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Radionuclide transit in patients with colon interposition
J
THoRAc CARDIOVASC SURG
1987;94:521-5
Radionuclide transit in patients with colon interposition To assess radionuclide transit in interposed segments of the colon, we examined 25 patients with colon interposition for benign esophageal disease. No such assessment has been reported previously. The most common indications for operation were esophageal strictures that developed after lye ingestion and reflux strictures not responding to other treatment. The operations were performed without thoracotomy by blunt esophageal dissection in 80 % of the patients. There were 18 antiperistaltic and seven isoperistaltic colon grafts. A large-field gamma camera and computer system were used. Data were collected at time intervals of 0.5 second during the first 30 seconds and at intervals of 30 seconds up to 20 minutes. The 5 % and 90 % stomach filling times, times to 50 % and 25 % activity levels, and residual activity levels as a percentage of the maxima were calculated in the upper, middle, and lower thirds of the colon grafts and of tbe normal esophagus of 10 healthy control subjects. The examinations were performed with the subject in a sitting position. AU parameters showed that emptying of the colon graft was markedly slower than that of tbe normal esophagus. The intra-abdominal third of the graft had a residual activity of 50.5% ± 15.7% after 20 minutes' observation. No differences between antiperistaltic and isoperistaltic grafts were observed. Reconstruction with proximal cologastric anastomosis and a short intra-adbominal colon graft segments is suggested.
Jouko Isolauri, M.D., Matti O. Koskinen, Ph.D., and Hannu Markkula, M.D.,
Tampere, Finland
Long-segment colon interposition is a well-established procedure in preserving esophageal continuity after resection, especially for benign esophageal disease.!? Long-term results have been mainly good and late complications, including development of primary colonic disease in the interposed segment and reflux colitis, are seldom reported.!" Although motor activity as a response to an acid infusion has been reported, the interposed colon is believed to act mainly as a passive conduit.I, 10-12 The patients usually are not able to drink or eat in a supine position, and recumbency for 1 to 3 hours after eating is not possible without a sense of regurgitation in many cases. Both of these observations point to a delayed emptying of the colon graft. The purposeof this study was to evaluate the emptying of the colon graft by measuring the radionuclide bolus transit From the Departments of Surgery (Drs. Isolauri and Markkula) and Clinical Physiology (Dr. Koskinen), Tampere University Central Hospital, Tampere, Finland. Received for publication July 29, 1986. Accepted for publication Oct. 7, 1986. Address for reprints: Jouko Isolauri, M.D., Department of Surgery, Tampere University Central Hospital, SF-33520 Tampere, Finland.
time in patients with colon interposition for benign esophageal disease. Patients and methods
During a 22 year period (March 1964 to March 1985) 60 patients underwent colon interposition for benign esophageal disease in Tampere University Central Hospital. By 1985, 14 patients had died of causes not related to colon interposition. The study group consisted of 25 cooperative patients with antiperistaltic and isoperistaltic, retrosternal, and posterior mediastinal colon grafts. There were limen and 14 women with a mean age of 60 years (range 34 to 76) at examination. The most common indication for operation was esophageal stricture that had developed after lye ingestion and had not responded to other treatment (Table I). The mean time from the operation to the examination was 61 months (range 5 to 175). The operation was performed without thoracotomy by blunt esophageal dissection in 20 patients. In the remainder a right thoracotomy and upper midline abdominal incision were used. There were no bypass operations and all the operations except two were performed in one stage. The segment to be interposed was from the left colon 521
The Journal of Thoracic and Cardiovascular Surgery
522 Isolauri, Koskinen, Markkula
1000 r - - - - - - - - - - - - - - - - - ,
>20 18
o
0
16
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o = Colon grafts (n=2S1
0= Controls (n=10)
o = Controls (n=10l
Fig. 1. The 5% stomach filling time. In two patients of the study group the time exceeded 20 seconds, being 30 and 40 seconds.
Table I. Causes of the benign esophageal disease No.
%
Lye corrosion Reflux stricture Other corrosion Other
12 2 5
48 24 8 20
Total
25
100
6
in 18 patients and from the right colon and colon transversum in four and three patients. There were seven isoperistaltic and 18 antiperistaltic colon grafts. In five patients the colon graft was placed retrosternally. All other grafts were in the posterior mediastinal space. The cologastric anastomosis was placed to the anterior antrum. An intra-abdominal loop of the graft above the cologastric anastomosis was left. Pyloroplasty was performed in each case. On examination none of the patients had dysphagia. Five patients had no symptoms of regurgitation. By sleeping in a half-sitting position and avoiding recumbency for 1 to 3 hours after eating, 16 patients could avoid these symptoms. Four patients had uncontrollable symptoms of regurgitation. The control group consisted of 10 normal volunteers (eight men and two women) with no symptoms or past history suggestive of any upper gastrointestinal tract disorder. The mean age of the group was 50 years (range 18 to 68).
Fig. 2. The 90% stomach filling time. Because of clinical data that patients with colon interposition are usually not able to eat or drink in a supine position, the examination were performed with the subjects in a sitting position. An 8 MBq dose (250 p,Ci) of technetium 99m-tin--eolloid in 10 ml of water was used as a tracer bolus. The upright position of the patient and a single swallow were used. The passage of the bolus was measured with a large-field gamma camera (Maxicamera 400-T) with an all-purpose collimator and a computer system (Gamma-ll). The upper end of the cricoid cartilage was marked with cobalt 57 buttons. Data were collected into 64 by 64 frames with time intervals of 0.5 second during the first 30 seconds and then with intervals of 30 seconds up to 20 minutes. In the analysis and stomach and three parts of the colon graft and esophagus were delineated by a normal region of interest technique, with the time activity curves for these calculated. Gamma cinematographic studies were useful in the selection of regions of interest in our patient group with unique esophageal function. A special computer program (Fortran IV) was constructed for the curve analysis. The following parameters were calculated from activity curves: for the stomach, the appearance times for 5% and 90% filling; for esophageal areas, the times to 50% and 25% activity levels in the downslope of the curves and the residual activities as a percentage of the maxima of regions of interest in question. The mean transit time was also calculated, but in this particular patient group, with a remarkably high residual activity, this measurement was not meaningful. The
Volume 94 Number 4 October 1987
Radionuclide transit after colon interposition
523
Table II. Colon graft and esophageal emptying measured as 50% and 25% activity levels in three graft and esophageal thirds Emptying time (sec)
25 % activity level
50 % activity level Upper third Study group (N = 25) Control group (N = 10)
5.4 ± 7.9 2.8 ± 1.3
I
Middle third
I
30.6 ± 57.9 4.7 ± 1.5
Lower third
Upper third
400 ± 527* 5.2 ± 1.4
40 ± 155 3.3 ± 1.4
I
Middle third 190 ± 420 5.6 ± 1.3
I
Lower third 456 ± 518t 6.4 ± 1.3
'The lowermost third of the colon graft did not reach 50% activity level in two patients. tThe lowermost third of the colon graft did not reach 25% activity level in 10 patients.
zero point of the time scale was always fixed at one point (0.5 second) before the peak activity of the first esophageal region of interest. The results of these calculations were expressed by the mean, the range, and one standard deviation. The Student's two-tailed independent t test was used to determine the statistical significance of the differences in the results of the study groups for these variables.
Results The mean appearance time for 5% stomach filling in the study group was 6.6 ± 9.7 seconds (range 0.1 to 40.0) and for 90% filling, 273.0 ± 253.0 seconds (range 6.0 to 660.0). In the control patients the values were, respectively, 1.6 ± 1.6 second (range 0.1 to 5.5) and 7.0 ± 2.3 second (range 3.5 to 11.5) (Figs. 1 and 2). The differences between the study and control groups were highly significant. The mean time to 50% activity level of the lower third of the colon graft was 400 ± 527 second and to 25% activity level, 456 ± 518 second. The 50% and 25% activity levels of the lower colon graft were not reached during the 20 minute observation period by two and 10 patients, respectively (Table II). In the control group, 50% activity of the lower esophageal third was reached on an average in 5.2 seconds and 25% activity, in 6.4 seconds (Table II), significantly more rapidly than in the colon graft. The mean residual activities of the upper, middle, and lower thirds of the colon grafts after 20 minutes' observation were 14.7% ± 14.9%,23.2% ± 16.1%, and 50.0% ± 15.7%, respectively. In the upper, middle, and lower thirds of the esophagus in the control group, these activities were 3.9% ± 3.5%, 4.6% ± 2.5%, and 4.4% ± 3.0%, respectively (Fig. 3). There were no significant differences in time to 5% and 90% filling of the stomach and mean residual activities of the colon graft thirds after 20 minutes of observation between isoperistaltic and antiperistaltic,
retrosternal, and posterior mediastinal colon grafts. Likewise, there were no differences between the "new" grafts «60 months from the operation to the examination, N = 15) and the "old" grafts (>60 months from the operation to the examination, N = 10).
Discussion Recent studies have demonstrated the usefulness of radionuclide transit as an indicator of abnormal esophageal function in patients with primary and secondary esophageal disorders.":" The advantages of the method over established procedures include speed, simplicity, ease of quantification, and low radiation 10ad.17 Several parameters have been used to describe the radionuclide transit: the time from initial entry of the bolus into the esophagus to total clearance from the esophagus; the time from entry of the bolus into the esophagus to return of less than 10% of peak activity; and the mean transit time.P'" Although measured, these parameters were not useful in maintaining the bolus transit in patients with colon interposition because of the remarkably high residual activity. Cinefluoroscopic studies have shown that the emptying of the colon graft is slow and varies in different examinations of the same patient. I I. 12. 18 Although cinefluoroscopic studies have not been able to demonstrate peristalsis in an interposed colon, later manometric studies have shown that motor activity exists, especially as a response to an acid infusion.P''<": 29 This may help in cleaning the interposed segment of acid refluxed from the stomach, especially in patients with incomplete vagotomy. However, the main factor in propelling the bolus to the stomach is believed to be gravity. I. 18.21 All the parameters used in the present study show that bolus transit of the interposed colon is markedly slower than that of the normal esophagus. The least difference was observed in the emptying of the upper third of the graft and the 5% filling time of the stomach. There were 10 patients in the study group whose 5%
524
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The Journal of Thoracic and Cardiovascular Surgery
0
20
0
~ 0= Colon grafts (n=25) 0= Controls (n=10)
Fig. 3. The end activities of the esophageal thirds after 20 minutes' observation.
stomach filling time did not exceed the mean value of the control group. Marked differences were observed in the two lower thirds of the colon graft. The lower the graft part examined, the greater were the standard deviations in the study group in each of the parameters. The intra-abdominal segment of the graft seems to act as a kind of second stomach. Its mean residual activity after 20 minutes of observation, even in an upright position, was 50% ± 15.7%. There was also high residual activity in the middle (23.6% ± 16.1%) and upper (14.7% ± 14.9%) thirds. Regurgitation is one of the most common harmful symptoms after colon interposition.v"'" Cinefluoroscopic studies have demonstrated that reflux occurs from the stomach into the interposed colonic segment. I I. 18 However, it is obvious that at least a part of the regurgitated material is retained ingested material from the graft, especially from the intra-abdominal part. An intra-abdominal colon graft loop situated in a highpressure zone effectively limits reflux." Because vagotomy is usually unavoidable in the operation, refluxed material from the stomach is mostly neutral. Alkaline mucus secreted by the colon graft protects the mucosa of the graft from acid injury in patients with incomplete vagotomy. IO Probably because of these factors, peptic ulceration of the graft is seldom reported. Placing the cologastric anastomosis to the proximal stomach may also help in preventing reflux." Because of the present results, proximal cologastric anastomosis on
the stomach with a short intra-abdominal colon graft loop should be considered. This would quicken the emptying of the graft, and regurgitation of the retained food from the graft should lessen. Full agreement has not been reached on the use of antiperistaltic or isoperistaltic colon grafts." 4. 23. 24 On the basis of observations of motor response of the colon graft to acid infusion and other stimuli, isoperistaltic interposition has been preferred to antiperistaltic grafts,-4. IO There were both antiperistaltic and isoperistaltic grafts in the study group. No difference between the groups in the parameters used in the study could be demonstrated. We also found no differences between patients operated on more than 60 months before the examination and those operated on less than 60 months before the examination, which points to the stability of the transit properties of the interposed colon. This study demonstrates the long radionuclide transit of colon interposition. Residual activities after 30 minutes of observation are high, especially in the intra-abdominal part of the graft. Changes in the site of the cologastric anastomosis and length of the intraabdominal colon graft segment are suggested.
I. 2. 3. 4. 5. 6.
7.
8. 9. 10. II.
REFERENCES Postlethwait RW. Colonic interposition for esophageal substitution. Surg Gynecol Obstet 1983;156:377-83. Kelly JP, Shackelford GD, Roper CL. Esophageal replacement with colonin children: functional results and long-term growth. Ann Thorac Surg 1983;36:634-43. Buntain WL, Payne WS, Lynn HB. Esophageal reconstruction for benign disease: a long-term appraisal. Am Surg 1980;46:67-79. Hankins JR, Cole FN, McLaughlin JS. Colon interposition for benign esophageal disease: experience with 23 patients. Ann Thorac Surg 1984;37:192-6: Wilkins EW Jr. Long-segment colon substitution for the esophagus. Ann Surg 1980;192:722-5. Nelson AM, Grayer DJ. Development of diverticular disease in the transplanted colon. Am J Gastroenterol 1979;72:660-1. Malcolm JA. Occurrenceof peptic ulcer in colon usedfor esophageal replacement. J THORAC CARDIOVASC SURG 1968;55:763-72. Perlmutter DH, Tapper D, Teele RL, Winter HS. Colobronchial fistula as a late complication of coloesophageal interposition. Gastroenterology 1984;86:1570-2. Pradhan DJ, Ikins PM. Ischemic colitis in esophageal substitution: an unusual and lethal complication of colon interposition. Am Surg 1975;41 :427-8. Jones EL, Skinner DB, DeMeester TR, Elkins RC, Zuidema GD. Response of the interposed human colonic segment to an acid challenge. Ann Surg 1973;177:75-8. Sieber AM, Sieber WK. Colon transplants as esophageal
Volume 94 Number 4 October 1987
12.
13. 14.
15.
16. 17.
18.
replacements: cineradiographic and manometric evaluation in children. Ann Surg 1968;168:116-22. Rodgers HM, Talbert JL, Moazam F, Telman AH. Functional and metabolic evaluation of colon replacement of the esophagus in children. J Pediatr Surg 1978;13:35-9. Kazem 1. A new scintigraphic technique for the study of the esophagus. AJR 1972;115:681-8. Russel COH, Hill LD, Holmes ER III, Hull DA, Gannon R, Pope CE II. Radionuclide transit: a sensitive screening test for esophageal dysfunction. Gastroenterology 1981; 80:887-92. Tolin RD, Malmud LS, Reilley J, Fisher RS. Esophageal scintigraphy to quantitate esophageal transit (quantitation of esophageal transit). Gastroenterology 1979;76:1402-8. Klein HA, Wald A. Computer analysis of radionuclide esophageal transit studies. J Nucl Med 1984;25:957-64. Benjamin SB, O'Donnel JK, Hancock J, Nielsen D, Castell DO. Prolonged radionuclide transit in "nutcracker esophagus." Dig Dis Sci 1983;28:775-9. Othersen HB Jr, Clatworthy HW Jr. Functional evalua-
Radionuclide transit after colon interposition
19.
20.
21.
22. 23. 24.
525
tion of esophageal replacement in children. J THORAC CARDIOVASC SURG 1967;53:55-63. Corazziari E, Mineo TC, Anzini F, Torsoli A, Ricci C. Functional evaluation of colon transplants used in esophageal reconstruction. Dig Dis Sci 1977;22:7-12. Benages A, Moreno-Ossett E, Paris F, et aI. Motor activity after colon replacement of esophagus. J THORAC CARDIOVASC SURG 1981;82:335-40. Clark J, Moraldi A, Moossa AR, Hall AW, DeMeester TR, Skinner DB. Functional evaluation of the interposed colon as an esophageal substitute. Ann Surg 1976;183:93100. Gregorie HB Jr. Esophagocoloplasty. Ann Surg 1972;175:740-9. Belsey R. Reconstruction of the esophagus with left colon. J THORAC CARDIOVASC SURG 1965;49:33-55. Neville WE, Najem AZ. Colon replacement of the esophagus for congenital and benign disease. Ann Thorac Surg 1983;36:626-33.
THoRAc CARDIOVASC SURG
1987;94:521-5
Radionuclide transit in patients with colon interposition To assess radionuclide transit in interposed segments of the colon, we examined 25 patients with colon interposition for benign esophageal disease. No such assessment has been reported previously. The most common indications for operation were esophageal strictures that developed after lye ingestion and reflux strictures not responding to other treatment. The operations were performed without thoracotomy by blunt esophageal dissection in 80 % of the patients. There were 18 antiperistaltic and seven isoperistaltic colon grafts. A large-field gamma camera and computer system were used. Data were collected at time intervals of 0.5 second during the first 30 seconds and at intervals of 30 seconds up to 20 minutes. The 5 % and 90 % stomach filling times, times to 50 % and 25 % activity levels, and residual activity levels as a percentage of the maxima were calculated in the upper, middle, and lower thirds of the colon grafts and of tbe normal esophagus of 10 healthy control subjects. The examinations were performed with the subject in a sitting position. AU parameters showed that emptying of the colon graft was markedly slower than that of tbe normal esophagus. The intra-abdominal third of the graft had a residual activity of 50.5% ± 15.7% after 20 minutes' observation. No differences between antiperistaltic and isoperistaltic grafts were observed. Reconstruction with proximal cologastric anastomosis and a short intra-adbominal colon graft segments is suggested.
Jouko Isolauri, M.D., Matti O. Koskinen, Ph.D., and Hannu Markkula, M.D.,
Tampere, Finland
Long-segment colon interposition is a well-established procedure in preserving esophageal continuity after resection, especially for benign esophageal disease.!? Long-term results have been mainly good and late complications, including development of primary colonic disease in the interposed segment and reflux colitis, are seldom reported.!" Although motor activity as a response to an acid infusion has been reported, the interposed colon is believed to act mainly as a passive conduit.I, 10-12 The patients usually are not able to drink or eat in a supine position, and recumbency for 1 to 3 hours after eating is not possible without a sense of regurgitation in many cases. Both of these observations point to a delayed emptying of the colon graft. The purposeof this study was to evaluate the emptying of the colon graft by measuring the radionuclide bolus transit From the Departments of Surgery (Drs. Isolauri and Markkula) and Clinical Physiology (Dr. Koskinen), Tampere University Central Hospital, Tampere, Finland. Received for publication July 29, 1986. Accepted for publication Oct. 7, 1986. Address for reprints: Jouko Isolauri, M.D., Department of Surgery, Tampere University Central Hospital, SF-33520 Tampere, Finland.
time in patients with colon interposition for benign esophageal disease. Patients and methods
During a 22 year period (March 1964 to March 1985) 60 patients underwent colon interposition for benign esophageal disease in Tampere University Central Hospital. By 1985, 14 patients had died of causes not related to colon interposition. The study group consisted of 25 cooperative patients with antiperistaltic and isoperistaltic, retrosternal, and posterior mediastinal colon grafts. There were limen and 14 women with a mean age of 60 years (range 34 to 76) at examination. The most common indication for operation was esophageal stricture that had developed after lye ingestion and had not responded to other treatment (Table I). The mean time from the operation to the examination was 61 months (range 5 to 175). The operation was performed without thoracotomy by blunt esophageal dissection in 20 patients. In the remainder a right thoracotomy and upper midline abdominal incision were used. There were no bypass operations and all the operations except two were performed in one stage. The segment to be interposed was from the left colon 521
The Journal of Thoracic and Cardiovascular Surgery
522 Isolauri, Koskinen, Markkula
1000 r - - - - - - - - - - - - - - - - - ,
>20 18
o
0
16
III
VI QJ
E -+-
0'1
c:
14 12 10
0~ l.J1
6
0
600
00
400
00
QJ
..... 0'1
c:
co
o
o
~
o
4 2
o
E
o
8 u,
800
C1'
B
200
r-
lOa
0= Colon grafts (n=2S)
o = Colon grafts (n=2S1
0= Controls (n=10)
o = Controls (n=10l
Fig. 1. The 5% stomach filling time. In two patients of the study group the time exceeded 20 seconds, being 30 and 40 seconds.
Table I. Causes of the benign esophageal disease No.
%
Lye corrosion Reflux stricture Other corrosion Other
12 2 5
48 24 8 20
Total
25
100
6
in 18 patients and from the right colon and colon transversum in four and three patients. There were seven isoperistaltic and 18 antiperistaltic colon grafts. In five patients the colon graft was placed retrosternally. All other grafts were in the posterior mediastinal space. The cologastric anastomosis was placed to the anterior antrum. An intra-abdominal loop of the graft above the cologastric anastomosis was left. Pyloroplasty was performed in each case. On examination none of the patients had dysphagia. Five patients had no symptoms of regurgitation. By sleeping in a half-sitting position and avoiding recumbency for 1 to 3 hours after eating, 16 patients could avoid these symptoms. Four patients had uncontrollable symptoms of regurgitation. The control group consisted of 10 normal volunteers (eight men and two women) with no symptoms or past history suggestive of any upper gastrointestinal tract disorder. The mean age of the group was 50 years (range 18 to 68).
Fig. 2. The 90% stomach filling time. Because of clinical data that patients with colon interposition are usually not able to eat or drink in a supine position, the examination were performed with the subjects in a sitting position. An 8 MBq dose (250 p,Ci) of technetium 99m-tin--eolloid in 10 ml of water was used as a tracer bolus. The upright position of the patient and a single swallow were used. The passage of the bolus was measured with a large-field gamma camera (Maxicamera 400-T) with an all-purpose collimator and a computer system (Gamma-ll). The upper end of the cricoid cartilage was marked with cobalt 57 buttons. Data were collected into 64 by 64 frames with time intervals of 0.5 second during the first 30 seconds and then with intervals of 30 seconds up to 20 minutes. In the analysis and stomach and three parts of the colon graft and esophagus were delineated by a normal region of interest technique, with the time activity curves for these calculated. Gamma cinematographic studies were useful in the selection of regions of interest in our patient group with unique esophageal function. A special computer program (Fortran IV) was constructed for the curve analysis. The following parameters were calculated from activity curves: for the stomach, the appearance times for 5% and 90% filling; for esophageal areas, the times to 50% and 25% activity levels in the downslope of the curves and the residual activities as a percentage of the maxima of regions of interest in question. The mean transit time was also calculated, but in this particular patient group, with a remarkably high residual activity, this measurement was not meaningful. The
Volume 94 Number 4 October 1987
Radionuclide transit after colon interposition
523
Table II. Colon graft and esophageal emptying measured as 50% and 25% activity levels in three graft and esophageal thirds Emptying time (sec)
25 % activity level
50 % activity level Upper third Study group (N = 25) Control group (N = 10)
5.4 ± 7.9 2.8 ± 1.3
I
Middle third
I
30.6 ± 57.9 4.7 ± 1.5
Lower third
Upper third
400 ± 527* 5.2 ± 1.4
40 ± 155 3.3 ± 1.4
I
Middle third 190 ± 420 5.6 ± 1.3
I
Lower third 456 ± 518t 6.4 ± 1.3
'The lowermost third of the colon graft did not reach 50% activity level in two patients. tThe lowermost third of the colon graft did not reach 25% activity level in 10 patients.
zero point of the time scale was always fixed at one point (0.5 second) before the peak activity of the first esophageal region of interest. The results of these calculations were expressed by the mean, the range, and one standard deviation. The Student's two-tailed independent t test was used to determine the statistical significance of the differences in the results of the study groups for these variables.
Results The mean appearance time for 5% stomach filling in the study group was 6.6 ± 9.7 seconds (range 0.1 to 40.0) and for 90% filling, 273.0 ± 253.0 seconds (range 6.0 to 660.0). In the control patients the values were, respectively, 1.6 ± 1.6 second (range 0.1 to 5.5) and 7.0 ± 2.3 second (range 3.5 to 11.5) (Figs. 1 and 2). The differences between the study and control groups were highly significant. The mean time to 50% activity level of the lower third of the colon graft was 400 ± 527 second and to 25% activity level, 456 ± 518 second. The 50% and 25% activity levels of the lower colon graft were not reached during the 20 minute observation period by two and 10 patients, respectively (Table II). In the control group, 50% activity of the lower esophageal third was reached on an average in 5.2 seconds and 25% activity, in 6.4 seconds (Table II), significantly more rapidly than in the colon graft. The mean residual activities of the upper, middle, and lower thirds of the colon grafts after 20 minutes' observation were 14.7% ± 14.9%,23.2% ± 16.1%, and 50.0% ± 15.7%, respectively. In the upper, middle, and lower thirds of the esophagus in the control group, these activities were 3.9% ± 3.5%, 4.6% ± 2.5%, and 4.4% ± 3.0%, respectively (Fig. 3). There were no significant differences in time to 5% and 90% filling of the stomach and mean residual activities of the colon graft thirds after 20 minutes of observation between isoperistaltic and antiperistaltic,
retrosternal, and posterior mediastinal colon grafts. Likewise, there were no differences between the "new" grafts «60 months from the operation to the examination, N = 15) and the "old" grafts (>60 months from the operation to the examination, N = 10).
Discussion Recent studies have demonstrated the usefulness of radionuclide transit as an indicator of abnormal esophageal function in patients with primary and secondary esophageal disorders.":" The advantages of the method over established procedures include speed, simplicity, ease of quantification, and low radiation 10ad.17 Several parameters have been used to describe the radionuclide transit: the time from initial entry of the bolus into the esophagus to total clearance from the esophagus; the time from entry of the bolus into the esophagus to return of less than 10% of peak activity; and the mean transit time.P'" Although measured, these parameters were not useful in maintaining the bolus transit in patients with colon interposition because of the remarkably high residual activity. Cinefluoroscopic studies have shown that the emptying of the colon graft is slow and varies in different examinations of the same patient. I I. 12. 18 Although cinefluoroscopic studies have not been able to demonstrate peristalsis in an interposed colon, later manometric studies have shown that motor activity exists, especially as a response to an acid infusion.P''<": 29 This may help in cleaning the interposed segment of acid refluxed from the stomach, especially in patients with incomplete vagotomy. However, the main factor in propelling the bolus to the stomach is believed to be gravity. I. 18.21 All the parameters used in the present study show that bolus transit of the interposed colon is markedly slower than that of the normal esophagus. The least difference was observed in the emptying of the upper third of the graft and the 5% filling time of the stomach. There were 10 patients in the study group whose 5%
524
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CO
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UJ
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BO
g,
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Clb
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0
~
60
40
~
0 0
20
100
0 0
60
~
c
3
2
100
>.
The Journal of Thoracic and Cardiovascular Surgery
0
20
0
~ 0= Colon grafts (n=25) 0= Controls (n=10)
Fig. 3. The end activities of the esophageal thirds after 20 minutes' observation.
stomach filling time did not exceed the mean value of the control group. Marked differences were observed in the two lower thirds of the colon graft. The lower the graft part examined, the greater were the standard deviations in the study group in each of the parameters. The intra-abdominal segment of the graft seems to act as a kind of second stomach. Its mean residual activity after 20 minutes of observation, even in an upright position, was 50% ± 15.7%. There was also high residual activity in the middle (23.6% ± 16.1%) and upper (14.7% ± 14.9%) thirds. Regurgitation is one of the most common harmful symptoms after colon interposition.v"'" Cinefluoroscopic studies have demonstrated that reflux occurs from the stomach into the interposed colonic segment. I I. 18 However, it is obvious that at least a part of the regurgitated material is retained ingested material from the graft, especially from the intra-abdominal part. An intra-abdominal colon graft loop situated in a highpressure zone effectively limits reflux." Because vagotomy is usually unavoidable in the operation, refluxed material from the stomach is mostly neutral. Alkaline mucus secreted by the colon graft protects the mucosa of the graft from acid injury in patients with incomplete vagotomy. IO Probably because of these factors, peptic ulceration of the graft is seldom reported. Placing the cologastric anastomosis to the proximal stomach may also help in preventing reflux." Because of the present results, proximal cologastric anastomosis on
the stomach with a short intra-abdominal colon graft loop should be considered. This would quicken the emptying of the graft, and regurgitation of the retained food from the graft should lessen. Full agreement has not been reached on the use of antiperistaltic or isoperistaltic colon grafts." 4. 23. 24 On the basis of observations of motor response of the colon graft to acid infusion and other stimuli, isoperistaltic interposition has been preferred to antiperistaltic grafts,-4. IO There were both antiperistaltic and isoperistaltic grafts in the study group. No difference between the groups in the parameters used in the study could be demonstrated. We also found no differences between patients operated on more than 60 months before the examination and those operated on less than 60 months before the examination, which points to the stability of the transit properties of the interposed colon. This study demonstrates the long radionuclide transit of colon interposition. Residual activities after 30 minutes of observation are high, especially in the intra-abdominal part of the graft. Changes in the site of the cologastric anastomosis and length of the intraabdominal colon graft segment are suggested.
I. 2. 3. 4. 5. 6.
7.
8. 9. 10. II.
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