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Colonic Replacement of Esophagus (Intrathoracic)
Colonic Replacement of Esophagus {Intrathoracic} DAVID WATERSTON, F.R.C.S.*
Reconstruction of the esophagus has proved a difficult surgical problem. In the past, various methods have been used and finally discarded because of poor function and frequent complications, both in the early postoperative period and years after operation. Although by no means free of problems, it appears now that colonic replacement of the esophagus has certain advantages over the use of skin tubes, gastric tubes or small intestine. One of the remaining questions is whether it is most advantageous to place the colonic segment in a retrosternal position or in the thoracic cavity. In our experience, intrathoracic reconstruction has been the most satisfactory method, particularly if there is a competent esophagogastric junction which can be preserved and utilized in the reconstruction.
Indications Colonic replacement of the esophagus may be indicated in patients with atresia of the esophagus when primary anastomosis is not possible, with severe stricture of the esophagus due to peptic ulceration or swallowing of corrosives, or with bleeding from esophageal varices when the portal hypertension cannot be controlled by other means.
Age at Operation For infants with esophageal atresia in whom primary anastomosis is not possible, the optimum age for the reconstruction of the esophagus is six months. At this age the thoracic cavity is small enough for good exposure of both diaphragm and apex of chest through a thoracotomy in the seventh space; the blood vessels supplying the colon are of good size and the pedicle is more easy to fashion. In my experience, reconstruction undertaken in the first few days of life carries a higher risk. Babies with esophageal atresia without fistula to the trachea have a very poorly de• Surgeon, The Hospital for Sick Children, Great Ormond Street, London, England
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DAVID WATERSTON
veloped gastrointestinal tract, so that a primary reconstruction with colon is hazardous. It is much safer to perform a preliminary gastrostomy and left cervical esophagostomy in the newborn period, and then to proceed to the definitive operation at six months of age. PRIMARY PROCEDURE IN THE NEWBORN
Those babies with esophageal atresia in whom there is air in the stomach on straight x-ray should have a right thoracotomy and a primary anastomosis in the usual manner. If the ends of the esophagus cannot be anastomosed because the gap between them is too wide, then the lower esophagus which entered the trachea should be trimmed back until good bleeding can be seen from the cut end. This is then carefully oversewn with interrupted fine silk sutures. Experience has shown that ligation in continuity or division and closure by a single ligature carries a high risk of rupture of the distal segment or recanalization of the fistula. The chest is then closed and gastrostomy and left cervical esophagostomy are performed. Postoperative Care After Preliminary Operation in the Newborn GASTROSTOMY FEEDINGS. Small gastrostomy feedings can be started 12 hours after operation and increased in amount until a normal schedule for weight is reached in three days. ORAL FEEDINGS. It is essential that babies with an esophagostomy be fed orally while their gastrostomy feedings are given. If this is not done these infants will not learn to enjoy the act of feeding and may become difficult problems in management after the gullet has been reconstructed. Ideally, the oral feedings should be given at the same time as the gastrostomy feedings are instilled; the normal act of oral feeding relaxes the pyloric sphincter and enables the gastrostomy feedings to be given more quickly and with less pressure. These infants with a gastrostomy and esophagostomy do not need to be kept in hospital while awaiting their final operation. Their mothers can be taught how to manage the gastrostomy feedings and the oral feedings which spill out through the esophagostomy opening. This does away with the necessity for long stay in hospital and the mothers get to know their infants and how to care for them. It also follows that the baby can be looked after by its mother more quickly after the reconstructive operation.
TECHNIQUE OF INTRATHORACIC ESOPHAGEAL RECONSTRUCTION
Preoperative Treatment
The child should be admitted to hospital for a few days before operation so that the nursing staff can get to know him and so that his colon can
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be prepared. No laxatives or enemas should be given. The colon of a six months old child is adequately sterilized with the following regimen: 48 hours preoperatively: succinylsulfathiazole (Sulfasuxidine) 0.5 gram every four hours by gastrostomy; 24 hours preoperatively: streptomycin 20 mg. per kilogram of body weight by injection.
Operative Treatment ANESTHESIA. Endotracheal anesthesia with a relaxant and full control of respiration should be used following suitable premedication. TECHNIQUE. With the child on the right side, a left lateral thoracotomy through the seventh interspace is made. Diathermy is used throughout the operation to minimize blood loss. The costal margin is divided at the diaphragm to give better exposure (Fig. 1, A). The abdominal cavity is opened by an incision around the periphery of the diaphragm close to its attachment to the chest wall (Fig. 1, B). This incision divides few branches of the phrenic nerve and leaves a well functioning diaphragm; through it excellent exposure of the splenic flexure
F Figure 1. A, The line of incision for the thoracotomy. B, The abdominal incision. C, Division of the colon at splenic and hepatic flexures. D, Reconstitution of the colon by anastomosis. E, Tunnel transfer of the colonic transplant into the chest, taking especial care to maintain the arterial supply. F, The colonic transplant has replaced the esophagus. (For details, see text.)
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and transverse colon is obtained. The transverse colon is brought out through the diaphragm and the greater omentum is freed from it; the middle colic artery is divided near its origin so that the transverse colon and splenic flexure are supplied by the ascending branch of the left colic artery. The colon is then divided at splenic and hepatic flexures and the continuity of the colon is reconstituted by anastomosis in one layer using interrupted sutures of fine silk (Fig. 1, C, D). For ease of apposition during this anastomosis the cut ends are held by noncrushing clamps of the Potts type. A small incision about 1 cm. in length is then made through the diaphragm posteriorly and about 3 cm. from the esophageal hiatus; a pair of blunt Spencer-Wells forceps is then passed from the chest and by blunt dissection burrowed through into the abdominal cavity; the tunnel thus made passes behind stomach and pancreas and splenic vessels, and the colonic transplant is drawn through the diaphragm into the chest (Fig. 1, D, E). Care must be taken to ensure that the pedicle passes without tension or twists and that there is good arterial supply to both ends of the colon in the chest. The lower stump of esophagus is now dissected out from the mediastinum without damaging in any way the important crura of the esophageal hiatus or the vagus nerves. After the esophagus is opened and cut back until good arterial bleeding is obtained, it is anastomosed to the distal cut end of the colon transplant; the anastomosis is made in one layer with fine interrupted silk sutures (Fig. 1, F). The cervical esophagostomy above the left clavicle is then dissected free from the skin; the esophagus is freed into the neck deep to the clavicular head of the sternomastoid. A blunt pair of forceps is passed behind the clavicle through the apex of the left chest into the pleural cavity. The point of entry into the pleural cavity must be carefully chosen under vision from the thoracotomy incision while the left lung is held back by a retractor. The blunt forceps are passed through the pleura medial and anterior to the left subclavian artery, care being taken not to damage the innominate vein or the left vagus nerve. Once the opening has been made it can then be enlarged by passing Hegar's dilators from above. When the opening has been enlarged a long pair of blunt forceps is passed through from the neck incision and the proximal end of the free colon graft pulled through above the clavicle. The graft is then placed behind the lung hilum posteriorly in the pleural cavity, care being taken that it is not twisted and that the pedicle is lying without tension as it passes through the diaphragm. Some excess colon may have to be trimmed off in the neck so that it can be anastomosed to the cervical esophagus. Again a single layer bf interrupted silk is used. The anastomosis now lies deep in the neck in the normal line of the es()pb,,. agus. The incision in the diaphragm is now clostld'in one layer using inter-
COLONIC REPLACEMENT OF ESOPHAGUS
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rupted silk, and before the chest is closed the position and blood supply of the graft is checked. The ribs are approximated with interrupted pericostal fine catgut and a tube drain left in the pleural cavity through a separate stab incision. Postoperative Care
The gastrostomy must be kept open and attached to a small funnel about 5 cm. above the level of the stomach. These children tend to swallow air postoperatively and it is important to keep the stomach deflated. The negative pressure in the chest will cause some distention of the colon transplant for a few days postoperatively until it regains its normal tone and peristalsis. It is necessary therefore to keep a small soft rubber tube through the nostril into the colon in the chest. This tube is attached to an underwater seal beneath the bed; this will give enough negative pressure to prevent any distention of the colon graft. The child is fed intravenously for 48 hours after operation and thereafter gastrostomy feeds may be started and increased to normal amounts over 48 hours. The pleural drain may be removed in 48 hours; the tube in the colon may be removed after about three days and oral feeding should be started when this tube is removed. If the child was accustomed to taking food by mouth before operation then the change-over from gastrostomy to oral feeding should present no problem. When a full and adequate intake by mouth has been reached, then the gastrostomy feeds may be stopped. Advantages of This Type of Intrathoracic Replacement
1. When this type of replacement is used for atresia of the esophagus, the cardiac sphincter may be conserved and reflux prevented into the new esophagus. 2. A very good length of colon is obtained by using the ascending branch of the left colic artery as a pedicle. 3. The ileocecal valve is conserved ·and the remaining colon functions normally. 4. The new esophagus is isoperistaltic in position. 5. The upper anastomosis may be performed either in the neck where it lies in the normal position of the esophagus, or at any level in the thoracic cavity according to the available length of upper esophagus. 6. The cervical anastomosis is easier to perform when the replacement lies posteriorly than when it is brought out in the midline from behind the sternum. Results
Results are detailed in Table 1.
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DAYI)) WATERSTON
Table 1.. Results of Intrathoracic Esophageal Reconstruction (Patients Treated at The Hospital for Sick Children, Great Ormond Street, London) ALIVE
Esophageal atresia ......... 20 Peptic stricture ......... " 11 Congenital stricture. . . . . .. 1 Caustic stricture.. . . . . . . .. 3 TOTAL . • . . . . . . . . . . . . . 35
DEAD
5*
o o o 5
TOTAL
25 11 1
3 40
* Includes one case operated on in newborn period in an infant with mongolism.
It appears that the transplanted colon grows with the child and the late results are satisfactory (Fig. 2) .
Figure 2. Child now aged 12 years. Duodenal atresia, esophageal atresia without fistula, colon replacement of esophagus in 1952. This child now eats normally and has no symptoms.
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1447
Postoperative Complications ISCHEMIA OF TRANSPLANT. The five deaths in this series have all been due to ischemia of the transplant due to technical difficulties at the operation. All these patients showed symptoms of severe and rapidly fatal shock which did not respond to resuscitation. These deaths occurred early in the series and there have been no deaths in the last 20 cases. LEAKAGE AND STRICTURE FROM CERVICAL ANASTOMOSIS. Fifteen cases have had some leakage from the neck postoperatively; nearly all of these have healed spontaneously after two to three weeks but five have had to have a revision of this anastomosis either because of stricture formation or persistent leak. PYLOROSPASM. If the vagus nerves have been preserved while dissecting out the lower pouch of esophagus, there is no need to perform a pyloroplasty. If, however, there is evidence of pylorospasm postoperatively as evidenced by failure of the gastrostomy feedings to run in easily, then a formal pyloroplasty should be performed.
SUMMARY
A method of intrathoracic replacement of the esophagus using the transverse colon on a pedicle of the left colic artery is· described. The Hospital for Sick Children Great Ormond Street London W. C. 1, England
Reconstruction of the esophagus has proved a difficult surgical problem. In the past, various methods have been used and finally discarded because of poor function and frequent complications, both in the early postoperative period and years after operation. Although by no means free of problems, it appears now that colonic replacement of the esophagus has certain advantages over the use of skin tubes, gastric tubes or small intestine. One of the remaining questions is whether it is most advantageous to place the colonic segment in a retrosternal position or in the thoracic cavity. In our experience, intrathoracic reconstruction has been the most satisfactory method, particularly if there is a competent esophagogastric junction which can be preserved and utilized in the reconstruction.
Indications Colonic replacement of the esophagus may be indicated in patients with atresia of the esophagus when primary anastomosis is not possible, with severe stricture of the esophagus due to peptic ulceration or swallowing of corrosives, or with bleeding from esophageal varices when the portal hypertension cannot be controlled by other means.
Age at Operation For infants with esophageal atresia in whom primary anastomosis is not possible, the optimum age for the reconstruction of the esophagus is six months. At this age the thoracic cavity is small enough for good exposure of both diaphragm and apex of chest through a thoracotomy in the seventh space; the blood vessels supplying the colon are of good size and the pedicle is more easy to fashion. In my experience, reconstruction undertaken in the first few days of life carries a higher risk. Babies with esophageal atresia without fistula to the trachea have a very poorly de• Surgeon, The Hospital for Sick Children, Great Ormond Street, London, England
1441
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DAVID WATERSTON
veloped gastrointestinal tract, so that a primary reconstruction with colon is hazardous. It is much safer to perform a preliminary gastrostomy and left cervical esophagostomy in the newborn period, and then to proceed to the definitive operation at six months of age. PRIMARY PROCEDURE IN THE NEWBORN
Those babies with esophageal atresia in whom there is air in the stomach on straight x-ray should have a right thoracotomy and a primary anastomosis in the usual manner. If the ends of the esophagus cannot be anastomosed because the gap between them is too wide, then the lower esophagus which entered the trachea should be trimmed back until good bleeding can be seen from the cut end. This is then carefully oversewn with interrupted fine silk sutures. Experience has shown that ligation in continuity or division and closure by a single ligature carries a high risk of rupture of the distal segment or recanalization of the fistula. The chest is then closed and gastrostomy and left cervical esophagostomy are performed. Postoperative Care After Preliminary Operation in the Newborn GASTROSTOMY FEEDINGS. Small gastrostomy feedings can be started 12 hours after operation and increased in amount until a normal schedule for weight is reached in three days. ORAL FEEDINGS. It is essential that babies with an esophagostomy be fed orally while their gastrostomy feedings are given. If this is not done these infants will not learn to enjoy the act of feeding and may become difficult problems in management after the gullet has been reconstructed. Ideally, the oral feedings should be given at the same time as the gastrostomy feedings are instilled; the normal act of oral feeding relaxes the pyloric sphincter and enables the gastrostomy feedings to be given more quickly and with less pressure. These infants with a gastrostomy and esophagostomy do not need to be kept in hospital while awaiting their final operation. Their mothers can be taught how to manage the gastrostomy feedings and the oral feedings which spill out through the esophagostomy opening. This does away with the necessity for long stay in hospital and the mothers get to know their infants and how to care for them. It also follows that the baby can be looked after by its mother more quickly after the reconstructive operation.
TECHNIQUE OF INTRATHORACIC ESOPHAGEAL RECONSTRUCTION
Preoperative Treatment
The child should be admitted to hospital for a few days before operation so that the nursing staff can get to know him and so that his colon can
1443
COLONIC REPLACEMENT OF ESOPHAGUS
be prepared. No laxatives or enemas should be given. The colon of a six months old child is adequately sterilized with the following regimen: 48 hours preoperatively: succinylsulfathiazole (Sulfasuxidine) 0.5 gram every four hours by gastrostomy; 24 hours preoperatively: streptomycin 20 mg. per kilogram of body weight by injection.
Operative Treatment ANESTHESIA. Endotracheal anesthesia with a relaxant and full control of respiration should be used following suitable premedication. TECHNIQUE. With the child on the right side, a left lateral thoracotomy through the seventh interspace is made. Diathermy is used throughout the operation to minimize blood loss. The costal margin is divided at the diaphragm to give better exposure (Fig. 1, A). The abdominal cavity is opened by an incision around the periphery of the diaphragm close to its attachment to the chest wall (Fig. 1, B). This incision divides few branches of the phrenic nerve and leaves a well functioning diaphragm; through it excellent exposure of the splenic flexure
F Figure 1. A, The line of incision for the thoracotomy. B, The abdominal incision. C, Division of the colon at splenic and hepatic flexures. D, Reconstitution of the colon by anastomosis. E, Tunnel transfer of the colonic transplant into the chest, taking especial care to maintain the arterial supply. F, The colonic transplant has replaced the esophagus. (For details, see text.)
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and transverse colon is obtained. The transverse colon is brought out through the diaphragm and the greater omentum is freed from it; the middle colic artery is divided near its origin so that the transverse colon and splenic flexure are supplied by the ascending branch of the left colic artery. The colon is then divided at splenic and hepatic flexures and the continuity of the colon is reconstituted by anastomosis in one layer using interrupted sutures of fine silk (Fig. 1, C, D). For ease of apposition during this anastomosis the cut ends are held by noncrushing clamps of the Potts type. A small incision about 1 cm. in length is then made through the diaphragm posteriorly and about 3 cm. from the esophageal hiatus; a pair of blunt Spencer-Wells forceps is then passed from the chest and by blunt dissection burrowed through into the abdominal cavity; the tunnel thus made passes behind stomach and pancreas and splenic vessels, and the colonic transplant is drawn through the diaphragm into the chest (Fig. 1, D, E). Care must be taken to ensure that the pedicle passes without tension or twists and that there is good arterial supply to both ends of the colon in the chest. The lower stump of esophagus is now dissected out from the mediastinum without damaging in any way the important crura of the esophageal hiatus or the vagus nerves. After the esophagus is opened and cut back until good arterial bleeding is obtained, it is anastomosed to the distal cut end of the colon transplant; the anastomosis is made in one layer with fine interrupted silk sutures (Fig. 1, F). The cervical esophagostomy above the left clavicle is then dissected free from the skin; the esophagus is freed into the neck deep to the clavicular head of the sternomastoid. A blunt pair of forceps is passed behind the clavicle through the apex of the left chest into the pleural cavity. The point of entry into the pleural cavity must be carefully chosen under vision from the thoracotomy incision while the left lung is held back by a retractor. The blunt forceps are passed through the pleura medial and anterior to the left subclavian artery, care being taken not to damage the innominate vein or the left vagus nerve. Once the opening has been made it can then be enlarged by passing Hegar's dilators from above. When the opening has been enlarged a long pair of blunt forceps is passed through from the neck incision and the proximal end of the free colon graft pulled through above the clavicle. The graft is then placed behind the lung hilum posteriorly in the pleural cavity, care being taken that it is not twisted and that the pedicle is lying without tension as it passes through the diaphragm. Some excess colon may have to be trimmed off in the neck so that it can be anastomosed to the cervical esophagus. Again a single layer bf interrupted silk is used. The anastomosis now lies deep in the neck in the normal line of the es()pb,,. agus. The incision in the diaphragm is now clostld'in one layer using inter-
COLONIC REPLACEMENT OF ESOPHAGUS
1445
rupted silk, and before the chest is closed the position and blood supply of the graft is checked. The ribs are approximated with interrupted pericostal fine catgut and a tube drain left in the pleural cavity through a separate stab incision. Postoperative Care
The gastrostomy must be kept open and attached to a small funnel about 5 cm. above the level of the stomach. These children tend to swallow air postoperatively and it is important to keep the stomach deflated. The negative pressure in the chest will cause some distention of the colon transplant for a few days postoperatively until it regains its normal tone and peristalsis. It is necessary therefore to keep a small soft rubber tube through the nostril into the colon in the chest. This tube is attached to an underwater seal beneath the bed; this will give enough negative pressure to prevent any distention of the colon graft. The child is fed intravenously for 48 hours after operation and thereafter gastrostomy feeds may be started and increased to normal amounts over 48 hours. The pleural drain may be removed in 48 hours; the tube in the colon may be removed after about three days and oral feeding should be started when this tube is removed. If the child was accustomed to taking food by mouth before operation then the change-over from gastrostomy to oral feeding should present no problem. When a full and adequate intake by mouth has been reached, then the gastrostomy feeds may be stopped. Advantages of This Type of Intrathoracic Replacement
1. When this type of replacement is used for atresia of the esophagus, the cardiac sphincter may be conserved and reflux prevented into the new esophagus. 2. A very good length of colon is obtained by using the ascending branch of the left colic artery as a pedicle. 3. The ileocecal valve is conserved ·and the remaining colon functions normally. 4. The new esophagus is isoperistaltic in position. 5. The upper anastomosis may be performed either in the neck where it lies in the normal position of the esophagus, or at any level in the thoracic cavity according to the available length of upper esophagus. 6. The cervical anastomosis is easier to perform when the replacement lies posteriorly than when it is brought out in the midline from behind the sternum. Results
Results are detailed in Table 1.
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DAYI)) WATERSTON
Table 1.. Results of Intrathoracic Esophageal Reconstruction (Patients Treated at The Hospital for Sick Children, Great Ormond Street, London) ALIVE
Esophageal atresia ......... 20 Peptic stricture ......... " 11 Congenital stricture. . . . . .. 1 Caustic stricture.. . . . . . . .. 3 TOTAL . • . . . . . . . . . . . . . 35
DEAD
5*
o o o 5
TOTAL
25 11 1
3 40
* Includes one case operated on in newborn period in an infant with mongolism.
It appears that the transplanted colon grows with the child and the late results are satisfactory (Fig. 2) .
Figure 2. Child now aged 12 years. Duodenal atresia, esophageal atresia without fistula, colon replacement of esophagus in 1952. This child now eats normally and has no symptoms.
COLONIC REPLACEMENT OF ESOPHAGUS
1447
Postoperative Complications ISCHEMIA OF TRANSPLANT. The five deaths in this series have all been due to ischemia of the transplant due to technical difficulties at the operation. All these patients showed symptoms of severe and rapidly fatal shock which did not respond to resuscitation. These deaths occurred early in the series and there have been no deaths in the last 20 cases. LEAKAGE AND STRICTURE FROM CERVICAL ANASTOMOSIS. Fifteen cases have had some leakage from the neck postoperatively; nearly all of these have healed spontaneously after two to three weeks but five have had to have a revision of this anastomosis either because of stricture formation or persistent leak. PYLOROSPASM. If the vagus nerves have been preserved while dissecting out the lower pouch of esophagus, there is no need to perform a pyloroplasty. If, however, there is evidence of pylorospasm postoperatively as evidenced by failure of the gastrostomy feedings to run in easily, then a formal pyloroplasty should be performed.
SUMMARY
A method of intrathoracic replacement of the esophagus using the transverse colon on a pedicle of the left colic artery is· described. The Hospital for Sick Children Great Ormond Street London W. C. 1, England