Motor activity after colon replacement of esophagus

J THORAC CARDIOVASC SURG 82:335-340, 1981

Original Communications

Motor activity after colon replacement of esophagus Manometric evaluation Motor activity of the colon transplant for esophageal reconstruction is a point of controversy. In this paper we present manometric studies carried out in 15 patients subjected to isoperistaltic colon interposition. Manometric studies were carried out with two polyvinyl water-jilled catheters inserted through pressure transducers. Basal colonic activity and motor activity following several stimuli and "dry swallows" were registered. The type of waves after stimuli were classified as (I) synchronous. (2) sequential or progressive, and (3) segmental. Details of the basal colonic waves and colon contractions after stimuli are given: i.e., rate, duration, amplitude, interval from the stimulus, and percentage of motor activity. The data reported here indicate the good motor response of the isoperistaltic colon to intraluminal injection of water or O. I N hydrochloric acid and to chachet swallowing. Only two free-symptoms patients did not have motor activity. One of them was submitted to manometric studies too soon after the operation. We conclude that the presence of sequential waves in the interposed segment likely can help to propel the contents of the colon into the stomach and to clear gastric juice if reflux from the stomach should occur.

Adolfo Benages, M.D.,* Eduardo Moreno-Ossett, M.D.,* Francisco Paris, M.D.,** Manuel T. Ridocci, M.D.,* Eduardo Blasco, M.D.,** Juan Pastor, M.D.,** Vicente Tarazona, M.D.,** Ramon Molina, M.D.,* and Francisco Mora, M.D.,* Valencia, Spain

Colon interposition is one of the accepted methods of esophageal reconstruction, especially after resection of benign disease of the esophagus.v" Motor activity of the colon transplant still remains controversial. In a small percentage of patients the swallowing process may be slow initially but may improve spontaneously From Centro Hospitalario "La Fe" and the University Hospital, Valencia, Spain. Received for publication Nov. 24, 1980. Accepted for publication Feb. 20, 1981. Address for reprints: Francisco Paris, M.D., Thoracic Surgery Service, Department of Surgery, Centro Hospita1ario "La Fe," Avenida Alferez Provisional 21. Valencia 9, Spain. *Esophageal Laboratory. University Hospital. **Service of Thoracic Surgery, Hospital "La Fe. "

after the early postoperative days. The late clinical results support colon interposition as the best esophageal substitute. I Early investigators':" denied the presence of motor activity in the transplanted colon segment. Further studies, however, demonstrated progressive waves in the interposed colon.v " This paper presents our manometric studies carried out in a series of colon replacements of the esophagus. Patients and method The study included 15 patients subjected to isoperistaltic transplantation of the colon, 11 male and four female subjects. The patients were between 7 and 71 years of age (mean 51 years). Clinical and operative data are shown in Table I. At the time of the study no

0022-5223/81/090335 +06$00.60/0 © 1981 The C. V. Mosby Co.

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Fig. 1. Two sequential colonic waves registered after injection of 30 ml of distilled water. PN, Pneumogram. Table I. Clinical and operative data Patient I 2

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M F M F F M M M F M M M M M M

Esophageal disease

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Level of anastomosis

Caustic stricture Caustic stricture Reflux stricture Reflux stricture Reflux stricture Reflux stricture Reflux stricture Reflux stricture Reflux stricture Reflux stricture Reflux stricture Middle third carcinoma Middle third carcinoma Middle third carcinoma Middle third carcinoma

Left Left Left Left Left Left Left Left Left Left Right Left Left Left Left

Middle esophagus, intrathoracic High esophagus, cervical Low esophagus, intrathora cic Low esophagus , intrathoracic Middle esophagus, intrathoracic Middle esophagus, intrathoracic Low esophagus, intrathoracic High esophagus, cerv ical Middle esophagus , intrathoracic Low esophagus, intrathoracic High esophagus, cervical High esophagu s, cerv ical Middle esophagus, intrathoracic High esophagus, cervical High esophagus, cervical

patients complained of dysphagia or clinical gastric reflux. Two patients had sensations of fullness after eating . After having an abdominocervical colon bypass for unresectable esophageal carcinoma, Patient 14 complained of severe anorexia and vomiting caused by peritoneal tumor implants producing partial obstruction at the duodenal level. Manometric studies were carried out with two polyvinyl water-filled open-tipped catheters, 1.5 mm inner diameter, inserted through pressure transducers (Hewlett-Packard Model 1280 C). Readings were taken at two points 5 em apart with the direct-writing Hewlett-Packard Model 7754 A recorder. The catheters were continuously perfused by a Harvard Model 975

Operat ion-study interval (mo) 36 8 60 30 24 14 12 12 6 6 6 14

3 2 1

pump at a rate of 0.3 mllmin. Baseline zero atmospheric pressure was adjusted by placing the transducers at the height of the midaxillary line with the patient in the supine position. The catheters were passed through the mouth into the colon and placed just above the diaphragm under fluoroscopic control . Basal colonic motor activity was registered for 10 minutes by measuring the habitual parameters of colonic waves: mean rate in minutes , mean duration in seconds, mean amplitude in millimeters of mercury, percentage of motor activity of the total observation time , and motility index as described by Connell, Avery-Jones, and Rowlands ." After this period of study, the colon was subjected to

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Colon replacement of esophagus

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Fig. 2. Four synchronous colonic waves registered after injection of 30 ml of distilled water. col ., Colon. PN , Pneumogram. A sterisk(*) indicates the start of the wave at two levels 5 cn apart.

Table II. Basal motor activity of the colon transplant: Details of parameters studied* Catheter level

Patients with motor activity

Mean of wave rate (min)

Mean wave duration (sec)

Mean wave amplitude (mm Hg)

Activity ( %)

Motility index

Proximal Distal

10/15 7/1 5

1.38 ± 0.63 0.82 ± 0.40

14.9 ± 3.24 16.9 ± 6.46

12.2 ± 7.75 16.8 ± 15.42

34 .3 ± 17.25 21.17 ± 10.02

447±47 1 252 ± 98. 1

• Mean and standard de viation of the total waves registered .

Table III. Colonic motor activity of patients after colon interposition in response to stimuli Intraluminal injection

No. of studied patient s

No . with sequential waves

No. with synchronous waves

No response

30 ml H20 30 ml 0. 1 N HCI

15 10 10

12 7 8

1* 1* 1*

2 2

Cachet swa llowi ng

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• Patient 14 had intraperitoneal tumor implants .

the following stimuli : (I ) intraluminal injection of 30 ml of distilled water adm inistered through an addit ional catheter placed 3 cm above the prox imal pressuremeasuring catheter; (2) intraluminal injection of 30 ml of O. I N hydrochloric acid ; and (3) swallowing of two empty pharmaceutical cachets at IO minute intervals. After these external stimuli , the patient was asked to make " dry swallows" of air and saliva, and pressures were recorded every 2 em as the catheter was pulled through the colon. Finally, the pressures were recorded every I cm from the esophagocolic anastomosi s to the pharyngoesophageal junction .

Colonic activity was studied for period s of IO mmutes following each stimulu s by recording the number of waves and the type of colonic activity generated. The types of responses after stimuli were classified by the system of Clark and associates tt as (1) sequential or progressive waves (Fig. 1), (2) synchronous waves when recorded simultaneously at two points 5 cm apart in the colon (Fig. 2), and (3) segmental waves when recorded in only one manometri c canal. The following details of the colon contractions were measured: (1) interval between the stimulus and colon response in seconds , (2) mean duration of waves in

338

The Journal of Thoracicand Cardiovascular Surgery

Benages et al.

Fig. 3. "Dry swallows" of only air and a small amount of saliva. Slight synchronous increase of pressure was registered in the colon transplant when the patient swallowed.

Table IV. Details of sequential colon contractions following colon stimuli* Interval stimulus-response (sec)

Stimuli Injection of 30 ml H.O Injection of 30 ml. 0.1 N HCI Cachet swallowing

Proximal catheter

85 ± 102.8

I

Distal catheter

Wave amplitude (mm Hg) Proximal catheter

I

Distal catheter

Wave duration (sec) Proximal catheter

90.8 ± 102.4

60.1 ± 16.6

81 ± 26.7

24 ± 8.3

70.2±11.7

74.5 ± 14.7

65.5 ± 17.1

91 ± 32.7

147.7 ± 157

154.1 ± 156

87.7 ± 31.5

68.2 ± 13

I

Distal catheter

Progressive rate (em/sec)

22.2 ± 6.03

1.1 ± 0.43

24.1 ± 6.9

23.1 ± 6.4

1.2 ± 0.67

26 ± 6.1

28 ± 4.9

0.96 ± 0.58

• Mean and standard deviation of the total registered waves. No significant differences in any figures.

seconds, (3) mean amplitude of waves in millimeters of mercury and (4) progressive rate expressed in centimeters per second.

Results Registered basal motor activity of the colon transplant is shown in Table II. Motor activity in this resting period was shown in 10 of 15 patients at the proximal, open-tipped catheter and in seven of 15 at the distal catheter. When patients were making "dry swallows," we found mild positive responses in six patients and no response to any swallowing in nine. A total of 220 "dry swallows" were performed, but in only 35 was a slight synchronous increase of pressure registered (Fig. 3). The colonic activity following the stimuli is shown in Tables III and IV. One example of a response to the injection of 30 ml of distilled water, showing two pro-

gressive waves, is seen in Fig. I. In 12 of 15 patients studied, sequential colonic response appeared after the injection of 0.1 N hydrochloric acid. Swallowing of a cachet produced sequential waves in eight of 10 patients studied. There was no response to stimuli in two patients. One had been operated upon I month before the manometric study was carried out and the other, 2 years before. Both patients were symptom free. Patient 14, who had peritoneal implants of an esophageal carcinoma producing obstruction in the duodenum, presented synchronous and antiperistaltic waves, probably an expression of secondary disordered motor activity of the colon. Motor activity through the esophagocolic anastomosis was studied in two patients. One catheter was placed in the esophagus proximal to the anastomosis

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Fig. 4. Motor activity through the esophagocolic anastomosis during "wet swallows ". When the patient swallowed a bolus of water the esophageal waves were followed by colonic waves. esoph ., Catheter in the esophagus. col., Catheter in the colon. W.S., Start of the wet swallow . PN, Pneumogram .

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Fig. s. Motor activity through the esophagocolic anastomosis during "dry swallows " by same patient as in Fig. 4, with the studies registered at the same level as in Fig. 4. The esophageal waves were not followed by colonic waves. esoph., Catheter in esophagus. col.. Catheter in colon . S, Swallowing . PN, Pneumogram.

and the other distally in the colon . In these two cases we found that when the patient swallowed a bolus of water . "wet swallows. " the esophageal wave registered in the proximal catheter was followed by a progressive colonic wave in the distal catheter (Fig. 4) . In "dry swallow" studies, no transmission of peristaltic

waves occurred between the esophagus and the transposed colonic segment (Fig . 5).

Discussion Preliminary studies of colon transplant motility using fluoroscopy, cineradiography, and manometric studies

The Journal of

340 Benages et at.

led to the conclusion that digestive transit through the colon was mainly passive depending on gravity. II Kelley'" concluded that the colon retains its ability to produce characteristic contractions. Later studies reported evidence of sequential waves in the interposed segment helping to propel ingested food and drink into the stomach and to clear the gastric juice if reflux from the stomach occurred. This controversy is important because, depending on the presence or absence of propulsive colonic motor activity in the correct direction, we must choose between isoperistaltic or antiperistaltic colon interposition. Belsey'" stated that the clinical long-term results of antiperistaltic transplantation seldom are entirely satisfactory to the patient. The data reported in this paper indicate the good motor response of the isoperistaltic colon to cachet swallowing and to the intraluminal injection of water or 0.1 N clorhydric acid solution. We have not found significant differences between the responses to the stimuli of water and 0.1 N hydrochloric acid. Only two patients have not had motor activity. One was subjected to manometric studies too early after operation, which might explain the failure to record motility. REFERENCES

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Belsey RH: Reconstruction of the esophagus with left colon. J THORAC CARDIOVASC SURG 49:33-35, 1965 Waterston D: Colonic replacement of esophagus. Surg Clin North Am 44: 1441-1447, 1964 Orsoni P, Toupet A: Utilisation de colon descendant et de la partie gauche du colon transverse pour I 'oesophagoplastie prethoracique, Presse Med 58:804, 1950 Reboud E, Rouzand E, Picaud R, Guerinei G: Utilisation du colon gauche dans la chirurgie de I 'oesophague. Mars Chir 5:669-678, 1966 Othersen HB, Clatworthy HW: Functional evaluation of

Thoracic and Cardiovascular Surgery

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