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Esophageal replacement in infants and children by colon interposition
Esophageal Replacement in Infants and Children By Colon Interposition
John R. Campbell, MD, Portland, Oregon Bruce R. Webber, MD, Portland, Oregon Marvin W. Harrison, MD, Portland, Oregon Timothy J. Campbell, MD, Portland, Oregon
Replacement of the esophagus is required in any referral center for pediatric surgery. Almost every method of esophageal substitution that has been described has been reported in infants and children. Atwell and Harrison [I] reported their experience with esophagogastrostomy in six pediatric patients with a 33 percent mortality rate, and Skinner [2] concludes that this technique is not acceptable in treating benign conditions. Gunning [3] reviewed an extensive experience with jejunal replacement, and it appears that this method is not suited to infants and children. Gastric tube esophagoplasty has several advocates, and an extensive experience has been reported in children [4-61. By far the most commonly used esophageal substitute in children is the colon ]7-241. Achieving a low complication rate with good functional results seems to depend on experience and the technique employed rather than on whether the stomach or colon is used for the substitute [15]. A specific operative strategy must be developed and continued with emphasis on meticulous technique. Intrathoracic colon interposition is a satisfactory means of substitution for a diseased esophagus in children. Material and Methods Retween 1966 and 1979, 23 colon interpositions were performed in 21 children at the Oregon Health Sciences IJniversity. The clinical records of these 21 patients were reviewed and form the basis for the present study.
Results As in most pediatric referral centers, the two most common conditions for which esophageal replacement was required were esophageal atresia and benign esophageal stricture caused by corrosive ingesCon. From the Department of Surgery, Division of Pediatric Surgery, School of Medicine. Oregon Health Sciences University, Portland, Oregon. Requests for reprints should be addressed to John R. Campbell, MD, Department of Surgery, Division of Pediatric Surgery, School of Medicine, Oregon Health Sciences University, 3181 SW. Sam Jackson Park Road, Portland, Oregon 97201. Presented at the 53rd Annual Meeting of the Pacific Coast Surgical Association, Napa, California, February 14-17, 1982.
Volume 144, July 1982
The largest group of patients consisted of 11 infants with esophageal atresia; 2 had no associated fistula, 1 had a proximal fistula, and 8 had a distal tracheoesophageal fistula. Primary anastomotic reconstruction was considered for all patients with esophageal anomalies. Nine underwent thoracotomy for esophageal atresia with proximal or distal fistula. When esophagoesophagostomy was not possible and esophageal substitution was necessary, division of the fistula, cervical esophagostomy, and gastrostomy were carried out. Primary repair was unsuccessful in three infants. The two patients with atresia without fistula were first considered for esophagoesophagostomy. When this was not possible, cervical esophagostomy and gastrostomy were performed. The average birth weight of the patients with esophageal atresia was 2,657 g. When colon interposition was undertaken their average weight was 9.1 kg and their average age 19 months. After esophageal substitution, only one patient had a decrease in the rate of weight gain. The other infants in the group maintained or increased in posit,ion on the growth curve (Figure 1). The second large group was the eight children who had corrosive strictures after ingestion of caustic material. These patients were treated initially with antibiotics and steroids and received an average of 20 esophageal dilatations before interposition of the colon. Esophageal substitution followed the injury by an average of 20 months, at which time the average age was 44 months. The average weight of patients in this group was 13.2 kg at the time of colon interposition. After esophageal substitution in this group, all but one patient maintained or increased in percentile of weight (Figure 1). Weight gain suggested catch-up growth in this group of patients. One child had an emetogenic esophageal perforation with extensive necrosis. A stricture in the remaining patient developed from retention of a foreign body in the esophagus for a long period. The surgical technique employed most often for primary substitution of the esophagus was that described by Waterston [7]. In 17 of 23 procedures this
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Campbell et al
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Figure 1. Change in age-related wetght percentile of patients with co/on interposition. Patients with esophageal atresia (/en) maintained position on the growth curve, while children with corrosive stricture (right) caught up after colon interposition.
technique was employed, using the transverse colon placed in a left intrathoracic position posterior to the hilum of the lung to reach the cervical esophagus (Figure 2). The blood supply was based on the left colic artery in every instance. One left colon segment was used and was placed in the left chest. Five of the esophageal substitutions were placed in the substernal position. Two of these operations were done to provide second replacements and three were substernal as the primary procedure. The right colon was used for four of the substernal placements. The distal anastomosis of the colon was to the stomach in all cases. This anastomosis was made to the posterior wall when the colon was placed intrathoracitally and to the anterior wall when placed substernally. The cervical anastomosis was performed at the initial operation in all but two instances. Appendectomy and gastrostomy were routinely performed in all patients. Pyloroplasty was carried out in 14, and pyloromyotomy in 6 patients. Because of gastric atony, one pyloromyotomy was revised to a pyloroplasty at a subsequent procedure. One patient had no drainage procedure and did not have delayed gastric emptying. The early complications of esophageal substitution are related primarily to perfusion of the graft segment of colon. These complications included cervical anastomotic leak in eight patients, pneumonia in two, decreased renal function in two, wound infection in two, and graft necrosis in four. Viability of the graft segment was considered marginal during four procedures. Two of these patients had failure of the graft, and one patient required late revision of a
30
Figure 2. The preferred position of the interposed segment of transverse colon for esophageal substitution. The segment is positioned behind the hi/urn of the left lung. Anastomosis to the esophagus is made in the neck and suspended and isolated there. Anastomosis to the stomach is made on the posterior surface of the fundus. This route is short and provides dependent drainage of the colon segment.
cervical stricture. Only one of the four patients with a marginal graft had no postoperative problems. One of the two patients with marginal graft viability accounted for the single death in this series. This occurred in a male patient who had tetralogy of Fallot, microcephaly, and esophageal atresia with a distal tracheoesophageal fistula. Cyanotic heart disease was not repaired before his esophageal replacement, and the necrotic graft was removed 3 days postoperatively. The course was complicated by Bacteroides peritonitis, splenic infarction, and congestive heart failure. He died 3 days after the graft had been removed. In two patients in whom the graft failed, no indication was present at the time of the surgery that the colon was not viable. Of the four patients with graft failure, two had second colon interpositions and one had a skin tube developed to substitute between the cervical esophagus and the colon in the mediastinum. The postoperative duration of hospitalization for all patients averaged 23 days. The duration of follow-up ranged from 1 to 11 years (average 5). Late complications included small bowel obstruction in 8 patients, dysphagia in 5, stricture in 4, symptomatic reflux, upper gastrointestinal hemorrhage, and poor gastric emptying in 1 each, psychological disturbances in 17, and family
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Esophageal Replacement
in 5. Eleven of’ the 20 surviving patients were followed up for 5 years or more. Preoperatively, 14 of’ I7 children were below the 10th percentile for weight. The patients with esophageal atresia lost an average of 1 percentile while t,hose with corrosive strictures gained an average of 12 percentiles (Figure 1) when weighed more t.han 1 year postoperatively. disturbances
Comments When esophageal substitution is required in children it has always been for benign disease. Because of their long life expectancy, the results of esophago:astrostomy appeared to preclude it as a serious choice [i?]. Likewise, jejunal interposition has had limited acc,eptance in children. Gavriliu [Is] reported experience with over 500 gastric tubes, and the procedure has been popularized in this country by Heimlich [17.18]. It is the procedure of choice in three large centers of pediatric surgery (4-6). By far the most, commonly employed operation in children, however, is colon interposition. Mortality in the present series was 4 percent (one t’atality). The patient who died had uncorrected cyanotic heart disease and would have been categorized a C risk by Wat,erston’s criteria. This carriers a poor prognosis [ 1.91.Were we to treat this patient again, we would not perform interposition until after cyanot ic heart disease had been corrected. Failure of the interposed colon segment has been linked with inadequate perfusion of the segment of colon. Two of the four graft failures had questionable viability of the co101~segment at the time of surgery. These were carefully observed and ultimately required resection of the interposed colon. The other twcl patients with colors segments considered to have marginal perfusion survived, one with an anastomotic leak and the other with no complication. In view of the survival of two of the four grafts considered marginal, these grafts should not be abandoned before viability is clearly defined. Inasmuch as three of four colon segments with marginal viability had complications of necrosis and leak of the anastomosis, a case can be made for delay of the esophagocoionic anastomosis until graft viability is assured. Anot,her approach might be to carry out a secondlook procedure at. 24 hours with the intention of removing the graft if it has failed. Two instances of graft failure and seven of eight esophagocolonic anastomotic leaks occurred in patients in whom the viability of the graft was not questionable. These results in the group with questionable viability and in the group with clinically satisfactory perfusion indicate that completion of the esophagocolonic anastomosis is appropriate when the technical precautions described are taken. Cervical anastomotic leaks are the most common complication in most series, with an incidence as high as 70 percent in one report [13]. Waterston [9] indi-
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by Colon Interposition
cates that one third of his patients had anastomotic leaks. When there is not graft failure, most leaks heal without development of a stricture if they are well drained. In t.his series there were four strictures, all preceded by cervical anastomotic leaks. While cervical anastomotic leaks occurred in about, one third of our patients in this series, no st,ricture has occurred since 197~0. Several technical details are important in minimizing the consequences of anastomotic leak and stricture. Nicks [ZO] concluded that effective mechanical bowel preparation is most important. He felt that the use of oral antibiotics permitted infection from altered flora. Beyond assuring a good vascular pedicle, providing a wide open thoracic inlet that does not lead to obstruction of venous drainage is very important [22]. Care is always taken IO secure the interposed segment to the clavicle or other structure at the newly creat,ed thoracic inlet to minimize tension on the anastomosis. The anastomosis is performed in such a way that should a leak occur it drains out the drain t.ract and not into the thorax. The anastomosis is done last t.o prolong the period of observing the viability of the graft. Anast.omosis to the stomach in each of the patients in this series presented no technical difficulty beyond the problems presented by acute graft necrosis, probably because of the proximal position of this anastomosis in relation to the vascular pedicle from the left colic artery. The most common long-term complication of surgery was intest,inal obstruction secondary t,o adhesions. Lengthy exposure of the abdominal viscera attendant with this procedure appears to be t.he most likely cause of the high incidence of adhesions as a cause of intestinal obstruction. As children realize the extent of their disease and restoration, there is often a conscious or unconscious feeling of dysfunction without, demonstrable mechanical cause. Dysphagia occurred in three of our patients in whom the barium swallow showed no evidence ofobstruction. In one patient these episodes could be correlated with parental strife. Modification of eating habits will alleviate dyfphagia in most patients. Patients can usually mlmmize sympt.oms by good mastication, admixing liquids with solids, and by not rushing through meals. I_Jntil a patient is old enough to understand the importance of good mastication, only food in small pieces should be offered. Remaining erect for approximately 1 hour after meals and not eating or drinking immediately before sleeping is also helpful in minimizing symptoms. Whether antiperistaltic or isoperistaltic in orientation, when the colon is used as an esophageal substitute it functions as a passive conduit 1621. Gastrocolic reflux is common if the gast.roesophageal junction has not been preserved [22]. Our single case of upper gastrointestinal bleeding occurred in a pat.ient, with a corrosive stricture 5
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Campbell et al
months before the performance of esophagectomy. Therefore, it is not established that the bleeding was from the interposed segment of colon. It is a rare complication not reported in many series and not proven to be from the colon interposed in this patient. Hemorrhage after colon interposition was the subject of a report by Stanley-Brown [23]. Of two cases, one was early and one late. Stress ulceration and peptic ulceration of the graft were theorized. The size of the patients in this group did not appear to have an effect on morbidity. Esophagocolonic anastomotic leaks and strictures were present in both the infants with esophageal atresia and in the children with strictures refractory to dilatation. Others have reported results with colon interposition in newborns [24]. Waterston [7] suggested that the 6 month old infant is large enough for convenient colon interposition. No infant weighing under 20 pounds underwent colon interposition in the present series. The timing of colon interposition in the patients who had corrosive strictures depended on the clinical judgment of failure of dilatation as the primary means of treatment. The dilatations and the judgment of failure were made by several different physicians and therefore were not uniform in application. The pattern of growth observed after colon interposition appeared related to the setting in which substitution of the esophagus was required. All but three of the patients were at or below the 10th percentile for weight according to age at the time of colon interposition (Figure 1). The infants with the background of esophageal atresia had little or no change in age-related weight. The patients with corrosive strictures tended to increase in percentile of weight related to age. Four patients (36 percent) with esophageal atresia had associated anomalies. One patient with cyanotic heart disease died and three patients grew poorly. The presence of these patients in this group may account for the apparent differences in growth among the groups. However, the specific anomalies present in these children cannot by themselves account for failure to thrive. Psychologic disturbances for both the child and the family are a frequent and difficult problem after colon interposition. It becomes necessary for the surgeon and supporting personnel to deal with the family members and patient as separate, interacting individuals. Each member’s separate and unique perspective of the disease process must be developed and understood for the family unit to act in a mutually supportive manner. Although all of our patients did not report problems, it is a serious adjustment for a child to grow and mature with a colon interposition. Social and physical retardation have been documented in several reports [1 ,I 1,221, but cannot be compared with any control group of unrepaired patients.
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Summary Colon replacement for the esophagus was used successfully in 20 of 21 pediatric patients. Intrathoracic placement of the colon segment was done in 18. Careful preparation and operative experience combined to reduce operative morbidity and mortality in an unfortunate group of patients. Satisfactory long-term results have been achieved. Careful technique, attention to detail, and perfection of a single technique may be more important than performing new surgical techniques when they are reported. Colon interposition performed by the Waterston technique utilizing the transverse colon is an effective means of substitution for a diseased esophagus in children. References 1. Atwell
2. 3.
4.
5. 6.
7. 8.
9. 10. 11.
12.
13.
14.
15.
16. 17. 18. 19.
JD, Harrison GSM. Observations on the role of esophagogastrostomy in infancy and childhood with particular reference to the long-term results and operative mortality. J Pediatr Surg 1980; 15:303-g. Skinner DB. Esophageal reconstruction. Am J Surg 1980; 139:810-4. Gunning AJ. The long term clinical state after resection with jejunal replacement. In: Smith RA, Smith RE, eds. Surgery of the oesophagus: the Coventry Conference. New York: Appleton-Century-Crofts, 1972:29-33. Anderson KD, Randolph JG. Gastric tube interposition: a satisfactory alternative to the colon for esophageal replacement in children. Ann Thorac Surg 1978;25:521-5. Cohen DH, Middleton AW, Fletcher J. Gastric tube esophagoplasty. J Pediatr Surg 1974;4:451-60. Ein SH, Shandling B, Simpson JS, Stephens CA, Vizas D. Fourteen years of gastric tubes. J Pediatr Surg 1978;13: 638-4 1. Waterston DJ. Colonic replacement of esophagus (intrathoracic). Surg Clin North Am 1964;44:1441-7. Azar t-i, Chrispin AR, Waterston DJ. Esophageal replacement with transverse colon in infants and children. J Pediatr Surg 1971;6:3-9. Waterston DJ. The long term clinical state after resection with colon replacement in children. In Ref 3:35-g. Gross RE, Firestone FN. Colonic reconstruction of the esophagus in infants and children. Surgery 1967;61:955-64. Othersen HB, Clatworthy HW. Functional evaluation of esophageal replacement in children. J Thorac Cardiovasc Surg 1967;53:55-63. Schiller M, Frye TR, Boles ET Jr. Evaluation of colonic replacement of the esophagus in children. J Pediatr Surg 1971;6:753-60. Blanchard H, Roy CC, Perreault G, et al. Retrosternal esophageal replacement in 18 children. Can J Surg 1972;15: 137-45. Rodgers BM, Talbert JF, Felman AH. Functional and metabolic evaluation of colon replacement of the esophagus in children. J Pediatr Surg 1978:13:35-g. Smith RA, Smith RE, eds. Surgery of the oesophagus: the Coventry Conference. New York: Appleton-Century-Crofts, 1972. Gavriliu D, Georgescue L. Esophagoplastie directa cu material gastric. Rev Stiint Med 1951;3:33-6. Heimlich HJ. Esophageal replacement with a reversed gastric tube. Dis Chest 1959;36:478-93. Heimlich HJ. Esophagoplasty with reversed gastric tube. Am J Surg 1972;123:8&91. Waterston DJ, Carter RE, Aberdeen E. Oesophageal atresia: tracheooesophageal fistula-a study of survival in 2 18 in-
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fants. Lancet 1962;1:819-22. 23. Nicks R. Colonic replacement of the oesophagus-some observations on infarction and wound leakage. Br J Surg 1967;54:124-8. 21. Chien KY, Wang PY, Lu KS. Esophagoplasty for corrosive stricture of the esophagus: an analysis of 60 cases. Ann Surg 1974;179:510-5. 22. Sieber AM, Sieber WK. Colon transplants as esophageal replacement: cineradiographic and manometric evaluation in children. Ann Surg 1968; 168: 116-22. 23. Stanley-Brown EG. Massive hemorrhage after colon interposition: early and late. J Pediatr Surg 1974;9:235-7. 24. White JJ. Early short segment left colon interposition for esophageal atresia. J Pediatr Surg 1976;11:735-8.
Discussion Alfred A. de Lorimier (San Francisco, CA): Esophageal substitution is a big subject because of the number of variables involved: (1) the indication for the procedure and the age of the patient, (2) the bowel segment to be used, (3) the position of the bowel substitute retrosternally or in the bed of the esophagus, (4) the position of the anastomosis proximally and distally, and (5) the necessity for and type of gastric emptying procedure. From a personal operative experience in a comparable number of children and from inheriting many patients in whom esophageal substitution was performed elsewhere, I am impressed that colon interposition in the bed of the esophagus is associated with the least number of functional problems. Dr. Campbell and his associates have emphasized this approach, and the critical analysis of their result is refreshing. Although the retrosternal bowel interposition is a shorter and technically easier operation than other approaches, my comparative follow-up evaluation shows that swallowing function is least satisfactory in these patients. One objection is the circuitous course required from the proximal esophagus around the trachea, which is associated with crowding of the thoracic inlet and produces a cosmetically unsightly bulging at the sternal area with swallowing. Fl;rthermore, there is invariably significant reflux back into the bowel interposition, because the distal end is at the level of the antrum. The combination of gastric peristalsis propelling the stomach contents from fundus to antrum and the gravity drainage from the interposition produces a yo-yoing of ingested food that may contribute to malabsorption, which is well-established in these patients, as well as dysphagia. 1do not believe the gastric tube is better than colon as an interposition. Although the integrity of the blood supply is theoretically better in the gastric tube, the incidence of cervical anastomotic leak and stricture is the same as in the colon. In addition, symptomatic gastric reflux seems to be greater with the gastric tube than with the colon interposition. The one indication for the gastric tube in preference to colon is poor anal sphincter control or a tendency to develop diarrhea. Waterston’s procedure of left thoracotomy and mobilization of the left colon through an incision at the costal margin of the diaphragm seems to be the best approach. The intraabdominal portion of the procedure can be easily done through a sixth intercostal space incision, and if necessary the thoracic inlet can be tunnelled by making another incision at the third or fourth intercostal space. If possible, I prefer to make the distal anastomosis in the
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144,Julv
1982
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by Colon Interposition
distal esophagus rather than the stomach. One disadvantage of the colon is a tendency to dilate and elongate with time, resulting in dysphagia. To avoid this the surgeon must not be timid in resecting a redundant lower segment of the colon so that the shortest possible tube is interposed. Dumping syndrome has been a problem in many of the children who had pyloroplasty. Because the interposition is a passive conduit, ingestion of solids usually necessitates swallowing liquids to propel the food down the conduit. Having to drink liquids makes dietary management of dumping very difficult. Therefore, preservation of the vagus nerve and avoidance of pyloroplasty is helpful. In Dragstet’s early experience with vagotomy alone for management of peptic ulcer, gastric retention occurred in only 20 percent of patients. There should be no apology for having to perform gastric drainage at a later date if gastric retention becomes a problem. I agree with Dr. Campbell and his co-authors that pyloromyotomy provides good drainage with no dumping. Esophageal atresia has accounted for about half of the indications for esophageal substitution in infants and children. We believe that interposition for treatment of esophageal atresia should be a rare phenomenon now. Even a long gap between the two ends of the esophagus can be eventually approximated by the technique of bougie elongation and multiple circumferential esophageal myotomies. Should an attempted primary anastomosis fail because of excessive tension, it is possible to oversew the two ends and return at a later date with esophagoesophagostomy. Although dysmotility and swallowing function are abnormal in esophageal atresia, the native esophagus is far better than an interposition of the other bowel segments for swallowing and reflux. Dr. Campbell and his group prefer the Waterston approach to’ esophageal substitution and emphasize the considerable learning curve required to obtain optimal results. We have been slower to adopt this approach, but after experiencing many different interposition procedures, we are convinced that the Waterston procedure is superior to any other in long-term functional results. These are difficult procedures which should be performed at referral centers by an experienced team that follows the course of these patients with analytic objectivity. John Lewis Cahill (Seattle, WA): I would like to put in a plug for the left colon substitution procedure as advocated by Mr. Waterston. A number of years ago I had an opportunity to spend some time with Mr. Waterston and was very impressed with the facility of the operation as performed by him and the long-term results. Many of these patients now are in their early twenties, and their growth and development has been very satisfactory. This prompted a review of a personal series with use of the left colon as substitution. There were no deaths in the series. One patient required reoperation because of failure of the graft. There were no early or late strictures, and the growth and development in these infants and children has been very satisfactory, wit,h the majority in the 80th to 90th percentile. The Waterston procedure is performed through the left chest with the anastomosis in the neck and utilizing, I think very importantly, the distal esophagus if possible so as to preserve the gastroesophageal junction. One of the advantages of the left intrathoracic colon is that the cardioesophageal sphincter is preserved. It is a one-stage
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procedure. A much better blood supply is available through the ascending branch of the left colic artery. It is an isoperistaltic conduit, and I believe that pyloroplasty is unnecessary. Eric W. Fonkalsrud (Los Angeles, CA): There are several methods of replacing the esophagus in children with esophageal atresia, caustic strictures, and various other problems, although esophageal replacement is generally performed less often than in previous years. I would like to indicate our favorable experience using the isoperistaltic right colon in a retrosternal approach since each of the preceding speakers took a stand in favor of the left colon in the left chest. There is increasing evidence that the colon, when used as an esophageal substitute, does have a mass contraction type of peristaltic action. It is not simply a conduit as was commonly believed a few years ago. The right colon does have an excellent blood supply for use in the chest, particularly in young children, and when placed in the retrosternal position seems to have less of a tendency to dilate than when placed in the left chest, providing the anterior mediastinum is not opened widely at operation. Also, it is a little more difficult to place the right colon in the left chest. The sternal head of the sternomastoid muscles should be detached and a segment of cartilage from the sternoclavicular junction removed to prevent pressure on the colon as it enters the neck. When placing the lower end of the colon onto the anterior surface of the stomach, this should be done high rather than near the pylorus in order to minimize reflux or obstruction. Lastly, many children who have colon interposition in childhood, particularly those with esophageal atresia, have esophageal dysmotility in the lower segment of the esophagus and frequently have reflux symptoms regardless of whether the lower esophagus is used for anastomosis or whether a colon interposition is used. One should perhaps consider doing at least pyloromotomy or pyloroplasty to minimize this type of reflux. Dr. Campbell, have you observed any peristaltic activity in the left colon interposition segments in your series? Robert C. Combs (Irvine, CA): Our essayists and others who do this work report the trouble with leakage in the neck and then stricture. We had such a case at the VA Hospital in Long Beach with a stricture that negated an otherwise successful operation. Our plastic surgeons took a segment of jejunum, cut it free, and anastomosed the artery to the transverse cervical artery and the vein to a vein lying nearby. We did an end-to-end anastomosis between the esophagus and the jejunum and between the
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jejunum and the remaining velous result.
good viable colon with a mar-
F. William Heer (San Francisco, CA): I have had occasion to work with Dr. Harry Bunke in esophageal replacement in San Francisco. Using the right colon, one has an excellent marginal artery. This is also true with the transverse colon in many instances. The authors reported 12 instances of critical vascular insufficiency in their experience, and I believe that many cervical vessels lend themselves in a stable field for microvascular anastomosis. Such an anastomosis to the terminal arcade will enhance the viability of this critical distal segment for the cervical anastomosis. I suggest you try this in the future as I think it will help with the vascular impairment problem. John R. Campbell (closing): Dr. de Lorimier has coined a phrase that well characterizes this series: the considerable learning curve. We certainly are doing things differently now than when we started this series in 1966. We would today perform distal anastomosis to the distal esophagus rather than to the posterior wall of the stomach if we had a distal esophagus that we thought was functional. We prefer pyloromyotomy to pyloroplasty since we believe that there is less dumping and that it is more functional. Dr. de Lorimier has pointed out that the need for this procedure should decrease in patients born with esophageal atresia when the newer approaches to this anomaly are employed. In our most recent experience the basic indication has been corrosive stricture of the esophagus. Dr. Cahill has pointed out the six advantages of the Waterston technique, and we subscribe to them. Our one death was in a cyanotic patient with tetralogy of Fallot in whom our cardiac surgeons preferred not to do the anatomic repair when there was a salivary fistula in the neck. Poor oxygenation in a transplant segment is not a good combination, and we learned that lesson early on our learning curve. Dr. Fonkalsrud has pointed out the utility of the right colon. We have found it a good segment in patients in whom the Waterston technique failed. We have not been impressed with the effectiveness of the mass contractions that are occasionally seen in these interposed colon segments. Dr. Combs and Dr. Heer, thank you for your comments about free jejunal grafts. We have not employed that technique in small children because the vessels have been so small. We have a considerable experience now at the Oregon Health Sciences University and Veterans Hospital with this technique in adults, but our patients were about 20 pounds and we think that the Waterston technique is preferable in patients of this size.
The American Journal of Surgery
John R. Campbell, MD, Portland, Oregon Bruce R. Webber, MD, Portland, Oregon Marvin W. Harrison, MD, Portland, Oregon Timothy J. Campbell, MD, Portland, Oregon
Replacement of the esophagus is required in any referral center for pediatric surgery. Almost every method of esophageal substitution that has been described has been reported in infants and children. Atwell and Harrison [I] reported their experience with esophagogastrostomy in six pediatric patients with a 33 percent mortality rate, and Skinner [2] concludes that this technique is not acceptable in treating benign conditions. Gunning [3] reviewed an extensive experience with jejunal replacement, and it appears that this method is not suited to infants and children. Gastric tube esophagoplasty has several advocates, and an extensive experience has been reported in children [4-61. By far the most commonly used esophageal substitute in children is the colon ]7-241. Achieving a low complication rate with good functional results seems to depend on experience and the technique employed rather than on whether the stomach or colon is used for the substitute [15]. A specific operative strategy must be developed and continued with emphasis on meticulous technique. Intrathoracic colon interposition is a satisfactory means of substitution for a diseased esophagus in children. Material and Methods Retween 1966 and 1979, 23 colon interpositions were performed in 21 children at the Oregon Health Sciences IJniversity. The clinical records of these 21 patients were reviewed and form the basis for the present study.
Results As in most pediatric referral centers, the two most common conditions for which esophageal replacement was required were esophageal atresia and benign esophageal stricture caused by corrosive ingesCon. From the Department of Surgery, Division of Pediatric Surgery, School of Medicine. Oregon Health Sciences University, Portland, Oregon. Requests for reprints should be addressed to John R. Campbell, MD, Department of Surgery, Division of Pediatric Surgery, School of Medicine, Oregon Health Sciences University, 3181 SW. Sam Jackson Park Road, Portland, Oregon 97201. Presented at the 53rd Annual Meeting of the Pacific Coast Surgical Association, Napa, California, February 14-17, 1982.
Volume 144, July 1982
The largest group of patients consisted of 11 infants with esophageal atresia; 2 had no associated fistula, 1 had a proximal fistula, and 8 had a distal tracheoesophageal fistula. Primary anastomotic reconstruction was considered for all patients with esophageal anomalies. Nine underwent thoracotomy for esophageal atresia with proximal or distal fistula. When esophagoesophagostomy was not possible and esophageal substitution was necessary, division of the fistula, cervical esophagostomy, and gastrostomy were carried out. Primary repair was unsuccessful in three infants. The two patients with atresia without fistula were first considered for esophagoesophagostomy. When this was not possible, cervical esophagostomy and gastrostomy were performed. The average birth weight of the patients with esophageal atresia was 2,657 g. When colon interposition was undertaken their average weight was 9.1 kg and their average age 19 months. After esophageal substitution, only one patient had a decrease in the rate of weight gain. The other infants in the group maintained or increased in posit,ion on the growth curve (Figure 1). The second large group was the eight children who had corrosive strictures after ingestion of caustic material. These patients were treated initially with antibiotics and steroids and received an average of 20 esophageal dilatations before interposition of the colon. Esophageal substitution followed the injury by an average of 20 months, at which time the average age was 44 months. The average weight of patients in this group was 13.2 kg at the time of colon interposition. After esophageal substitution in this group, all but one patient maintained or increased in percentile of weight (Figure 1). Weight gain suggested catch-up growth in this group of patients. One child had an emetogenic esophageal perforation with extensive necrosis. A stricture in the remaining patient developed from retention of a foreign body in the esophagus for a long period. The surgical technique employed most often for primary substitution of the esophagus was that described by Waterston [7]. In 17 of 23 procedures this
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5c
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4c
=? c p 30 2 d 5 f
\
20
8
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Postop
Figure 1. Change in age-related wetght percentile of patients with co/on interposition. Patients with esophageal atresia (/en) maintained position on the growth curve, while children with corrosive stricture (right) caught up after colon interposition.
technique was employed, using the transverse colon placed in a left intrathoracic position posterior to the hilum of the lung to reach the cervical esophagus (Figure 2). The blood supply was based on the left colic artery in every instance. One left colon segment was used and was placed in the left chest. Five of the esophageal substitutions were placed in the substernal position. Two of these operations were done to provide second replacements and three were substernal as the primary procedure. The right colon was used for four of the substernal placements. The distal anastomosis of the colon was to the stomach in all cases. This anastomosis was made to the posterior wall when the colon was placed intrathoracitally and to the anterior wall when placed substernally. The cervical anastomosis was performed at the initial operation in all but two instances. Appendectomy and gastrostomy were routinely performed in all patients. Pyloroplasty was carried out in 14, and pyloromyotomy in 6 patients. Because of gastric atony, one pyloromyotomy was revised to a pyloroplasty at a subsequent procedure. One patient had no drainage procedure and did not have delayed gastric emptying. The early complications of esophageal substitution are related primarily to perfusion of the graft segment of colon. These complications included cervical anastomotic leak in eight patients, pneumonia in two, decreased renal function in two, wound infection in two, and graft necrosis in four. Viability of the graft segment was considered marginal during four procedures. Two of these patients had failure of the graft, and one patient required late revision of a
30
Figure 2. The preferred position of the interposed segment of transverse colon for esophageal substitution. The segment is positioned behind the hi/urn of the left lung. Anastomosis to the esophagus is made in the neck and suspended and isolated there. Anastomosis to the stomach is made on the posterior surface of the fundus. This route is short and provides dependent drainage of the colon segment.
cervical stricture. Only one of the four patients with a marginal graft had no postoperative problems. One of the two patients with marginal graft viability accounted for the single death in this series. This occurred in a male patient who had tetralogy of Fallot, microcephaly, and esophageal atresia with a distal tracheoesophageal fistula. Cyanotic heart disease was not repaired before his esophageal replacement, and the necrotic graft was removed 3 days postoperatively. The course was complicated by Bacteroides peritonitis, splenic infarction, and congestive heart failure. He died 3 days after the graft had been removed. In two patients in whom the graft failed, no indication was present at the time of the surgery that the colon was not viable. Of the four patients with graft failure, two had second colon interpositions and one had a skin tube developed to substitute between the cervical esophagus and the colon in the mediastinum. The postoperative duration of hospitalization for all patients averaged 23 days. The duration of follow-up ranged from 1 to 11 years (average 5). Late complications included small bowel obstruction in 8 patients, dysphagia in 5, stricture in 4, symptomatic reflux, upper gastrointestinal hemorrhage, and poor gastric emptying in 1 each, psychological disturbances in 17, and family
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in 5. Eleven of’ the 20 surviving patients were followed up for 5 years or more. Preoperatively, 14 of’ I7 children were below the 10th percentile for weight. The patients with esophageal atresia lost an average of 1 percentile while t,hose with corrosive strictures gained an average of 12 percentiles (Figure 1) when weighed more t.han 1 year postoperatively. disturbances
Comments When esophageal substitution is required in children it has always been for benign disease. Because of their long life expectancy, the results of esophago:astrostomy appeared to preclude it as a serious choice [i?]. Likewise, jejunal interposition has had limited acc,eptance in children. Gavriliu [Is] reported experience with over 500 gastric tubes, and the procedure has been popularized in this country by Heimlich [17.18]. It is the procedure of choice in three large centers of pediatric surgery (4-6). By far the most, commonly employed operation in children, however, is colon interposition. Mortality in the present series was 4 percent (one t’atality). The patient who died had uncorrected cyanotic heart disease and would have been categorized a C risk by Wat,erston’s criteria. This carriers a poor prognosis [ 1.91.Were we to treat this patient again, we would not perform interposition until after cyanot ic heart disease had been corrected. Failure of the interposed colon segment has been linked with inadequate perfusion of the segment of colon. Two of the four graft failures had questionable viability of the co101~segment at the time of surgery. These were carefully observed and ultimately required resection of the interposed colon. The other twcl patients with colors segments considered to have marginal perfusion survived, one with an anastomotic leak and the other with no complication. In view of the survival of two of the four grafts considered marginal, these grafts should not be abandoned before viability is clearly defined. Inasmuch as three of four colon segments with marginal viability had complications of necrosis and leak of the anastomosis, a case can be made for delay of the esophagocoionic anastomosis until graft viability is assured. Anot,her approach might be to carry out a secondlook procedure at. 24 hours with the intention of removing the graft if it has failed. Two instances of graft failure and seven of eight esophagocolonic anastomotic leaks occurred in patients in whom the viability of the graft was not questionable. These results in the group with questionable viability and in the group with clinically satisfactory perfusion indicate that completion of the esophagocolonic anastomosis is appropriate when the technical precautions described are taken. Cervical anastomotic leaks are the most common complication in most series, with an incidence as high as 70 percent in one report [13]. Waterston [9] indi-
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cates that one third of his patients had anastomotic leaks. When there is not graft failure, most leaks heal without development of a stricture if they are well drained. In t.his series there were four strictures, all preceded by cervical anastomotic leaks. While cervical anastomotic leaks occurred in about, one third of our patients in this series, no st,ricture has occurred since 197~0. Several technical details are important in minimizing the consequences of anastomotic leak and stricture. Nicks [ZO] concluded that effective mechanical bowel preparation is most important. He felt that the use of oral antibiotics permitted infection from altered flora. Beyond assuring a good vascular pedicle, providing a wide open thoracic inlet that does not lead to obstruction of venous drainage is very important [22]. Care is always taken IO secure the interposed segment to the clavicle or other structure at the newly creat,ed thoracic inlet to minimize tension on the anastomosis. The anastomosis is performed in such a way that should a leak occur it drains out the drain t.ract and not into the thorax. The anastomosis is done last t.o prolong the period of observing the viability of the graft. Anast.omosis to the stomach in each of the patients in this series presented no technical difficulty beyond the problems presented by acute graft necrosis, probably because of the proximal position of this anastomosis in relation to the vascular pedicle from the left colic artery. The most common long-term complication of surgery was intest,inal obstruction secondary t,o adhesions. Lengthy exposure of the abdominal viscera attendant with this procedure appears to be t.he most likely cause of the high incidence of adhesions as a cause of intestinal obstruction. As children realize the extent of their disease and restoration, there is often a conscious or unconscious feeling of dysfunction without, demonstrable mechanical cause. Dysphagia occurred in three of our patients in whom the barium swallow showed no evidence ofobstruction. In one patient these episodes could be correlated with parental strife. Modification of eating habits will alleviate dyfphagia in most patients. Patients can usually mlmmize sympt.oms by good mastication, admixing liquids with solids, and by not rushing through meals. I_Jntil a patient is old enough to understand the importance of good mastication, only food in small pieces should be offered. Remaining erect for approximately 1 hour after meals and not eating or drinking immediately before sleeping is also helpful in minimizing symptoms. Whether antiperistaltic or isoperistaltic in orientation, when the colon is used as an esophageal substitute it functions as a passive conduit 1621. Gastrocolic reflux is common if the gast.roesophageal junction has not been preserved [22]. Our single case of upper gastrointestinal bleeding occurred in a pat.ient, with a corrosive stricture 5
31
Campbell et al
months before the performance of esophagectomy. Therefore, it is not established that the bleeding was from the interposed segment of colon. It is a rare complication not reported in many series and not proven to be from the colon interposed in this patient. Hemorrhage after colon interposition was the subject of a report by Stanley-Brown [23]. Of two cases, one was early and one late. Stress ulceration and peptic ulceration of the graft were theorized. The size of the patients in this group did not appear to have an effect on morbidity. Esophagocolonic anastomotic leaks and strictures were present in both the infants with esophageal atresia and in the children with strictures refractory to dilatation. Others have reported results with colon interposition in newborns [24]. Waterston [7] suggested that the 6 month old infant is large enough for convenient colon interposition. No infant weighing under 20 pounds underwent colon interposition in the present series. The timing of colon interposition in the patients who had corrosive strictures depended on the clinical judgment of failure of dilatation as the primary means of treatment. The dilatations and the judgment of failure were made by several different physicians and therefore were not uniform in application. The pattern of growth observed after colon interposition appeared related to the setting in which substitution of the esophagus was required. All but three of the patients were at or below the 10th percentile for weight according to age at the time of colon interposition (Figure 1). The infants with the background of esophageal atresia had little or no change in age-related weight. The patients with corrosive strictures tended to increase in percentile of weight related to age. Four patients (36 percent) with esophageal atresia had associated anomalies. One patient with cyanotic heart disease died and three patients grew poorly. The presence of these patients in this group may account for the apparent differences in growth among the groups. However, the specific anomalies present in these children cannot by themselves account for failure to thrive. Psychologic disturbances for both the child and the family are a frequent and difficult problem after colon interposition. It becomes necessary for the surgeon and supporting personnel to deal with the family members and patient as separate, interacting individuals. Each member’s separate and unique perspective of the disease process must be developed and understood for the family unit to act in a mutually supportive manner. Although all of our patients did not report problems, it is a serious adjustment for a child to grow and mature with a colon interposition. Social and physical retardation have been documented in several reports [1 ,I 1,221, but cannot be compared with any control group of unrepaired patients.
32
Summary Colon replacement for the esophagus was used successfully in 20 of 21 pediatric patients. Intrathoracic placement of the colon segment was done in 18. Careful preparation and operative experience combined to reduce operative morbidity and mortality in an unfortunate group of patients. Satisfactory long-term results have been achieved. Careful technique, attention to detail, and perfection of a single technique may be more important than performing new surgical techniques when they are reported. Colon interposition performed by the Waterston technique utilizing the transverse colon is an effective means of substitution for a diseased esophagus in children. References 1. Atwell
2. 3.
4.
5. 6.
7. 8.
9. 10. 11.
12.
13.
14.
15.
16. 17. 18. 19.
JD, Harrison GSM. Observations on the role of esophagogastrostomy in infancy and childhood with particular reference to the long-term results and operative mortality. J Pediatr Surg 1980; 15:303-g. Skinner DB. Esophageal reconstruction. Am J Surg 1980; 139:810-4. Gunning AJ. The long term clinical state after resection with jejunal replacement. In: Smith RA, Smith RE, eds. Surgery of the oesophagus: the Coventry Conference. New York: Appleton-Century-Crofts, 1972:29-33. Anderson KD, Randolph JG. Gastric tube interposition: a satisfactory alternative to the colon for esophageal replacement in children. Ann Thorac Surg 1978;25:521-5. Cohen DH, Middleton AW, Fletcher J. Gastric tube esophagoplasty. J Pediatr Surg 1974;4:451-60. Ein SH, Shandling B, Simpson JS, Stephens CA, Vizas D. Fourteen years of gastric tubes. J Pediatr Surg 1978;13: 638-4 1. Waterston DJ. Colonic replacement of esophagus (intrathoracic). Surg Clin North Am 1964;44:1441-7. Azar t-i, Chrispin AR, Waterston DJ. Esophageal replacement with transverse colon in infants and children. J Pediatr Surg 1971;6:3-9. Waterston DJ. The long term clinical state after resection with colon replacement in children. In Ref 3:35-g. Gross RE, Firestone FN. Colonic reconstruction of the esophagus in infants and children. Surgery 1967;61:955-64. Othersen HB, Clatworthy HW. Functional evaluation of esophageal replacement in children. J Thorac Cardiovasc Surg 1967;53:55-63. Schiller M, Frye TR, Boles ET Jr. Evaluation of colonic replacement of the esophagus in children. J Pediatr Surg 1971;6:753-60. Blanchard H, Roy CC, Perreault G, et al. Retrosternal esophageal replacement in 18 children. Can J Surg 1972;15: 137-45. Rodgers BM, Talbert JF, Felman AH. Functional and metabolic evaluation of colon replacement of the esophagus in children. J Pediatr Surg 1978:13:35-g. Smith RA, Smith RE, eds. Surgery of the oesophagus: the Coventry Conference. New York: Appleton-Century-Crofts, 1972. Gavriliu D, Georgescue L. Esophagoplastie directa cu material gastric. Rev Stiint Med 1951;3:33-6. Heimlich HJ. Esophageal replacement with a reversed gastric tube. Dis Chest 1959;36:478-93. Heimlich HJ. Esophagoplasty with reversed gastric tube. Am J Surg 1972;123:8&91. Waterston DJ, Carter RE, Aberdeen E. Oesophageal atresia: tracheooesophageal fistula-a study of survival in 2 18 in-
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fants. Lancet 1962;1:819-22. 23. Nicks R. Colonic replacement of the oesophagus-some observations on infarction and wound leakage. Br J Surg 1967;54:124-8. 21. Chien KY, Wang PY, Lu KS. Esophagoplasty for corrosive stricture of the esophagus: an analysis of 60 cases. Ann Surg 1974;179:510-5. 22. Sieber AM, Sieber WK. Colon transplants as esophageal replacement: cineradiographic and manometric evaluation in children. Ann Surg 1968; 168: 116-22. 23. Stanley-Brown EG. Massive hemorrhage after colon interposition: early and late. J Pediatr Surg 1974;9:235-7. 24. White JJ. Early short segment left colon interposition for esophageal atresia. J Pediatr Surg 1976;11:735-8.
Discussion Alfred A. de Lorimier (San Francisco, CA): Esophageal substitution is a big subject because of the number of variables involved: (1) the indication for the procedure and the age of the patient, (2) the bowel segment to be used, (3) the position of the bowel substitute retrosternally or in the bed of the esophagus, (4) the position of the anastomosis proximally and distally, and (5) the necessity for and type of gastric emptying procedure. From a personal operative experience in a comparable number of children and from inheriting many patients in whom esophageal substitution was performed elsewhere, I am impressed that colon interposition in the bed of the esophagus is associated with the least number of functional problems. Dr. Campbell and his associates have emphasized this approach, and the critical analysis of their result is refreshing. Although the retrosternal bowel interposition is a shorter and technically easier operation than other approaches, my comparative follow-up evaluation shows that swallowing function is least satisfactory in these patients. One objection is the circuitous course required from the proximal esophagus around the trachea, which is associated with crowding of the thoracic inlet and produces a cosmetically unsightly bulging at the sternal area with swallowing. Fl;rthermore, there is invariably significant reflux back into the bowel interposition, because the distal end is at the level of the antrum. The combination of gastric peristalsis propelling the stomach contents from fundus to antrum and the gravity drainage from the interposition produces a yo-yoing of ingested food that may contribute to malabsorption, which is well-established in these patients, as well as dysphagia. 1do not believe the gastric tube is better than colon as an interposition. Although the integrity of the blood supply is theoretically better in the gastric tube, the incidence of cervical anastomotic leak and stricture is the same as in the colon. In addition, symptomatic gastric reflux seems to be greater with the gastric tube than with the colon interposition. The one indication for the gastric tube in preference to colon is poor anal sphincter control or a tendency to develop diarrhea. Waterston’s procedure of left thoracotomy and mobilization of the left colon through an incision at the costal margin of the diaphragm seems to be the best approach. The intraabdominal portion of the procedure can be easily done through a sixth intercostal space incision, and if necessary the thoracic inlet can be tunnelled by making another incision at the third or fourth intercostal space. If possible, I prefer to make the distal anastomosis in the
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1982
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distal esophagus rather than the stomach. One disadvantage of the colon is a tendency to dilate and elongate with time, resulting in dysphagia. To avoid this the surgeon must not be timid in resecting a redundant lower segment of the colon so that the shortest possible tube is interposed. Dumping syndrome has been a problem in many of the children who had pyloroplasty. Because the interposition is a passive conduit, ingestion of solids usually necessitates swallowing liquids to propel the food down the conduit. Having to drink liquids makes dietary management of dumping very difficult. Therefore, preservation of the vagus nerve and avoidance of pyloroplasty is helpful. In Dragstet’s early experience with vagotomy alone for management of peptic ulcer, gastric retention occurred in only 20 percent of patients. There should be no apology for having to perform gastric drainage at a later date if gastric retention becomes a problem. I agree with Dr. Campbell and his co-authors that pyloromyotomy provides good drainage with no dumping. Esophageal atresia has accounted for about half of the indications for esophageal substitution in infants and children. We believe that interposition for treatment of esophageal atresia should be a rare phenomenon now. Even a long gap between the two ends of the esophagus can be eventually approximated by the technique of bougie elongation and multiple circumferential esophageal myotomies. Should an attempted primary anastomosis fail because of excessive tension, it is possible to oversew the two ends and return at a later date with esophagoesophagostomy. Although dysmotility and swallowing function are abnormal in esophageal atresia, the native esophagus is far better than an interposition of the other bowel segments for swallowing and reflux. Dr. Campbell and his group prefer the Waterston approach to’ esophageal substitution and emphasize the considerable learning curve required to obtain optimal results. We have been slower to adopt this approach, but after experiencing many different interposition procedures, we are convinced that the Waterston procedure is superior to any other in long-term functional results. These are difficult procedures which should be performed at referral centers by an experienced team that follows the course of these patients with analytic objectivity. John Lewis Cahill (Seattle, WA): I would like to put in a plug for the left colon substitution procedure as advocated by Mr. Waterston. A number of years ago I had an opportunity to spend some time with Mr. Waterston and was very impressed with the facility of the operation as performed by him and the long-term results. Many of these patients now are in their early twenties, and their growth and development has been very satisfactory. This prompted a review of a personal series with use of the left colon as substitution. There were no deaths in the series. One patient required reoperation because of failure of the graft. There were no early or late strictures, and the growth and development in these infants and children has been very satisfactory, wit,h the majority in the 80th to 90th percentile. The Waterston procedure is performed through the left chest with the anastomosis in the neck and utilizing, I think very importantly, the distal esophagus if possible so as to preserve the gastroesophageal junction. One of the advantages of the left intrathoracic colon is that the cardioesophageal sphincter is preserved. It is a one-stage
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Campbell et al
procedure. A much better blood supply is available through the ascending branch of the left colic artery. It is an isoperistaltic conduit, and I believe that pyloroplasty is unnecessary. Eric W. Fonkalsrud (Los Angeles, CA): There are several methods of replacing the esophagus in children with esophageal atresia, caustic strictures, and various other problems, although esophageal replacement is generally performed less often than in previous years. I would like to indicate our favorable experience using the isoperistaltic right colon in a retrosternal approach since each of the preceding speakers took a stand in favor of the left colon in the left chest. There is increasing evidence that the colon, when used as an esophageal substitute, does have a mass contraction type of peristaltic action. It is not simply a conduit as was commonly believed a few years ago. The right colon does have an excellent blood supply for use in the chest, particularly in young children, and when placed in the retrosternal position seems to have less of a tendency to dilate than when placed in the left chest, providing the anterior mediastinum is not opened widely at operation. Also, it is a little more difficult to place the right colon in the left chest. The sternal head of the sternomastoid muscles should be detached and a segment of cartilage from the sternoclavicular junction removed to prevent pressure on the colon as it enters the neck. When placing the lower end of the colon onto the anterior surface of the stomach, this should be done high rather than near the pylorus in order to minimize reflux or obstruction. Lastly, many children who have colon interposition in childhood, particularly those with esophageal atresia, have esophageal dysmotility in the lower segment of the esophagus and frequently have reflux symptoms regardless of whether the lower esophagus is used for anastomosis or whether a colon interposition is used. One should perhaps consider doing at least pyloromotomy or pyloroplasty to minimize this type of reflux. Dr. Campbell, have you observed any peristaltic activity in the left colon interposition segments in your series? Robert C. Combs (Irvine, CA): Our essayists and others who do this work report the trouble with leakage in the neck and then stricture. We had such a case at the VA Hospital in Long Beach with a stricture that negated an otherwise successful operation. Our plastic surgeons took a segment of jejunum, cut it free, and anastomosed the artery to the transverse cervical artery and the vein to a vein lying nearby. We did an end-to-end anastomosis between the esophagus and the jejunum and between the
34
jejunum and the remaining velous result.
good viable colon with a mar-
F. William Heer (San Francisco, CA): I have had occasion to work with Dr. Harry Bunke in esophageal replacement in San Francisco. Using the right colon, one has an excellent marginal artery. This is also true with the transverse colon in many instances. The authors reported 12 instances of critical vascular insufficiency in their experience, and I believe that many cervical vessels lend themselves in a stable field for microvascular anastomosis. Such an anastomosis to the terminal arcade will enhance the viability of this critical distal segment for the cervical anastomosis. I suggest you try this in the future as I think it will help with the vascular impairment problem. John R. Campbell (closing): Dr. de Lorimier has coined a phrase that well characterizes this series: the considerable learning curve. We certainly are doing things differently now than when we started this series in 1966. We would today perform distal anastomosis to the distal esophagus rather than to the posterior wall of the stomach if we had a distal esophagus that we thought was functional. We prefer pyloromyotomy to pyloroplasty since we believe that there is less dumping and that it is more functional. Dr. de Lorimier has pointed out that the need for this procedure should decrease in patients born with esophageal atresia when the newer approaches to this anomaly are employed. In our most recent experience the basic indication has been corrosive stricture of the esophagus. Dr. Cahill has pointed out the six advantages of the Waterston technique, and we subscribe to them. Our one death was in a cyanotic patient with tetralogy of Fallot in whom our cardiac surgeons preferred not to do the anatomic repair when there was a salivary fistula in the neck. Poor oxygenation in a transplant segment is not a good combination, and we learned that lesson early on our learning curve. Dr. Fonkalsrud has pointed out the utility of the right colon. We have found it a good segment in patients in whom the Waterston technique failed. We have not been impressed with the effectiveness of the mass contractions that are occasionally seen in these interposed colon segments. Dr. Combs and Dr. Heer, thank you for your comments about free jejunal grafts. We have not employed that technique in small children because the vessels have been so small. We have a considerable experience now at the Oregon Health Sciences University and Veterans Hospital with this technique in adults, but our patients were about 20 pounds and we think that the Waterston technique is preferable in patients of this size.
The American Journal of Surgery