surg 36:73-77, 1983 22. Tunell WP: Corrosive strictures of the esophagus, in Welch KJ, Randolph JG, Ravitch MM, et al (eds): Pediatric Surgery. Chicago, IL, Year Book, 1986, pp 698-703 23. Daly JF, Cardona JC: Corrosive esophagitis. Am J Surg 93:242-247, 1957 24. Postlethwait RW: Surgery of the Esophagus. New York, NY, Appleton-Century-Crofts, 1979, pp 415-438
THOUGH THE indications have not been clearly efined, some of the strictures resulting from chemical injuries necessitate esophageal replacement for treatment. 1-5Successful outcome following replacement by colon and reversed gastric tubes has been reported in children. 6,7 However, the colon is generally accepted as the more appropriate substitute. 8,9 Use of the colon for replacing the esophagus allows the stomach to be left in its normal position. In this regard it has definite advantages over transplanting the stomach to the thoracic cavity. A retrospective clinical study was undertaken to evaluate the indications and results of colonic replacement in the treatment of caustic esophageal strictures in children. MATERIALS AND METHODS During a I3-year period between 1976 and 1989, 50 children underwent colonic replacement for the treatment of caustic esophJournal of Pediatric Surgery, Vol 27, No 6 (June), 1992: pp 771-774
ageal strictures in the Department of Pediatric Surgery of Hacettepe University Children's Hospital. The ages of patients varied between 1 and 8 years. Twenty-seven patients (54%) were under 6 years of age; 34 were male (68%) and 16 were female (32%). The strictures were caused by lye in 45 patients, by acids in 2 patients, and by other alkalies in the remaining 3 patients. All the patients were admitted after the strictures had developed complications. Colonic replacement as an initial treatment was only performed in patients who could not swallow saliva and had total or near-total obliteration of the lumen involving more than 3 cm of an esophageal segment. The decision to carry out colonic replacement as a succeeding mode of treatment was made in patients who had difficulties during swallowing meat and bread within a month period following the last dilation after the completion of 1-year dilation program. Patients who had previously experienced an esophageal perforation had colonic replacement if bleeding and difficulties developed during further dilations. All the patients had a gastrostomy for feeding or dilation or both. Preoperative esophagograms were obtained. Once the need for colonic replacement was ascertained a barium enema was performed, to evaluate the anatomic appearance of the colon. Interposition with the colonic segment on a pedicle of the midcolic vessels was uniformly performed in single stage by one of the two most senior authors (N.B., A.H.). Right colon was used in 48 and left in the remaining 2 patients. We have used the right colon and terminal ileum for the transplant in most instances, but some prefer the left colon. When the right colon is used, the loop is brought up in an isoperistaltic fashion. If the left colon is used, the loop is antiperistaltic. This appears to make very little difference in the function of the transplant, and both seem equally satisfactory. Substernal tunneling for the colon transplant was carried out. Abdominal entry is usually made through a high midline or paramedian incision. All the attachments of the cecum, terminal ileum, right colon, hepatic flexure, and the right side of the transverse colon are completely mobilized, leaving only the mesocoIon in place at this stage of the procedure. When the colon is elevated the various arteries can be readily identified by transillumination. The inspected transplant uses the middle colic artery as the blood supply for the entire transplant, sacrificing the right colic and ileocolic arteries. Circulation through the marginal artery is usually adequate for the transplant. The right colic artery is carefully isolated and temporary occlusion is maintained for 15 to 20 minutes. During this time the appendix can be removed and preparation of the terminal ileum for division is completed. At the end of the period of temporary occlusion the marginal vessels must be very carefully inspected for the presence of pulsations and the color of the colon is noted. If the
From the Department of Pediatric Surgery Hacettepe University Children's Hospital, Ankara, Turkey. Date accepted:April 16, 1991. Address reprint requests to Hidya Z. Giindo~du, MD, Hacettepe ~ocuk Hastanesi, ~ocuk CerrahisiAna Bilim Dah, Sthhiye, Ankara 06100, Turkey. Copyright 9 1992 by W.B. Saunders Company 0022-3468/92/2706-0025503.00/0 771
GLINDO(3DU ET AL
772 Table 1. Indications for Colonic Replacement
Table 3. Early Postoperative Complications
No. of Patients
(%)
21
(42)
2
(4)
Total or nearly total obliteration of lumen which involves an esophageal segment longer than 3 cm and causes difficulty in swallowing saliva Difficulties and bleeding during dilating a patient who has previously experienced an esophageal perforation Difficulties in swallowing meat and bread within 1 month following last dilation after the completion of 1-year chronic dilation program, Bleeding and difficulties during further dilations
Leak at the cervical anastomosis Mild pneumonia Necrosis of a segment of the transplant Wound infection in abdominal incision
No. of Patients
(%)
25 25 1 2
(50) (50) (2) (4)
Indications for colonic replacement are shown in Table 1. The most common operative complication was pneumothorax. Because of the retrosternal blunt
dissection during transplantation other operative complications were venous congestion at the cervical end of colon, hematoma in the cervical anastomosis and redundancy of the replaced colon (Table 2). A patient with redundant colon had difficultyin swallowing and necessitated partial resection of transplant 1 year after the replacement. Early postoperative complications were leak at the cervical esophagocolic anastomosis, mild pneumonia, necrosis of the cervical end of the colonic segment, and wound infection in the abdominal incision (Table 3). The patient with necrosis of the cervical end of colonic segment had undergone another replacement procedure. Late complications of colonic replacement were stricture at the cervical anastomosis, dumping symptoms, intermittent nocturnal regurgitation, and upper gastrointestinal bleeding (Table 4). Strictures of the cervical anastomosis were relieved with i to 3 dilations in 10 patients and 4 to 12 dilations in 8. The remaining 4 patients required over 12 dilations for relief. Strictures of the cervical anastomosis were significantly higher in patients whose esophageal strictures involved the cervical esophagus (P < .05) (Table 5). All of the cervical anastomotic strictures were encountered in patients who had anastomotic leak during the early postoperative period. In 50 patients follow-up was available for more than 1 year. Clinical appraisal of these patients are shown in Table 6. Patients who were entirely asymptomatic and could eat anything they wished were classified as excellent. Those who had no dysphagia but needed to chew their food carefully were classified as good. Patients who required repeated dilation or who had same dysphagia were classified as fair. Except for one late death due to massive bleeding from the ulceration of transplanted colon, all patients had a satisfactory oral intake and none had a persistent salivary fistula.
Table 2. Operative Complications
Table 4. Postoperative Late Complications
Total
16 11
(32) (22)
50
(100)
colon remains pink and there are good pulsations in the marginal arteries, the right colic artery is divided close to its origin from the superior mesenteric. The terminal ileum is divided, leaving adequate blood supply through segmental vessels. Careful division of the mesentery then leaves the right side of the transverse colon, the ascending colon, and the terminal ileum with its main blood supply on a pedicle from the midcolic artery. The continuity of the intestinal tract is restored by end-to-end ileotransverse colostomy. Experience has shown that the middle colic artery pedicle of the transplant should be passed behind the stomach, because in several instances the pressure of the middle colic artery when brought up anteriorly causes compression of the pyloric end of the stomach with resulting obstruction. This maneuver must be carefully carried out to prevent torsion of the middle colic artery and its vein. A curved incision is then made in the neck. The sternocleidomastoid muscle and carotid sheath are retracted laterally and the esophageal space entered. The anterior attachment of the diaphram to the lover margin of the sternum is divided through the abdominal incision. By sharp and blunt dissection with the fingers, a tunnel can be made retrosternally. Care is taken to avoid entering the pleural cavities, although this is not always possible; if a pneumothorax results, this is corrected either by needle aspiration or an intercostal catheter immediately postoperatively. The colon transplant with the terminal ileum, if used, is then brought up through the substernal tunnel. The distal end of the transplant is anostomosed to the anterior wall of the stomach with two layers of sutures. The anastomosis between the esophagus and the ileum or cecum may be performed at this stage. Then the procedure is terminated by suturing the esophagus and the terminal ileum to the skin margins of the cervical incision and routine closure of the abdominal incision. Pyloroplasty is not routinely performed and the strictured esophagus is left in situ. Patients were followed for at least I year following replacement. RESULTS
Pneumothorax Venous congestion Cervical hematoma Redundancy in replaced colon
No. of Patients
(%)
18 17 4 4
(36) (34) (8) (8)
Stricture at the cervical anastomosis Dumping symptoms Intermittent nocturnal regurgitation Upper gastrointestinal bleeding
No. of Patients
(%)
22 12 7 4
(44) (24) (14) (8)
COLONIC REPLACEMENT OF CAUSTIC STRICTURES
773
Table 5. The Relation of Stricture of Cervical Anastomosis With Caustic Esophageal Strictures Involved Cervical Esophagus
Table 6. Long-Term Results (1 to 13 years) in 50 Patients No. of
CervicalAnastomotic Stricture
Results
Cervical Esophageal Segment
Yes
No
Total
Involved
20
10
30
Not involved Total
2 22
18 28
20 50
40 (80) 5 (10)
Fair Late death
4 (8) 1 (2)
Total
DISCUSSION
The colon is preferred as an esophageal replacement as it is more resistant to peptic ulceration because of its mucus production. 1~ True peristalsis does not occur in the intact colon and emptying of the transplanted colon is effected primarily by gravity and strong mass peristaltis. ~3,14 The indications of esophageal substitution for the treatment of caustic strictures are controversial. Although some authors suggest replacement as an initial mode of treatment, ~5-~7others reserve this for persisting dilations. 18a9 However, opinions about how long to persist with dilations are not uniform and the suggested time intervals vary between 3 and 12 months. 2~ Daly and Cardona described the indications to be complete stenosis with failure to establish a lumen, marked irregularity and pocketing of the esophagus, severe reaction and mediastinitis as a result of dilation, presence of a fistula, inability to maintain a lumen above 40F bougie, and inability or refusal of the patient to undergo repeated dilations. 23 Although we persisted with dilations in the patients with marked irregularity and pocketing of the esophagus, our other indications have been in accord with Daly and Cardona's. Proximal anastomotic leak is the most common early complication in reconstruction of the esophagus from colon, the incidence ranging as high as 70% in one series. 24 Leakage of anastomosis in the neck was reported to occur in as many as 25% of cases. 24 We encountered 25 leaks in 50 patients (50%); however, all these leaks closed spontaneously. Incidence of anastomotic stricture has been described as being 15% to 100% in reported series. ~,2,7,14 It usually
Patients (%)
Excellent Good
50 (100)
occurred at the proximal esophageal anastomosis but could develop in the gastric anastomosis. Stricture of the cervical anastomosis often resolves with time and long-term dilation is rarely necessary. Late strictures developed in 23 patients and this was more than in Shiller's series. 14 We encountered 23 strictures in 50 patients; 22 were cervical (44%) and 1 was gastric (2%) anastomotic stricture. After operation 10 patients needed no more than 3 dilations but 2 patients needed repeated dilations for normal swallowing. At the end of this review we found that in 50 patients, 46 (92%) could swallow well, 3 of them needed repeated dilation, one gastric anastomotic stricture needed operative revision, and one patient died in another medical center because of massive bleeding from an ulceration site of the transplanted colon. After long-term follow-up ranging from 1 to 13 years, we saw that the children with esophageal substitution for lye strictures usually return to the previously established growth curve according to their nutritional status and we did not see malignancy of the transposed colon segment. Late major complications included mild dysphagia, intermittent nocturnal regurgitation, dumping after meals that could be corrected conservatively, and one cologastric anastomotic stricture that required operative correction. " Colonic interposition is our choice of treatment for caustic esophageal strictures in some selected children and provides excellent results if surgeons give sufficient attention to the demonstration of a good blood supply and protection of the vessels. Complications can be corrected and give satisfactory long-term results.
REFERENCES 1. Anderson KD: Esophageal substitution, in Holder TM, Ashcraft KW (eds): Pediatric Surgery. Philadelphia, PA, Saunders, 1980, pp 284-291 2. Azar H, Cripsin AR, Waterston DS: Esophageal replacement with transverse colon in infants and children. J Pediatr Surg 6:3-9, 1971 3. Berkowita WP, Raper CL, Spector G J, et al: Surgical management of severe lye burns of the esophagus by colon interposition. Ann Otol Rhinol Laryngol 84:576-582, 1975 4. Blanchard H, Roy CC, Perrealut G, et al: Retrosternal
esophageal replacement in 18 children. Can J Surg 15:137-145, 1972 5. Hendren WM, Hendren WG: Colon Interposition for esophagus in children. J Pediatr Surg 20:1985 6. Anderson KD, Randolph JG: Gastric tube interposition: A satisfactory alternative to the colon for esophageal replacement in children. Ann Thorac Surg 25:521-525, 1970 7. Ein SH, Shandling B, Simpson JS, et al: Fourteen years of gastric tubes. J Pediatr Surg 13:638-641, 1978 8. Sherman CD, Waterston D J: Oesophageal reconstruction in children using colon. Arch Dis Child 32:11-16, 1957
774
9. Rodgers BM, Talbert JL, Moazam F, et al: Functional and metabolic evaluation of colon replacement of the esophagus in children. J Pediatr Surg 13:35-39, 1978 10. Schechter JJ, Sequitz RH: The colon as replacement for the esophagus: Its resistance to reflux or gastric juice. Wis Med J 38:677-690, 1959 11. Sirak HD, Clatworthy HW, Elliot DW: An evolution of jejunal and colonic transplants in experimental esophagitis. Surgery 36:399-405, 1954 12. Longino LA, Wolley MJ, Gross RE: Esophageal replacement in infants and children with the use of a segment of colon. JAMA 171:1187-1192, 1959 13. Othersen HB, Clatworthy HW: Functional evaluation of esophageal replacement in children. J Thorac Cardiovasc Surg 53:55-62, 1967 14. Schiller M, Frye TR, Boles ET: Evaluation of colonic replacement of the esophagus in children. J Pediatr Surg 6:753 760, 1971 15. Burford TH, Webb WR, Ackerman L: Caustic burns of the esophagus and their surgical management. A clinico-experimental correlation. Ann Surg 138:453-460, 1953
GONDOGDU ET AL
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