R the resumption of the normal swallowing mechanism

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1 Reconstruction the Left Colon of the Esophagus With Min-Hsiung Huang, MD, Chih-Yi Sung, MD, Hon-Ki Hsu, MD, Biing-ShiunHuang, MD, Wen-Hu Hsu, MD, and Kwang-Yu Chien, MD Division of Thoracic Surgery, Department of Surgery, National Yang-Ming Medical College, and Veterans General Hospital-Taipei, Taipei, Republic of China This report reviews our experience with 96 patients with benign or malignant stricture of the esophagus who underwent interposition of the left colon with or without esophageal resection from July 98 to June 987. There were 67 male and 9 female patients ranging in age from 8 to 8 years. Thirty-seven patients had fibrotic stricture secondary to corrosive injury of the esophagus, 4 had cancer of the esophagus, and 7 had cancer of the gastric cardia. The incidence of postoperative complications and surgical mortality, respectively, was 6.% and.7% for patients with corrosive stricture of the esophagus, 35.7% and.9% for patients with cancer of the esophagus, and 35.% and 5.8% for patients with cancer of the gastric cardia. Reconstruction resulted in good function in 75.6% of the patients with corrosive stricture of the esophagus, 66.6% of the patients with cancer of the esophagus, and 7.5% of patients with cancer of the gastric cardia. The morbidity and mortality were higher in the group with malignant esophageal strictures because of advanced age, poor general condition of the patient, and extent of the surgical procedure needed. Cervical anastomotic leakage was the most frequently encountered complication (3.5%), and all the poorfunction results were caused by this complication. In our experience, reconstruction of the esophagus with left colon is a satisfactory method that can be accomplished with acceptable morbidity and mortality. The left colon is a durable and functional substitute. (Ann Thoruc Surg 989;48:66-4) estoration of the continuity of the alimentary tract and R the resumption of the normal swallowing mechanism poses a challenging problem in the management of benign and malignant stricture of the esophagus. The use of the left colon, either for replacement or bypass of the esophagus, was reported in 9. Kelling [l] used the transverse colon in the isoperistaltic position as an esophageal substitute, and Vulliet [] described use of the transverse colon but placed it in an antiperistaltic position. Since then, the left colon has become a favored organ for reconstruction of the esophagus because it is easy to isolate and has an excellent blood supply from the concomitant vessels with the marginal artery of Drummond. We have used the left colon as an esophageal substitute in 96 patients, and describe here the operative techniques and the results. We conclude that using the left colon as an esophageal substitute can be accomplished with acceptable morbidity and mortality. Material and Methods This series consists of 96 patients in whom reconstruction of the esophagus was accomplished with the left colon during the 5-year period July 98 to June 987. Among the 96 patients, 37 underwent esophageal reconstruction for corrosive stricture of the esophagus. Their age ranged Accepted for publication July 7, 989 Address reprint requests to Dr Huang, Division of Thoracic Surgery, Department of Surgery, Veterans General Hospital-Taipei, Shih-Pai, Taipei 7, Republic of China. from 8 to 6 years. Forty-two patients with cancer of the esophagus underwent esophageal reconstruction ( palliative bypass procedures and resections with reconstruction). They ranged in age from 49 to 8 years. Seventeen patients with cancer of the gastric cardia underwent total gastrectomy, distal esophagectomy, and reconstruction of the esophagus with intrathoracic interposition of a segment of colon. Their age ranged from 56 to 7 years (Table ). Preoperative Preparation Bowel preparation consisted of a low-residue diet and warm saline solution enemas for two days, then a clear liquid diet with oral administration of g of neomycin or erythromycin for four doses, and finally a cleansing enema on the day before operation. If there were no symptoms or signs of colonic disease, barium enema or colonoscopy was not routinely performed. Operative Technique for Corrosive Stricture The operation is carried out by the two-team approach. The patient is put in the supine position with the head rotated to the right and the neck hyperextended for proper exposure of the cervical region. Standard endotracheal general anesthesia is used. The skin is prepared from the tip of the left mastoid process to the pubis. The operation starts with an abdominal exploration through a long midline incision. Exploration is focused particularly on the colon to determine its suitability and on the stomach to determine if there is any intrinsic disease or damage caused by the caustic agent. After 989 by The Society of Thoracic Surgeons

2 Ann Thorac Surg 989;48:664 HUANGETAL 66 Table. Summary of Preoperative Patient Data No. of Age Sex Diagnosis Patients (Yd (W) Corrosive stricture (8-6) 4/3 Carcinoma of 4 6 (49-8) 375 esophagus Carcinoma of cardia 7 6 (56-7) 6/ Total /9 proper evaluation, preparation of the left colon based on the left colic artery for isoperistaltic transplantation is carried out. The colon is mobilized by incising the lateral peritoneal reflection from the sigmoid to the splenic flexure and by incising the relatively avascular attachments of the greater omentum to the transverse colon. The lienocolic attachments to the splenic flexure are divided. The descending colon, splenic flexure, and transverse colon can now be held up. The mesocolon is transilluminated and its vascular pattern is examined (Fig ). The flow in the marginal artery is examined by palpation. The site of division of the transverse colon and its marginal artery and the descending colon and its marginal artery are selected in relation to the length of substitute needed (Fig ). Nothing is divided until these vessels have been temporarily obstructed with bulldog clamps at the sites of their planned division and show adequate terminal perfusion (Fig 3). A long segment of colon is obtained by dividing the middle colic artery proximal to its major bifurcation and by dividing the colon distal to both branches of the left colic artery (Fig 4). Meanwhile, the second team explores the cervical esophagus through an oblique incision in the left side of the neck anterior to the sternocleidomastoid muscle. The prevertebral plane is entered by retracting the carotid sheath laterally. The esophagus is exposed and encircled with tape; care is taken not to injure the recurrent laryn- Fig. The length of the substitute is measured so that the transplant can be brought to the neck without tension. geal nerve. The esophagus is transected as low as possible and the distal end is closed with sutures. An extrapleural retrosternal tunnel is constructed by blunt finger dissection from both ends of the sternum. The prepared colonic segment and its vascular pedicle are then brought up through this tunnel in an isoperistaltic manner to the neck where it should lie comfortably without tension. Special care is taken not to twist the colonic segment because this could compromise the venous return. The two teams then carry out the three necessary anastomoses. The performance of the esophagocolic anastomosis is the most critical and must be done meticulously. The cologastric anastomosis is carried out endto-side to the anterior aspect of the midbody of the stomach or to the jejunum if the stomach has been damaged by the caustic agent. Pyloroplasty is performed as needed but not routinely. A chest roentgenogram is made immediately after operation to check whether pneumothorax is present. Operative Technique for Cancer of Esophagus Five of the 4 patients in this group had tracheoesophageal fistula, poor pulmonary function, or distant metas- Fig I. After the transverse colon and descending colon have been mobilized, the vascular pattern is examined and the left colic artery is visible. Fig 3. The middle colic artery and vein are obstructed with bulldog clamps to make sure that perfusion of the transplant is adequate.

3 66 HUANG ET AL Ann Thorac Surg 989;48:66-4 tasis, and received only palliative colon bypass with the technique just described. The other 37 patients underwent initial exploratory thoracotomy. Only 8 were found to have an unresectable lesion and underwent palliative colon bypass. The other 9 patients had resection of the esophagus through a right posterolateral thoracotomy with repositioning of the patient in the supine position for reconstruction. Because the stomach in these patients had intrinsic disease or had been resected in the past, the left colon was used for reconstruction. (Normally, the stomach is our choice for replacement of the esophagus.) Operative Technique for Cancer of Cardia of Stomach Seventeen patients underwent total gastrectomy and distal esophagectomy through a left thoracoabdominal incision with reconstruction of the esophagus. An intrathoracic short-segment colon interposition was anastomosed distally to the jejunum. Evaluation of Functional Results The patient who tolerates a solid or soft diet without complaint is classified as having good function. If mild dysfunction is present but the patient can tolerate a soft or semiliquid diet with the help of intermittent dilation and maintains satisfactory nutrition, he or she is classified as having fair function. When major dysphagia persists Table. Complications Cancer Corrosive Cancer of of Injury Esophagus Cardia Complication (n = 37) (n = 4) (n = 7) Anastornotic leakage Bile reflux Wound infection Suffocation Necrosis of transplant Vocal cord palsy Intestinal obstruction Pneumothorax Empyema Wound disruption 3 8 Total 6 (6.) 5 (35.7) 6 (35.) and the patient must have regular dilation or revision of the anastomosis, he or she is classified as having poor function. Results For the 37 patients having reconstruction for corrosive stricture of the esophagus, the overall complication rate was 6.% (637) with three cervical anastomotic leaks, one necrosis of the transplant, one vocal cord palsy, and one intestinal obstruction. There was only one death, for a mortality rate of.7% (/37). The patient with necrosis of the transplant died of sepsis on the tenth postoperative day. The functional result was good in 75.6% of the patients, fair in 6.%, and poor in 8.%. In the group with cancer of the esophagus, the overall complication. rate was 35.7% (5/4) with eight cervical anastomotic leaks, two wound infections, two vocal cord palsies, one suffocation, one empyema, and one wound disruption. The overall mortality rate was.9% (5/4). Two patients died of pneumonia, died of sepsis, and died of suffocation. The functional outcome was as follows: good, 66.6% of the patients; fair,.4%; and poor,.9%. For the group with cancer of the gastric cardia, the overall complication rate was 35.% (6/7) with two anastomotic leaks at the intrathoracic esophagocolostomy, two cases of bile reflux, one wound infection, and one pneumothorax. There was one death, which was due to sepsis, for a mortality rate of 5.8% (/7). The functional results were as follows: good, 7.5% of the patients; fair, 7.6%; poor,.7% (Tables 4). Fig 4. The substitute is taken with adequate length and good perfusion such that the reconstruction can be performed without tension. Comment When reconstruction of the esophagus is indicated in a patient with dysphagia caused by either malignant or benign stricture of the esophagus, there are several substitutes from which to choose. An ideal substitute must

4 Ann Thorac Surg 989;48:66-4 HUANG ET AL 663 Table 3. Causes of Death" Corrosive Cancer of Cancer Injury Esophagus of Cardia Cause (n = 37) (n = 4) (n = 7) Pneumonia Sepsis Suffocation Total l(.7) 5 (.9) (5.8) fulfill several criteria, including complete and permanent relief of dysphagia, no late complications or sequelae, acceptable operative mortality and morbidity rates, ability to replace the entire esophagus and hypopharynx where necessary, technique applicable to infants and children, and technique allowing resection and reconstruction in a single-stage procedure. In addition, it is helpful if the technique can be taught to the resident or trainee of average ability [3]. If there is no substitute that fulfills all of these criteria, the surgeon must individualize the choice. The stomach is the organ most frequently used for substitution or bypass of a malignant stricture of the esophagus unless it has intrinsic disease such as peptic ulcer, has been operated on previously, or is to be included in the resection. The stomach provides adequate length and excellent blood supply from the right gastric and right gastroepiploic arteries, and requires only one anastomosis. The major disadvantage of using the stomach as an esophageal substitute is the frequency of reflux. Skinner and Belsey [4] reported a 7% incidence of severe esophagitis after reconstruction of the esophagus with stomach for benign stricture, and suggested reconstruction with colon for patients with an anticipated long life expectancy. The advantages of interposition of an isoperistaltic segment of jejunum for esophageal reconstruction are its active peristalsis and rarity of subsequent intrinsic jejunal disease. The disadvantage is that the "bowstring" vascular pedicle is accompanied by a long loop of redundant jejunum. Because of this disadvantage, the jejunum is seldom used for reconstruction. Despite the necessity for three anastomoses, the colon is a very satisfactory substitute for the esophagus. The advantages of the left colon include the following: the isoperistaltic transplant is of sufficient length to replace Table 4. Function of Substitute" Patient Group Good Fair Poor Corrosive injury 8 (75.6) 6 (6.) 3 (8.) Cancer of 8 (66.6) 9 (.4) 5 (.9) esophagus Cancer of cardia (7.5) 3 (7.6) (.7) Total 68 (7.8) 8 (8.7) (.4) the entire esophagus; the blood supply from the left colic artery is robust and rarely prone to anastomotic variation; and no redundancy or kinking, frequently seen with jejunum, is encountered. However, there are several contraindications to its use: variation in the vascular pattern of the marginal arteries; marked mesenteric arteriosclerosis; and intrinsic colon disease such as diverticulosis, diverticulitis, polyps, or carcinoma. Preference for the left colon over the right results from its more consistent marginal vessels. The marginal artery of the right colon may be incomplete in as many as 7% of patients. The lack of continuity is most often between the ileocolic and right colic arteries or between the middle and right colic arteries near the hepatic flexure. In.6% of patients, the right colic artery was absent altogether. In addition, the right colon can have relatively poor venous drainage [5-7]. Wilkins [8] reported that necrosis developed in 75.6% of 3 right colon replacements, but in only.9% of 68 left colon substitutions. Preoperative inferior mesenteric angiography was used in the patients seen early in our series to evaluate the vascular pattern of the left colon; we found no defect in the marginal artery in those patients. This invasive examination was then abandoned and the vascular condition was evaluated directly at operation. Only 3 patients were found to have a questionable blood supply, and in them, jejunum was used as the substitute. Although there are three anastomoses in colon procedures, the anastomoses are carried out by two teams of surgeons to shorten the operative time. Among our 96 patients who had reconstruction, the morbidity rate was much higher for those with malignant disease (35.7%) of the esophagus than benign stricture (6.%). We have found several factors that might contribute to the difference. () The mean age of patients with benign stricture of the esophagus (3.9 years) was much younger than that of those with malignant stricture (6.6 years). () In the group with corrosive injury of the esophagus, the operation is not as extensive as for malignant stricture because the patient requires only a laparotomy and cervical incision for the bypass operation; but with malignant stricture of the esophagus, the patient must undergo thoracotomy for resection of the esophagus or exploration before palliative bypass, thus resulting in some pulmonary complications. (3) The general condition of the patient with malignant stricture is poorer than that of the patient with benign stricture, especially in the late stages. For the same reasons, the mortality rate is also much lower (.7%) for patients with benign stricture than those with malignant stricture (.9%, 5.8%). Cervical anastomotic leakage is still the leading complication encountered in esophageal reconstruction. The incidence was only 8.% for patients with corrosive injury of the esophagus, but 9% for patients with cancer of the esophagus and.7% for those with cancer of the gastric cardia. The most important factors in preventing this complication are preservation of the marginal artery, gentle handling of the transplant, maintenance of venous return, and creation of a roomy tunnel [9]. The overall morbidity and mortality rates in this series are similar to those in a previous series of our patients

5 664 HUANGETAL Ann Thorac Surg 989:48:66-4 having reconstruction of the esophagus with stomach (morbidity, 3.8%, and mortality, 4.5%) [lo]. As for the function of the substitute, 7.8% of patients undergoing reconstruction with colon regained good swallowing function, 8.7% obtained fair function, and only.4% had poor function. Most of the poor-function results were due to cervical anastomotic leakage. Unusual attention to details of technique is mandatory to avoid complications and late swallowing problems. We thank Dr Earle W. Wilkins, Jr, for reviewing the manuscript. References. Kelling G. Osophagoplastik mit Hilfe des Querkolon. Zentralbl Chir 9;38:9-.. Vulliet H. De l'oesophagoplastie et des diverses modifications. Sem Med 9;3:5% Belsey R. Reconstruction of the esophagus with left colon. J Thorac Cardiovasc Surg 965;49: Skinner DB, Belsey RHR. Surgical management of esophageal reflux and hiatus hernia: long-term results with 3 patients. J Thorac Cardiovasc Surg 967;53:3% Ventemiglia R, Khalil K, Fraziero, Mountain C. The role of preoperative mesenteric arteriography in colon interposition. J Thorac Cardiovasc Surg 977;74: El-Domerii A, Martini N, Beattie E. Esophageal reconstruction by colon interposition. Arch Surg 97;: Nicks R. Colon replacement of the esophagussome observations on infarction and wound leakage. Br J Surg 967; 54: Wilkins EW Jr. Long-segment colon substitution for the esophagus. Ann Surg 98;9: Beattie EJ Jr, Economou SG. Atlas of advanced surgical techniques. Philadelphia: W.B. Saunders, 968:5%7.. Wang P-y, Chien K-y. Surgical treatment of carcinoma of the esophagus and cardia among the Chinese. Ann Thorac Surg 983;35:4>5.