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The Retrosternal Colonic Esophageal Substitute in Children
The Retrosternal Colonic Esophageal Substitute in Children ARTHUR DEBOER, M.D., F.A.C.S.*
The use of the colon as a substitute for the esophagus is a well established surgical procedure. 3 However, the operation is usually done for cancer of the esophagus and, therefore, long-term survivors are few. Because so few patients have been followed long enough, there remains some doubt concerning the ability of the colon to serve as a durable substitute for the esophagus. Although others2 have used the colon for replacement of the esophagus in lesions such as esophageal varices, even these cases fail so far to provide long-term survivals. The use of the colon as a substitute in infants born with atresia of the esophagus, as suggested by Neville,3, 6, 7, 8 should be an ideal test of its long-term efficacy. The purpose of this study is to determine whether children can swallow efficiently and grow normally if the colon is used as a substitute for the esophagus. Our review is based on 14 children who have had the right colon placed in a retrosternal, extrapleural position. These children have been followed from three to eight years postoperatively. UNDERLYING PATHOLOGY
Although the common denominator in this group of patients was the use of the right colon and placement of it in a retrosternal position, the pathologic conditions of the esophagus were: (a) atresia of the esophagus without a fistula in eight patients; (b) esophageal varices in four, and (c) lye strictures in two. In the first group, atresia of the esophagus without a fistula, each newborn infant had an exploratory thoracotomy performed to prove that there was insufficient esophagus above the diaphragm to permit an end-to-end anastomosis. If the above condition was confirmed, a cervical esophagostomy and a gastrostomy were done to allow the infants to thrive for 18 to 24 months. * Associate Attending Surgeon, The Children's Memorial Hospital, Chicago, Illinois 1449
* 1450
ARTHUR DEBoER
The group of patients with esophageal varices were all treatectl with the accepted shunt pro8edures prior to esophagectomy. One patient had seven operations, which included splenectomy, three venous shunts, ligation of esophageal varices, and partial gastrectomy, before an esophagectomy with colon replacement was done to control recurrent bleeding. The colon replacement was used as a last recourse rather than as a preliminary treatment in this patient and the other three. The third group, those with lye strictures, included patients who did not respond to numerous dilatations performed by Dr. Paul Holinger. These patients had extensive strictures involving the esophagus from the level of the arch of the aorta to the cardia of the stomach.
SURGICAL TECHNIQUE
Each of the 14 patients was subjected to a one-stage procedure, using one operating team. The operation was done with the ehild in a supine position, using a right paramedian abdominal incision. The right colon was mobilized, placing it in a retrosternal position. The ordinary precautions of insuring adequate blood supply, no tension on the anastomosis, suffieient length without redundancy, and good position of the transplanted colon, were taken. The colon was usually brought over the duodenum, but occasionally it was brought behind the pylorus through the gastrohepatic ligament if necessary to shorten the distance to the cervical esophagus. The distal anastomosis, that is, the anastomosis between the right transverse colon and stomach, was made on the anterior wall of the stomach, approximately at the junction of the middle and distal third. The proximal anastomosis, that is, between the cecum and upper esophagus, was done through a low neck incision. Continuity of the gastrointestinal tract was re-established by an. anastomosis between the terminal ileum and the left transverse colon. If either pleural cavity had been entered during the retrostern.al dissection, a water-seal type of drainage tube was inserted. If the pleural cavity was not entered, a portable roentgenogram was taken while the patient was still on the operating table to make sure there was no unrecognized pneumothorax. RESULTS
Deaths There were two deaths in this group. One child died immediately after a long and .difficult operation. A mucous plug became lodged in the right bronchus during transit to the intensive care unit. ~he child became cyanotic and was immediately intubated and given suction through the
THE RETROSTERNAL COLONIC ESOPHAGEAL SUBSTITUTE IN CHILDREN
1451
tube. Cardiac arrest developed and the patient failed to respond to cardiac massage. A more careful appraisal of the patient with auscultation of the chest before moving him from the operating room may have indicated partial obstruction of the airway. This could have been corrected before dangerous encroachment upon the airway occurred. The second death was caused by cardiac arrest while the patient was undergoing a secondary revision of a cervical fistula. This child, representing one of our earliest cases of colon transplants, developed a leak from the upper anastomosis and the decision was made to close the leak surgically. Because we anticipated only a short operation confined to the neck, endotracheal anesthesia was not used. The child developed partial respiratory obstruction with hypoxia and the cardiac standstill was not recognized early enough to salvage the youngster. We feel both of these deaths could have been avoided. Both were related to an inadequate airway, and this impresses one with the necessity of maintaining good air exchange during as well as after the operation.
Complications There were four leaks from the upper anastomosis. All except one closed spontaneously, and this one probably would have closed if given additional time to heal spontaneously. From our experience, it is not necessary to re-explore the neck for a leak from the cervical anastomosis unless viability of the transplanted colon is in doubt. Four patients developed strictures at the site of the upper anastomosis. Three of the four strictures developed after a leak from the anastomotic site. All but one responded well to dilatations. The one patient who did not respond satisfactorily to dilatations required a second operation to revise the anastomosis. From our experience, the strictures which are recognized early and treated promptly with dilatations respond well and usually do not require surgical revision. The only failure of dilatation therapy was in a child who was not seen for three months following operation. By this time the stricture became so fixed and rigid that dilatations were ineffectual. Visits are necessary at least monthly to detect early signs of stricture by noting the patient's inability to handle solids. Dilatations have been as satisfactory in strictures of the esophago-colonic anastomoses in this group as in strictures of the esophageal anastomoses in infants with tracheo-esophageal fistula repair. Three children developed serious respiratory difficulty during the early postoperative period. Two patients were treated satisfactorily with high humidity tents and tracheal aspirations. The third child was found apneic and unconscious in bed the night following operation. After aspiration of the airway and insertion of an endotracheal tube, the child responded but' continued to have marked respiratory obstruction. A tracheotomy was done with little relief. It seemed as though the trachea was angulated
'
ARTHUR DEBoER
1452
Figure 1. A postoperative roentgenogram showing the trachea deviated to the left by the colon transplant at the level of the thoracic inlet.
and partially compressed, suggesting inadequate space between the upper sternum anteriorly and the vertebral column posteriorly. Subsequent roentgenograms showed the transplanted colon lying on the left side and the trachea pushed to the right of the midline (Fig. 1). Using the cecum for the upper anastomosis, as was done in this group, has a distinct disadvantage because of its bulk and the resultant crowding of the structures of the thoracic inlet. If the terminal ileum were used instead of the cecum, perhaps there would be less crowding of the airway.
FOLLOW·UP
Twelve patients have been examined periodically, with one lost to follow-up. This child was followed for four years, then moved to Puerto Rico, and has not been examined since. It has been encouraging how amazingly well these children progress after they recover from the surgical procedure. Although it is our impression that these children are somewhat stunted in their growth pattern, they still are within the normal range of the accepted growth and development grids. Usually the child with a
TO
THE RETROSTERNAL COLONIC ESOPHAGEAL SUBSTITUTE IN CHILDREN
1453
substitute esophagus remains smaller than the other children in the family. This was quite striking in the case of twins whose weights varied only 2 ounces at birth. One of them was born with atresia of the esophagus and was given a colon transplant. At eight years of age this child is considerably smaller than his twin brother, in spite of normal eating habits (Fig. 2). Four of the 12 children followed have had some type of foreign body removed from the esophagus. A typical example is a child who had swallowed a button which temporarily obstructed the lumen of the esophagus but passed spontaneously while he was awaiting esophagoscopy (Fig. 3). Because of the presence of narrowing at the junction of the esophagus and substituted colon or colon and stomach, foreign bodies may become lodged at these points, producing esophageal obstruction. In the absence of a stricture, a probable cause for obstruction is that the anastomotic site has scar tissue which is less elastic than the normal esophagus. Another contributing factor in the failure of foreign bodies to pass is that the substitute esophagus (colon) is angulated too acutely in an anterior direction at the upper anastomosis. The normal posterior-lying esophagus, having been sutured to an anteriorly placed colon, creates an unfavorable angle, and thereby hinders the free flow of esophageal content, whether it be food or foreign body. This reasoning, we feel, also explains the difficulty some of these children have in swallowing nonliquid foods rapidly. It is not unusual
Figure 2. Photograph of twin brothers 8 years of age. The smaller has had a colon transplant for 6 years.
1454
Figure 3. Roentgenograms showing the foreign body beyond the anastomosis in the upper portion of transplanted colon.
for parents to state that the child has no difficulty except that he occasionally "chokes" on soft food, such as mashed potatoes. As the children become older, they are aware of this problem and eat more slowly. This difficulty has never been a serious problem but parents are warned not to allow the young children to have large pieces of food to chew, so that the likelihood of a bolus of food obstructing the esophagus is kept to a minimum. Another disturbing but not disastrous consequence of this operation is distinctly audible borborygmi from the esophagus. This is especially disconcerting if the child is in a quiet schoolroom. The air that is normally swallowed does not pass quietly through the esophagus but is churned with fluid in the substitute esophagus (colon) in peristaltic waves and noisily gurgles along. These peristaltic movements of the "esophagus" can be heard easily in quiet surroundings especially if the patient's mouth is open. In one case, a teacher failed to understand this child's problem and insisted he was being defiant. We were especially interested in following these children over a long period of time to determine whether or not the colon could withstand gastric secretions. It was with this in mind that"all patients were carefully screened in regard to ulceration, stricture, or bleeding at the gastrocolonic anastomosis. One child complained of pain in the abdomen, especially at night. Several roentgenograms were taken and no evidence of ulceration or stricture could be demonstrated. A second child returned to the clinic with a hemoglobin of 4 grams. There was no occult blood in the stools, nor was there any abnormality found in the roentgenograms. On further investigation, it appeared that the anemia was an iron deficiency anemia,
THE RETROSTERNAL COLONIC ESOPHAGEAL SUBSTITUTE IN CHILDREN
1455
and after supplementing the diet the hemoglobin promptly rose to normal. Of this group, four children have been followed for eight years with no difficulty from the anastomosis of the stomach to the transplanted colon. Ulceration of the colon has been described, 9 but we have not experienced this problem so far in this SInall group of patients. It has been proposed that the normal cardiac sphincter should be utilized by anastomosing the transplanted colon to the stump of esophagus proximal to the sphincter to prevent reflux of gastric contents into the substitute esophagus. 1o We have been concerned about the amount of reflu'X into the colon, and its sequelae. Although there is no evidence of bleeding, ulceration, or stricture of the gastrocolonic anastomosis, reflux must exist. We presumed the most likely factors in producing reflux would be pressure that pushes the stomach contents into the substitute esophagus, or a position that drains the gastric fluid into the colon. Three children were studied using barium to fill the stomach. After the stomach was filled, sandbags were placed on the abdomen and the child was asked to strain, simulating a Valsalva Inaneuver. We were unable to demonstrate any reflux of barium into the colon (Fig. 4). The child was then placed on his abdomen and put into a deep Trendelenburg position. Again, we were unable to see any reflux of barium into the colon (Fig. 5).
Figure 4. The barium-filled stomach during Valsalva maneuver, with no reflux into substitute esophagus.
f 1456
ARTHUR DEBoER
Figure 5. Patient in deep Trendelenburg position, placed on his abdomen following barium ingestion. There is some retained barium from the swallow but no reflux from the stomach is demonstrable.
SUMMARY AND CONCLUSIONS
A review of 14 cases of esophageal replacement with a portion of the right colon in a retrosternal position, with follow-up for periods up to eight years, suggests that the colon is a satisfactory substitute for the esophagus. The major causes of operative deaths and complications are primarily airway in origin. Angulation of the trachea from pressure of the transplanted colon, crowding of the thoracic inlet, pneumothorax and retained secretions are all to be considered in avoiding lethal respiratory obstruction in the postoperative period. A tracheotomy may not help and may even worsen the condition, particularly if the trachea is displaced from the midline. After recovery from the operation, adequate and perhaps normal nourishment, growth and development usually follow. Parents should be instructed how to care for the child who has a colonic substitute for an esophagus. It would appear that if the angulation at the upper anastomosis could be avoided by placing the transplanted colon into the pleural cavity, swallowing would be more efficient.
f' THE RETROSTERNAL COLONIC ESOPHAGEAL SUBSTITUTE IN CHILDREN
1457
There seems to be very little reflux of gastric contents into the substitute esophagus (colon) if it is sutured to the anterior wall of the stomach and placed into the anterior mediastinum. In our series there has been no evidence of ulceration, bleeding or stricture formation at the gastrocolonic anastomosis.
REFERENCES 1. Dale, W. A. and Shennan, C. D., Jr.: Late reconstruction of congenital esophageal atresia by intrathoracic colon transplantation. J. Thoracic Surg. 29: 344, 1955. 2. Koop, C. E. and Raddy, S. R.: Colonic replacement of distal esophagus and proximal stomach in the management of bleeding varices in children. Ann. Surg. 147: 17, 1958. 3. Longmire, W. P., Jr. and Ravitch, M. M.: A new method of constructing an artificial esophagus. Ann. Surg. 123: 819, 1946. 4. Mahoney, E. B. and Shennan, C. D., Jr.: Total esophagoplasty using intrathoracic right colon. Surgery 35: 935, 1954. 5. Moroney, J.: Colonic replacement of the stomach. Lancet 1: 993,1951. 6. Neville, W. E., Smith, A. E. and Storer, J.: Use of the transverse colon for reconstruction of the esophagus in tracheo-esophageal fistula. Ann. Surg. 144: 1045, 1956. 7. Neville, W. E. and Clowes, G. H. A.: Reconstruction of the esophagus with segments of the colon. J. Thoracic Surg. 35: 2, 1958. 8. Neville, W. E. and Clowes, G. H. A.: Colon replacement of the esophagus in children for congenital and acquired diseases. J. Thoracic Surg. 40: 507, 1960. 9. Petrov, B. A. and Sytnik, A. P.: Peptic ulcer of the large intestine in esophagoplasty. Khirurgilia (Moskva) 39: 107, Feb. 1963. 10. Shennan, C. B., Jr. and Waterston, D.: Oesophageal reconstruction in children using intrathoracic colon. Arch. Dis. Child. 32: 11, 1957. 11. Sirak, H. D. and Clatworthy, H. W., Jr.: An evaluation of jejunal and colic transplants in experimental esophagitis. Surgery 36: 399, 1954.
720 North Michigan Avenue Chicago, Illinois 60611
The use of the colon as a substitute for the esophagus is a well established surgical procedure. 3 However, the operation is usually done for cancer of the esophagus and, therefore, long-term survivors are few. Because so few patients have been followed long enough, there remains some doubt concerning the ability of the colon to serve as a durable substitute for the esophagus. Although others2 have used the colon for replacement of the esophagus in lesions such as esophageal varices, even these cases fail so far to provide long-term survivals. The use of the colon as a substitute in infants born with atresia of the esophagus, as suggested by Neville,3, 6, 7, 8 should be an ideal test of its long-term efficacy. The purpose of this study is to determine whether children can swallow efficiently and grow normally if the colon is used as a substitute for the esophagus. Our review is based on 14 children who have had the right colon placed in a retrosternal, extrapleural position. These children have been followed from three to eight years postoperatively. UNDERLYING PATHOLOGY
Although the common denominator in this group of patients was the use of the right colon and placement of it in a retrosternal position, the pathologic conditions of the esophagus were: (a) atresia of the esophagus without a fistula in eight patients; (b) esophageal varices in four, and (c) lye strictures in two. In the first group, atresia of the esophagus without a fistula, each newborn infant had an exploratory thoracotomy performed to prove that there was insufficient esophagus above the diaphragm to permit an end-to-end anastomosis. If the above condition was confirmed, a cervical esophagostomy and a gastrostomy were done to allow the infants to thrive for 18 to 24 months. * Associate Attending Surgeon, The Children's Memorial Hospital, Chicago, Illinois 1449
* 1450
ARTHUR DEBoER
The group of patients with esophageal varices were all treatectl with the accepted shunt pro8edures prior to esophagectomy. One patient had seven operations, which included splenectomy, three venous shunts, ligation of esophageal varices, and partial gastrectomy, before an esophagectomy with colon replacement was done to control recurrent bleeding. The colon replacement was used as a last recourse rather than as a preliminary treatment in this patient and the other three. The third group, those with lye strictures, included patients who did not respond to numerous dilatations performed by Dr. Paul Holinger. These patients had extensive strictures involving the esophagus from the level of the arch of the aorta to the cardia of the stomach.
SURGICAL TECHNIQUE
Each of the 14 patients was subjected to a one-stage procedure, using one operating team. The operation was done with the ehild in a supine position, using a right paramedian abdominal incision. The right colon was mobilized, placing it in a retrosternal position. The ordinary precautions of insuring adequate blood supply, no tension on the anastomosis, suffieient length without redundancy, and good position of the transplanted colon, were taken. The colon was usually brought over the duodenum, but occasionally it was brought behind the pylorus through the gastrohepatic ligament if necessary to shorten the distance to the cervical esophagus. The distal anastomosis, that is, the anastomosis between the right transverse colon and stomach, was made on the anterior wall of the stomach, approximately at the junction of the middle and distal third. The proximal anastomosis, that is, between the cecum and upper esophagus, was done through a low neck incision. Continuity of the gastrointestinal tract was re-established by an. anastomosis between the terminal ileum and the left transverse colon. If either pleural cavity had been entered during the retrostern.al dissection, a water-seal type of drainage tube was inserted. If the pleural cavity was not entered, a portable roentgenogram was taken while the patient was still on the operating table to make sure there was no unrecognized pneumothorax. RESULTS
Deaths There were two deaths in this group. One child died immediately after a long and .difficult operation. A mucous plug became lodged in the right bronchus during transit to the intensive care unit. ~he child became cyanotic and was immediately intubated and given suction through the
THE RETROSTERNAL COLONIC ESOPHAGEAL SUBSTITUTE IN CHILDREN
1451
tube. Cardiac arrest developed and the patient failed to respond to cardiac massage. A more careful appraisal of the patient with auscultation of the chest before moving him from the operating room may have indicated partial obstruction of the airway. This could have been corrected before dangerous encroachment upon the airway occurred. The second death was caused by cardiac arrest while the patient was undergoing a secondary revision of a cervical fistula. This child, representing one of our earliest cases of colon transplants, developed a leak from the upper anastomosis and the decision was made to close the leak surgically. Because we anticipated only a short operation confined to the neck, endotracheal anesthesia was not used. The child developed partial respiratory obstruction with hypoxia and the cardiac standstill was not recognized early enough to salvage the youngster. We feel both of these deaths could have been avoided. Both were related to an inadequate airway, and this impresses one with the necessity of maintaining good air exchange during as well as after the operation.
Complications There were four leaks from the upper anastomosis. All except one closed spontaneously, and this one probably would have closed if given additional time to heal spontaneously. From our experience, it is not necessary to re-explore the neck for a leak from the cervical anastomosis unless viability of the transplanted colon is in doubt. Four patients developed strictures at the site of the upper anastomosis. Three of the four strictures developed after a leak from the anastomotic site. All but one responded well to dilatations. The one patient who did not respond satisfactorily to dilatations required a second operation to revise the anastomosis. From our experience, the strictures which are recognized early and treated promptly with dilatations respond well and usually do not require surgical revision. The only failure of dilatation therapy was in a child who was not seen for three months following operation. By this time the stricture became so fixed and rigid that dilatations were ineffectual. Visits are necessary at least monthly to detect early signs of stricture by noting the patient's inability to handle solids. Dilatations have been as satisfactory in strictures of the esophago-colonic anastomoses in this group as in strictures of the esophageal anastomoses in infants with tracheo-esophageal fistula repair. Three children developed serious respiratory difficulty during the early postoperative period. Two patients were treated satisfactorily with high humidity tents and tracheal aspirations. The third child was found apneic and unconscious in bed the night following operation. After aspiration of the airway and insertion of an endotracheal tube, the child responded but' continued to have marked respiratory obstruction. A tracheotomy was done with little relief. It seemed as though the trachea was angulated
'
ARTHUR DEBoER
1452
Figure 1. A postoperative roentgenogram showing the trachea deviated to the left by the colon transplant at the level of the thoracic inlet.
and partially compressed, suggesting inadequate space between the upper sternum anteriorly and the vertebral column posteriorly. Subsequent roentgenograms showed the transplanted colon lying on the left side and the trachea pushed to the right of the midline (Fig. 1). Using the cecum for the upper anastomosis, as was done in this group, has a distinct disadvantage because of its bulk and the resultant crowding of the structures of the thoracic inlet. If the terminal ileum were used instead of the cecum, perhaps there would be less crowding of the airway.
FOLLOW·UP
Twelve patients have been examined periodically, with one lost to follow-up. This child was followed for four years, then moved to Puerto Rico, and has not been examined since. It has been encouraging how amazingly well these children progress after they recover from the surgical procedure. Although it is our impression that these children are somewhat stunted in their growth pattern, they still are within the normal range of the accepted growth and development grids. Usually the child with a
TO
THE RETROSTERNAL COLONIC ESOPHAGEAL SUBSTITUTE IN CHILDREN
1453
substitute esophagus remains smaller than the other children in the family. This was quite striking in the case of twins whose weights varied only 2 ounces at birth. One of them was born with atresia of the esophagus and was given a colon transplant. At eight years of age this child is considerably smaller than his twin brother, in spite of normal eating habits (Fig. 2). Four of the 12 children followed have had some type of foreign body removed from the esophagus. A typical example is a child who had swallowed a button which temporarily obstructed the lumen of the esophagus but passed spontaneously while he was awaiting esophagoscopy (Fig. 3). Because of the presence of narrowing at the junction of the esophagus and substituted colon or colon and stomach, foreign bodies may become lodged at these points, producing esophageal obstruction. In the absence of a stricture, a probable cause for obstruction is that the anastomotic site has scar tissue which is less elastic than the normal esophagus. Another contributing factor in the failure of foreign bodies to pass is that the substitute esophagus (colon) is angulated too acutely in an anterior direction at the upper anastomosis. The normal posterior-lying esophagus, having been sutured to an anteriorly placed colon, creates an unfavorable angle, and thereby hinders the free flow of esophageal content, whether it be food or foreign body. This reasoning, we feel, also explains the difficulty some of these children have in swallowing nonliquid foods rapidly. It is not unusual
Figure 2. Photograph of twin brothers 8 years of age. The smaller has had a colon transplant for 6 years.
1454
Figure 3. Roentgenograms showing the foreign body beyond the anastomosis in the upper portion of transplanted colon.
for parents to state that the child has no difficulty except that he occasionally "chokes" on soft food, such as mashed potatoes. As the children become older, they are aware of this problem and eat more slowly. This difficulty has never been a serious problem but parents are warned not to allow the young children to have large pieces of food to chew, so that the likelihood of a bolus of food obstructing the esophagus is kept to a minimum. Another disturbing but not disastrous consequence of this operation is distinctly audible borborygmi from the esophagus. This is especially disconcerting if the child is in a quiet schoolroom. The air that is normally swallowed does not pass quietly through the esophagus but is churned with fluid in the substitute esophagus (colon) in peristaltic waves and noisily gurgles along. These peristaltic movements of the "esophagus" can be heard easily in quiet surroundings especially if the patient's mouth is open. In one case, a teacher failed to understand this child's problem and insisted he was being defiant. We were especially interested in following these children over a long period of time to determine whether or not the colon could withstand gastric secretions. It was with this in mind that"all patients were carefully screened in regard to ulceration, stricture, or bleeding at the gastrocolonic anastomosis. One child complained of pain in the abdomen, especially at night. Several roentgenograms were taken and no evidence of ulceration or stricture could be demonstrated. A second child returned to the clinic with a hemoglobin of 4 grams. There was no occult blood in the stools, nor was there any abnormality found in the roentgenograms. On further investigation, it appeared that the anemia was an iron deficiency anemia,
THE RETROSTERNAL COLONIC ESOPHAGEAL SUBSTITUTE IN CHILDREN
1455
and after supplementing the diet the hemoglobin promptly rose to normal. Of this group, four children have been followed for eight years with no difficulty from the anastomosis of the stomach to the transplanted colon. Ulceration of the colon has been described, 9 but we have not experienced this problem so far in this SInall group of patients. It has been proposed that the normal cardiac sphincter should be utilized by anastomosing the transplanted colon to the stump of esophagus proximal to the sphincter to prevent reflux of gastric contents into the substitute esophagus. 1o We have been concerned about the amount of reflu'X into the colon, and its sequelae. Although there is no evidence of bleeding, ulceration, or stricture of the gastrocolonic anastomosis, reflux must exist. We presumed the most likely factors in producing reflux would be pressure that pushes the stomach contents into the substitute esophagus, or a position that drains the gastric fluid into the colon. Three children were studied using barium to fill the stomach. After the stomach was filled, sandbags were placed on the abdomen and the child was asked to strain, simulating a Valsalva Inaneuver. We were unable to demonstrate any reflux of barium into the colon (Fig. 4). The child was then placed on his abdomen and put into a deep Trendelenburg position. Again, we were unable to see any reflux of barium into the colon (Fig. 5).
Figure 4. The barium-filled stomach during Valsalva maneuver, with no reflux into substitute esophagus.
f 1456
ARTHUR DEBoER
Figure 5. Patient in deep Trendelenburg position, placed on his abdomen following barium ingestion. There is some retained barium from the swallow but no reflux from the stomach is demonstrable.
SUMMARY AND CONCLUSIONS
A review of 14 cases of esophageal replacement with a portion of the right colon in a retrosternal position, with follow-up for periods up to eight years, suggests that the colon is a satisfactory substitute for the esophagus. The major causes of operative deaths and complications are primarily airway in origin. Angulation of the trachea from pressure of the transplanted colon, crowding of the thoracic inlet, pneumothorax and retained secretions are all to be considered in avoiding lethal respiratory obstruction in the postoperative period. A tracheotomy may not help and may even worsen the condition, particularly if the trachea is displaced from the midline. After recovery from the operation, adequate and perhaps normal nourishment, growth and development usually follow. Parents should be instructed how to care for the child who has a colonic substitute for an esophagus. It would appear that if the angulation at the upper anastomosis could be avoided by placing the transplanted colon into the pleural cavity, swallowing would be more efficient.
f' THE RETROSTERNAL COLONIC ESOPHAGEAL SUBSTITUTE IN CHILDREN
1457
There seems to be very little reflux of gastric contents into the substitute esophagus (colon) if it is sutured to the anterior wall of the stomach and placed into the anterior mediastinum. In our series there has been no evidence of ulceration, bleeding or stricture formation at the gastrocolonic anastomosis.
REFERENCES 1. Dale, W. A. and Shennan, C. D., Jr.: Late reconstruction of congenital esophageal atresia by intrathoracic colon transplantation. J. Thoracic Surg. 29: 344, 1955. 2. Koop, C. E. and Raddy, S. R.: Colonic replacement of distal esophagus and proximal stomach in the management of bleeding varices in children. Ann. Surg. 147: 17, 1958. 3. Longmire, W. P., Jr. and Ravitch, M. M.: A new method of constructing an artificial esophagus. Ann. Surg. 123: 819, 1946. 4. Mahoney, E. B. and Shennan, C. D., Jr.: Total esophagoplasty using intrathoracic right colon. Surgery 35: 935, 1954. 5. Moroney, J.: Colonic replacement of the stomach. Lancet 1: 993,1951. 6. Neville, W. E., Smith, A. E. and Storer, J.: Use of the transverse colon for reconstruction of the esophagus in tracheo-esophageal fistula. Ann. Surg. 144: 1045, 1956. 7. Neville, W. E. and Clowes, G. H. A.: Reconstruction of the esophagus with segments of the colon. J. Thoracic Surg. 35: 2, 1958. 8. Neville, W. E. and Clowes, G. H. A.: Colon replacement of the esophagus in children for congenital and acquired diseases. J. Thoracic Surg. 40: 507, 1960. 9. Petrov, B. A. and Sytnik, A. P.: Peptic ulcer of the large intestine in esophagoplasty. Khirurgilia (Moskva) 39: 107, Feb. 1963. 10. Shennan, C. B., Jr. and Waterston, D.: Oesophageal reconstruction in children using intrathoracic colon. Arch. Dis. Child. 32: 11, 1957. 11. Sirak, H. D. and Clatworthy, H. W., Jr.: An evaluation of jejunal and colic transplants in experimental esophagitis. Surgery 36: 399, 1954.
720 North Michigan Avenue Chicago, Illinois 60611