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Surgical treatment of late dysfunction of an esophagocoloplasty
Journal of Visceral Surgery (2010) 147, e395—e398
CLINICAL CASE
Surgical treatment of late dysfunction of an esophagocoloplasty A. Moussi ∗, S. Daldoul , B.S. Gherib , A. Zaouche Service de chirurgie générale « A », hôpital Charles-Nicolle, boulevard 9-Avril-1938, 1006 Tunis, Tunisia Available online 28 September 2010
KEYWORDS Colon; Esophagus; Colon interposition; Caustic stricture; Redundancy
Summary Replacement of the esophagus by colon interposition often has late complications, frequently due to technical defects. We report the case of a patient who presented 12 years after surgery with complex dysfunctions of a colonic interposition, including cervical and retrosternal strictures associated with a redundant portion of the colon graft. The interest of this case lies in its combination of many late complications of this surgery in a single person together with the simplicity of the treatment. © 2010 Elsevier Masson SAS. All rights reserved.
Introduction Despite experience over the past century and mastery of the relevant surgical techniques, replacement of the esophagus by colon interposition remains major surgery. Surgical morbidity is substantial, and its late complications are frequent. We report a case that illustrates the complexity of the late dysfunction of this replacement, in contrast to the ease of its surgical management.
Case report This 61-year-old woman underwent surgery in 1986 in a different hospital for caustic stricture of the esophagus and the pyloric antrum. A left transverse colon graft was interposed, pedicled to the left middle colic artery, placed isoperistaltically in the anterior mediastinum. A year later, stricture of the esophagocolic anastomosis was treated by 15 sessions of endoscopic dilatation. Twelve years later, the patient’s symptoms included low dysphagia to solids and fluids, associated with abdominal pain and early postprandial vomiting. The first revision took place in a clinic, after a diagnosis of gastroduodenal anastomotic stricture. A transformation of the Pean into a Finsterer reconstruction was performed, without modifying the
∗
Corresponding author. E-mail address: [email protected] (A. Moussi).
1878-7886/$ — see front matter © 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2010.08.006
e396
Figure 1. Barium swallow: short stricture of esophagocolic anastomosis, centered and not too narrow, (arrows).
cologastric anastomosis on the posterior side of the stomach. This operation did not resolve the problem; the persistent symptoms were only relieved by gastric suction. The patient consulted in our department in November 1998. At that time, the various morphologic and endoscopic explorations showed three anomalies: • stricture of the esophagocolic anastomosis, visible on barium images (Fig. 1), and confirmed by esophagoscopy; • pleating with multiple elbows of the colon graft, above a narrow retrosternal stricture, and located 6 or 7 cm above the xiphoid process (Fig. 2); • a long redundant segment of the coloplasty, beginning above the permeable cologastric anastomosis and measuring 25—30 cm in length (Fig. 3). Fig. 4 illustrates the three problems presented by the patient. Note that the barium swallow images suggest that the right colon is redundant, but we had no idea of the vascular situation of the right colon and, in particular, of the quality of the right branch of the middle colic artery. The surgery in September 1998 used a dual cervical and abdominal approach. The study of vascularization showed that while the right middle colic artery had been sacrificed, a good-quality branch of the ileocolic artery could be used for ileocoloplasty, if needed. Nonetheless, use of this branch ileocolic artery for right ileocolic vascularization should be accompanied by a long ileal segment, and its vascularization might be poor. Release of the abdominal portion of the coloplasty from the cologastric anastomosis up to the xiphoid process showed approximately 40 cm of well-vascularized colon, sufficiently long to be raised to the neck. Releasing the retrosternal portion of the graft was difficult, especially
A. Moussi et al.
Figure 2. Barium swallow: multiple pleats of the colon graft with a retrosternal stricture (arrow).
given that it was performed blind. Despite the substantial risk of damaging the coloplasty and especially its vascular pedicle by blind dissection, we did not perform a sternotomy to dissect the retrosternal portion of the graft because the abdominal portion was well vascularized and could be lifted to the neck without difficulty. The stricture at 7 cm above the xiphoid process corresponded to a narrowed colosternal lip. The esophagocolic anastomosis was the site of a fibrous stricture that extended for 1.5 cm. Both the cologastric and gastrojejunal anastomoses, 2 cm apart, were wide. We performed a simple resection of the redundant proximal colon, which corresponded to the midsternal portion of the graft, removing the cervical stricture by creating a new esophagocolic end-to-side anastomosis, with no tension, with healthy edges, and well vascularized. The postoperative course was simple. Barium swallow on the eighth postoperative day showed a rectilenear graft with a patent esophagocolic anastomosis with no leakage; since then, the patient has been eating correctly, without problems, and has gained weight. Ten years later, she is satisfied.
Discussion Esophageal replacement by a coloplasty is the treatment of choice for patients with benign esophageal stricture who have a long life expectancy [1,2]. Nonetheless, it is a complex and delicate intervention, characterized by elevated operative morbidity and by the late occurrence of complications that can sometimes require complex and repeated revisions [1—12]. These late complications, often due to technical flaws at the original surgery, must be distin-
Surgical treatment of late dysfunction of an esophagocoloplasty
Figure 3. Esophagocolic transit: colon redundancy (delimited by the arrows). (Est: stomach).
guished from the functional results and quality of life, both of which are excellent in most cases [1,2,6]. The rate of late complications after esophagocoloplasty can reach 55% [3] and the need for revisional surgery for these complications ranges from 15 to 50% [1—3]. Redundant colon, stricture of the cervical and cologastric anastomoses, cologastric reflux, and late postsurgical occlusions are the principal causes for surgical revision [1,13]. Stricture of the cervical anastomosis is the most common late complication of this type of coloplasty. Its rate in the literature ranges from 2.3 to 60% [1,6,7,11,12]. It can be treated simply by several sessions of endoscopic dilatation. In extreme cases, it may require repeated surgery for strictureplasty, resection of the sclerotic tissue surrounding the stricture, a new anastomosis, the creation of a new colon graft, or resection of the stricture with interposition of a free jejunal graft [2,4,5,11]. Redundant colon (excess graft length) is seen in 4 to 5% of cases [5,7,10]. It is one of the principal causes of late revision [8,13]. As in our patient, this complication is often due to the creation of a long graft, and it can be prevented by careful measurement of the useful length of the graft [2,6]. It is essential to adapt this conduit to the length of its vascular pedicle during the coloplasty because the graft length is determined by the pedicle length [11]. Other potential causal or pathogenic factors may include a hiatal orifice insufficiently enlarged during the coloplasty, aspiration of the coloplasty by negative thoracic pressure after opening the pleura [12], stricture of the cologastric anastomosis [8], stricture of the hiatal orifice or the lower retrosternal tun-
e397
Figure 4. Diagram of the esophagocoloplasty: (1) Stricture of the esophagocolic anastomosis; (2) Retrosternal stricture; (3) Redundant colon segment.
nel orifice [8], and finally, gastric emptying disorders [8]. Functional impairment of the graft over the years may play a role in the onset of this complication [5,9]. The cologastric anastomosis on the anterior side of the stomach may lead to less redundancy because of its short, direct route [11]. We performed the cologastric anastomosis on the posterior face of the antrum, with a border to prevent reflux and to avoid gastric compression by the vascular pedicle of the graft. When redundancy is asymptomatic, expectant management is standard practice [5,6]. In the case of complications or bothersome symptoms, surgery is required [2,5,6,8,11]. Several surgical techniques can be suggested: resection of the redundant colon, with or without disconnecting the cologastric anastomosis [5], a mechanical colo-colon anastomosis at the height of the long segment, similar to an ileal or colonic pouch [8] or a simple resection of the anastomosis when the redundant segment forms a cul-de-sac. In addition to resection of the redundant colon and creation of a new cologastric anastomosis, Shokrollahi et al. recommend placing mechanical sutures longitudinally on the antimesenteric edge of the coloplasty, for a diameter of 4 to 5 cm [10]. The literature on the surgical management of these late coloplasty complications is sparse. It can vary from simple enlargement of the stricture at the cervical anastomosis to the creation of a new colonic, gastric or jejunal graft [3—6]. The indications for each technique as well as the best approach must be dealt with on a case-by-case basis.
e398 This case is unusual in its combination of several late complications in the same patient and by the relative simplicity of the treatment undertaken. Several treatment modalities were considered before surgery. The choices were as follows.
Correction of the coloplasty Correction of the coloplasty at three levels, using a cervicosternolaparotomy followed by a strictureplasty of the retrosternal stricture, enlargement of the esophagocolic anastomosis, and resection of the abdominal redundant segment as close as possible to the colon to avoid damaging the vascular pedicle. The dissection of the colon graft and its vascular pedicle must be meticulous and prudent to avoid damaging them and requiring a new transplant [14].
Excision of the coloplasty Excision of this coloplasty and its replacement by a right colon graft, if colon vascularization so permitted. During surgery, study of the colic vascularization showed that the right middle colic artery had been sacrificed and that a good ileocolic branch artery existed. It could be used to vascularize a right colon segment [11] but required the use of a long ileal segment, the vascularization of which would be poor. Test clamping is always required to verify the vascularization and viability of the potential graft.
Total release of the coloplasty Total release of the coloplasty by both the cervical and abdominal routes, raising it to the neck, after resection of the redundant portion; a new esophagocolic anastomosis would be possible, if the distance between the retrosternal stricture and the cologastric anastomosis was satisfactory. This distance was measured during surgery at 40 cm. Accordingly, without recourse to either a sternotomy or creation of a new graft, the retrosternal and cervical portions of the graft were resected, and a new esophagocolic anastomosis created.
Conclusion The late complications of coloplasty can be successfully treated by surgery. This surgery is often complex but it can also be simple, as it was in this case.
A. Moussi et al.
Conflict of interest statement Nothing declared.
References [1] Curet-Scott MJ, Fergusson MM, Little AG, Skinner DB. Colon interposition for benign esophageal disease. Surgery 1987;102:568—74. [2] DeMeester SR. Colon interposition following esophagectomy. Dis Esophagus 2001;14:169—72. [3] Dunn JCY, Fonkalsrud EW, Applebaum H, Shaw WW, Atkinson JB. Reoperation after esophageal replacement in childhood. J Ped Surg 1999;34:1630—2. [4] Domreis JS, Jobe BA, Aye RW, Deveney KE, Sheppard B, Deveney CW. Management of long-term failure after colon interposition for benign disease. Am J Surg 2002;183:544—6. [5] Jeyasingham K, Lerut T, Belsey RHR. Functional and mechanical sequelae of colon interposition for benign esophageal disease. Eur J Cardiothorac Surg 1999;15:327—32. [6] Kotsis L, Krisar Z, Orban K, Csekeo A. Late complications of coloesophagoplasty and long-term features of adaptation. Eur J Card Thorac Surg 2002;21:79—83. [7] Rishi D, Robert PS, Ashish R, Matthew JF, Dirk CS, Robert CM. Surgical management of late complications after colonic interposition for esophageal atresia. Ann Thorac Surg 2008;86:1965—7. [8] Bonavina L, Chella B, Segalin A, Luzzano S. Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty. Ann Thorac Surg 1998;65:1446—8. [9] Peppes G, Payne HR, Jeyasingham K. Ambulatory motility patterns of the transposed short segment colon. Gut 1993;34:1572—5. [10] Shokrollahi K, Barham P, Blazeby JM, Alderson D. Surgical revision of dysfunctional colonic interposition after esophagoplasty. Ann Thorac Surg 2002;74:1708—11. [11] Chirica M, de Chaisemartin C, Munoz-Bongrand N, et al. Reconstruction œsophagienne pour séquelles de brûlure caustique : coloplasties, mode d’emploi. J Chir 2009;146: 240—9. [12] Zoran B, Gerzic MD, Knezevic JB, et al. Esophagocoloplasty in the management of postcorrosive strictures of the esophagus. Ann Surg 1990;210:329—36. [13] Strauss DC, Forshaw MJ, Tandon RC, Mason RC. Surgical management of colonic redundancy following esophageal replacement. Dis Esophagus 2008;21:1—5. [14] Cattan P, Chiche P, Berney T, Halimi B, Aiden K, Celerier M, et al. Surgical approach by cervicosternolaparotomy for the treatment of extended cervical stenoses after reconstruction for caustic injury. J Thorac Cardiovasc Surg 2001;122: 384—6.
CLINICAL CASE
Surgical treatment of late dysfunction of an esophagocoloplasty A. Moussi ∗, S. Daldoul , B.S. Gherib , A. Zaouche Service de chirurgie générale « A », hôpital Charles-Nicolle, boulevard 9-Avril-1938, 1006 Tunis, Tunisia Available online 28 September 2010
KEYWORDS Colon; Esophagus; Colon interposition; Caustic stricture; Redundancy
Summary Replacement of the esophagus by colon interposition often has late complications, frequently due to technical defects. We report the case of a patient who presented 12 years after surgery with complex dysfunctions of a colonic interposition, including cervical and retrosternal strictures associated with a redundant portion of the colon graft. The interest of this case lies in its combination of many late complications of this surgery in a single person together with the simplicity of the treatment. © 2010 Elsevier Masson SAS. All rights reserved.
Introduction Despite experience over the past century and mastery of the relevant surgical techniques, replacement of the esophagus by colon interposition remains major surgery. Surgical morbidity is substantial, and its late complications are frequent. We report a case that illustrates the complexity of the late dysfunction of this replacement, in contrast to the ease of its surgical management.
Case report This 61-year-old woman underwent surgery in 1986 in a different hospital for caustic stricture of the esophagus and the pyloric antrum. A left transverse colon graft was interposed, pedicled to the left middle colic artery, placed isoperistaltically in the anterior mediastinum. A year later, stricture of the esophagocolic anastomosis was treated by 15 sessions of endoscopic dilatation. Twelve years later, the patient’s symptoms included low dysphagia to solids and fluids, associated with abdominal pain and early postprandial vomiting. The first revision took place in a clinic, after a diagnosis of gastroduodenal anastomotic stricture. A transformation of the Pean into a Finsterer reconstruction was performed, without modifying the
∗
Corresponding author. E-mail address: [email protected] (A. Moussi).
1878-7886/$ — see front matter © 2010 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jviscsurg.2010.08.006
e396
Figure 1. Barium swallow: short stricture of esophagocolic anastomosis, centered and not too narrow, (arrows).
cologastric anastomosis on the posterior side of the stomach. This operation did not resolve the problem; the persistent symptoms were only relieved by gastric suction. The patient consulted in our department in November 1998. At that time, the various morphologic and endoscopic explorations showed three anomalies: • stricture of the esophagocolic anastomosis, visible on barium images (Fig. 1), and confirmed by esophagoscopy; • pleating with multiple elbows of the colon graft, above a narrow retrosternal stricture, and located 6 or 7 cm above the xiphoid process (Fig. 2); • a long redundant segment of the coloplasty, beginning above the permeable cologastric anastomosis and measuring 25—30 cm in length (Fig. 3). Fig. 4 illustrates the three problems presented by the patient. Note that the barium swallow images suggest that the right colon is redundant, but we had no idea of the vascular situation of the right colon and, in particular, of the quality of the right branch of the middle colic artery. The surgery in September 1998 used a dual cervical and abdominal approach. The study of vascularization showed that while the right middle colic artery had been sacrificed, a good-quality branch of the ileocolic artery could be used for ileocoloplasty, if needed. Nonetheless, use of this branch ileocolic artery for right ileocolic vascularization should be accompanied by a long ileal segment, and its vascularization might be poor. Release of the abdominal portion of the coloplasty from the cologastric anastomosis up to the xiphoid process showed approximately 40 cm of well-vascularized colon, sufficiently long to be raised to the neck. Releasing the retrosternal portion of the graft was difficult, especially
A. Moussi et al.
Figure 2. Barium swallow: multiple pleats of the colon graft with a retrosternal stricture (arrow).
given that it was performed blind. Despite the substantial risk of damaging the coloplasty and especially its vascular pedicle by blind dissection, we did not perform a sternotomy to dissect the retrosternal portion of the graft because the abdominal portion was well vascularized and could be lifted to the neck without difficulty. The stricture at 7 cm above the xiphoid process corresponded to a narrowed colosternal lip. The esophagocolic anastomosis was the site of a fibrous stricture that extended for 1.5 cm. Both the cologastric and gastrojejunal anastomoses, 2 cm apart, were wide. We performed a simple resection of the redundant proximal colon, which corresponded to the midsternal portion of the graft, removing the cervical stricture by creating a new esophagocolic end-to-side anastomosis, with no tension, with healthy edges, and well vascularized. The postoperative course was simple. Barium swallow on the eighth postoperative day showed a rectilenear graft with a patent esophagocolic anastomosis with no leakage; since then, the patient has been eating correctly, without problems, and has gained weight. Ten years later, she is satisfied.
Discussion Esophageal replacement by a coloplasty is the treatment of choice for patients with benign esophageal stricture who have a long life expectancy [1,2]. Nonetheless, it is a complex and delicate intervention, characterized by elevated operative morbidity and by the late occurrence of complications that can sometimes require complex and repeated revisions [1—12]. These late complications, often due to technical flaws at the original surgery, must be distin-
Surgical treatment of late dysfunction of an esophagocoloplasty
Figure 3. Esophagocolic transit: colon redundancy (delimited by the arrows). (Est: stomach).
guished from the functional results and quality of life, both of which are excellent in most cases [1,2,6]. The rate of late complications after esophagocoloplasty can reach 55% [3] and the need for revisional surgery for these complications ranges from 15 to 50% [1—3]. Redundant colon, stricture of the cervical and cologastric anastomoses, cologastric reflux, and late postsurgical occlusions are the principal causes for surgical revision [1,13]. Stricture of the cervical anastomosis is the most common late complication of this type of coloplasty. Its rate in the literature ranges from 2.3 to 60% [1,6,7,11,12]. It can be treated simply by several sessions of endoscopic dilatation. In extreme cases, it may require repeated surgery for strictureplasty, resection of the sclerotic tissue surrounding the stricture, a new anastomosis, the creation of a new colon graft, or resection of the stricture with interposition of a free jejunal graft [2,4,5,11]. Redundant colon (excess graft length) is seen in 4 to 5% of cases [5,7,10]. It is one of the principal causes of late revision [8,13]. As in our patient, this complication is often due to the creation of a long graft, and it can be prevented by careful measurement of the useful length of the graft [2,6]. It is essential to adapt this conduit to the length of its vascular pedicle during the coloplasty because the graft length is determined by the pedicle length [11]. Other potential causal or pathogenic factors may include a hiatal orifice insufficiently enlarged during the coloplasty, aspiration of the coloplasty by negative thoracic pressure after opening the pleura [12], stricture of the cologastric anastomosis [8], stricture of the hiatal orifice or the lower retrosternal tun-
e397
Figure 4. Diagram of the esophagocoloplasty: (1) Stricture of the esophagocolic anastomosis; (2) Retrosternal stricture; (3) Redundant colon segment.
nel orifice [8], and finally, gastric emptying disorders [8]. Functional impairment of the graft over the years may play a role in the onset of this complication [5,9]. The cologastric anastomosis on the anterior side of the stomach may lead to less redundancy because of its short, direct route [11]. We performed the cologastric anastomosis on the posterior face of the antrum, with a border to prevent reflux and to avoid gastric compression by the vascular pedicle of the graft. When redundancy is asymptomatic, expectant management is standard practice [5,6]. In the case of complications or bothersome symptoms, surgery is required [2,5,6,8,11]. Several surgical techniques can be suggested: resection of the redundant colon, with or without disconnecting the cologastric anastomosis [5], a mechanical colo-colon anastomosis at the height of the long segment, similar to an ileal or colonic pouch [8] or a simple resection of the anastomosis when the redundant segment forms a cul-de-sac. In addition to resection of the redundant colon and creation of a new cologastric anastomosis, Shokrollahi et al. recommend placing mechanical sutures longitudinally on the antimesenteric edge of the coloplasty, for a diameter of 4 to 5 cm [10]. The literature on the surgical management of these late coloplasty complications is sparse. It can vary from simple enlargement of the stricture at the cervical anastomosis to the creation of a new colonic, gastric or jejunal graft [3—6]. The indications for each technique as well as the best approach must be dealt with on a case-by-case basis.
e398 This case is unusual in its combination of several late complications in the same patient and by the relative simplicity of the treatment undertaken. Several treatment modalities were considered before surgery. The choices were as follows.
Correction of the coloplasty Correction of the coloplasty at three levels, using a cervicosternolaparotomy followed by a strictureplasty of the retrosternal stricture, enlargement of the esophagocolic anastomosis, and resection of the abdominal redundant segment as close as possible to the colon to avoid damaging the vascular pedicle. The dissection of the colon graft and its vascular pedicle must be meticulous and prudent to avoid damaging them and requiring a new transplant [14].
Excision of the coloplasty Excision of this coloplasty and its replacement by a right colon graft, if colon vascularization so permitted. During surgery, study of the colic vascularization showed that the right middle colic artery had been sacrificed and that a good ileocolic branch artery existed. It could be used to vascularize a right colon segment [11] but required the use of a long ileal segment, the vascularization of which would be poor. Test clamping is always required to verify the vascularization and viability of the potential graft.
Total release of the coloplasty Total release of the coloplasty by both the cervical and abdominal routes, raising it to the neck, after resection of the redundant portion; a new esophagocolic anastomosis would be possible, if the distance between the retrosternal stricture and the cologastric anastomosis was satisfactory. This distance was measured during surgery at 40 cm. Accordingly, without recourse to either a sternotomy or creation of a new graft, the retrosternal and cervical portions of the graft were resected, and a new esophagocolic anastomosis created.
Conclusion The late complications of coloplasty can be successfully treated by surgery. This surgery is often complex but it can also be simple, as it was in this case.
A. Moussi et al.
Conflict of interest statement Nothing declared.
References [1] Curet-Scott MJ, Fergusson MM, Little AG, Skinner DB. Colon interposition for benign esophageal disease. Surgery 1987;102:568—74. [2] DeMeester SR. Colon interposition following esophagectomy. Dis Esophagus 2001;14:169—72. [3] Dunn JCY, Fonkalsrud EW, Applebaum H, Shaw WW, Atkinson JB. Reoperation after esophageal replacement in childhood. J Ped Surg 1999;34:1630—2. [4] Domreis JS, Jobe BA, Aye RW, Deveney KE, Sheppard B, Deveney CW. Management of long-term failure after colon interposition for benign disease. Am J Surg 2002;183:544—6. [5] Jeyasingham K, Lerut T, Belsey RHR. Functional and mechanical sequelae of colon interposition for benign esophageal disease. Eur J Cardiothorac Surg 1999;15:327—32. [6] Kotsis L, Krisar Z, Orban K, Csekeo A. Late complications of coloesophagoplasty and long-term features of adaptation. Eur J Card Thorac Surg 2002;21:79—83. [7] Rishi D, Robert PS, Ashish R, Matthew JF, Dirk CS, Robert CM. Surgical management of late complications after colonic interposition for esophageal atresia. Ann Thorac Surg 2008;86:1965—7. [8] Bonavina L, Chella B, Segalin A, Luzzano S. Surgical treatment of the redundant interposed colon after retrosternal esophagoplasty. Ann Thorac Surg 1998;65:1446—8. [9] Peppes G, Payne HR, Jeyasingham K. Ambulatory motility patterns of the transposed short segment colon. Gut 1993;34:1572—5. [10] Shokrollahi K, Barham P, Blazeby JM, Alderson D. Surgical revision of dysfunctional colonic interposition after esophagoplasty. Ann Thorac Surg 2002;74:1708—11. [11] Chirica M, de Chaisemartin C, Munoz-Bongrand N, et al. Reconstruction œsophagienne pour séquelles de brûlure caustique : coloplasties, mode d’emploi. J Chir 2009;146: 240—9. [12] Zoran B, Gerzic MD, Knezevic JB, et al. Esophagocoloplasty in the management of postcorrosive strictures of the esophagus. Ann Surg 1990;210:329—36. [13] Strauss DC, Forshaw MJ, Tandon RC, Mason RC. Surgical management of colonic redundancy following esophageal replacement. Dis Esophagus 2008;21:1—5. [14] Cattan P, Chiche P, Berney T, Halimi B, Aiden K, Celerier M, et al. Surgical approach by cervicosternolaparotomy for the treatment of extended cervical stenoses after reconstruction for caustic injury. J Thorac Cardiovasc Surg 2001;122: 384—6.