Salvage of a Failed Colon Interposition in the Esophagus With a Free Jejunal Graft

Transcription

1 Case Report Salvage of a Failed Colon Interposition in the Esophagus With a Free Jejunal Graft JACK FISHER, M.D., Section of Plastic and Reconstructive Surgery; W. SPENCER PAYNE, M.D., Section of Thoracic, Cardiovascular, Vascular, and General Surgery; GEORGE B. IRONS, Jr., M.D., Section of Plastic and Reconstructive Surgery A patient who had sustained lye burns of the esophagus had undergone reconstruction with a colon interposition. Because of necrosis and stricture of the interposed colon, he was unable to manage salivary secretions and was maintained on gastrostomy feedings. The defect from the pharynx to the midmanubrial level was reconstructed with a free jejunal graft by using microvascular surgical techniques. At 18-month follow-up, barium swallow roentgenography showed flow through the jejunal and colonic segments and into the stomach. The patient gained 15.9 kg postoperatively and was able to consume a normal diet. Reconstruction of the esophagus after caustic injury remains a challenging problem. Many techniques have evolved, including the use of stomach, small bowel, and colon. Although the mortality associated with reconstruction of the esophagus with colon interposition has decreased, the rate of complications is still substantial. 1 From reports in the literature, this complication rate varies from 5 to 35%. Anastomotic strictures occur in approximately 10% of patients as a late complication, and necrosis of the colon ensues in approximately 8% of patients. The distal portion of the colon farthest from its blood supply is in greatest jeopardy. A delay in the diagnosis of necrosis is associated with considerable morbidity and mortality. Occasionally, the colon can be remobilized and the defect can be closed primarily. If the area of necrosis is extensive, however, a substitute conduit must be used. With advances in microvascular surgical techniques, the use of free intestinal transfers has become increasingly popular, and the use of free vascularized jejunum for reconstruction after esophagolaryngectomy has become an accepted procedure. Another use of microvascular bowel transfer is salvaging a failed reconstruction such as partial necrosis after a previous colon interposition. One of the limitations of free intestinal transfer is the length of bowel segment that can be transferred on a single vascular pedicle; the maximal length seems to range from 18 to 22 cm. A longer segment of bowel is difficult to convert into a straight conduit, and a second microvascular anastomosis may be necessary. Therefore, total replacement of the esophagus with use of microvascular surgical techniques has limitations. In patients in whom the distal portion of a colon interposition has necrosed, the use of a free bowel transfer to restore continuity seems particularly appropriate. In the following case report, a 20-cm segment of vascularized free jejunum was used to repair a defect from the pharynx to the midmanubrial level. REPORT OF CASE A 32-year-old man had sustained an extensive caustic injury to his mouth, pharynx, and esophagus during an episode of depression and a suicide attempt by the ingestion of lye on Feb. 18, Despite early and appropriate medical management, intractable dysphagia and weight loss had ensued. On May 28,1981, he had undergone isoperistaltic, substernal, right colon interposition at another institution. On the basis of written reports, this procedure had consisted of mobilization of the right side of the colon on a middle colic vascular pedicle, which had been passed through the gastrohepatic omentum and through a substernal tunnel into the neck. The cervical portion of the esophagus had been transected, and its distal cervical end had been closed with a stapling device. An end-to-end cervical esophagocecostomy had been performed in the neck after an appendectomy and an end-to-side cologastrostomy had been done in the abdomen. Bowel continuity had been restored by an ileotransverse colostomy, and a feeding gastrostomy tube had been inserted. The short segment of the terminal ileum attached to the cecum had been brought to the outside through the cervical incision as a controlled fistula. The distal native esophagus remained in continuity with the stomach, but bilateral Mayo Clin Proc 59: ,

2 198 ESOPHACEAL RECONSTRUCTION Mayo Clin Proc, March 1984, Vol 59 Barium swallow roentgenography revealed extensive stricture of the hypopharynx and the cervical portion of the esophagus and leakage from the cervical fistula (Fig. 2). At no time was there filling of the interposed segment of colon. A fistulous tract from the neck area to the patient's native esophagus was noted. Retrograde fiberoptic endoscopy via the gastrostomy site failed to permit visual inspection of either the native esophagus or the interposed colon. With the patient under general anesthesia, the left side of the neck was explored through an incision along the anterior border of the sternomastoid muscle. The fistulous tract in the neck led to an abscess (5 cm in diameter) in the prevertebral area. Another tract extended interiorly from this abscess cavity into the chest, and injection of Hypaque demonstrated that this tract communicated with the native esophagus. The cervical portion of the esophagus, cecum, and terminal ileum were not identified in the neck. Peroral fiberoptic endoscopy permitted the passage of a Puestow wire through the pharyngeal stricture, and it was retrieved from the upper end of the cervical abscess cavity. Graduated dilators inserted over this wire permitted the subsequent passage of a 38-F Maloney dilator from the mouth into the cervical wound. With use of this bougie as a palpable guide, the cervical incision was extended cephalad toward the angle of the jaw. This extension allowed access to the base of the skull and the retropharyngeal space in front of the cervical vertebrae. A vertical incision was made in the posterior wall of the pharynx, and the introitus of the larynx was visualized. Fig. 1. Roentgenogram of gastroesophageal area after retrograde injection of contrast medium via the gastrostomy tube. Note filling of interposed substernal colon to a point 5 cm below clavicular heads. truncal vagotomy and pyloromyotomy had been performed. The patient subsequently had been fed by gastrostomy tube but experienced a breakdown of the cervical wound, causing all saliva and orally ingested material to drain externally through the neck wound. When the patient was initially examined at our institution in October 1981, he had a draining cervical esophageal fistula and was unable to swallow saliva or water without coughing. Physical examination revealed scarring between the tongue and the floor of the mouth and pooling of secretions in the hypopharynx. Subsequent fiberoptic examination disclosed a high-grade stricture of the hypopharynx beginning immediately posterior to the larynx, which precluded the passage of the scope. The larynx, vocal cords, and trachea were otherwise normal. A draining sinus tract, 1 cm in diameter, was present in the middle of the cervical scar. Swallowing of water produced immediate paroxysms of coughing and a trickle of water from this cervical fistula. The injection of contrast medium into the gastrostomy tube with the patient in the Trendelenburg position demonstrated a normal stomach with reflux up the interposed substernal colon to a point 5 cm below the clavicular heads behind the manubrium (Fig. 1). Selective angiography demonstrated a patent arterial blood supply to the interposed colon as far as the midportion of the manubrium. Fig. 2. Barium swallow roentgenogram, showing stricture of hypopharynx and cervical portion of esophagus. Arrowhead points to a cervical cutaneous fistula.

3 Mayo Clin Proc, March 1984, Vol 59 ESOPHAGEAL RECONSTRUCTION 199 The abdomen was explored, and dilation of the gastric stoma permitted introduction of a DeBakey femoral tun neling device into the stomach. This device was advanced cephalad along the substernal colon until progress was arrested behind the manubrium. In order to gain access to the sloughed and atretic blind end of the substernal colon, the left lateral half of the manubrium, the medial aspect of the clavicle, and the anterior end of the first rib were resected. Cephalad ad vancement of the device brought the atretic end of the colon into view at the midmanubrial level. After definition of the ends of the defect between the pharynx and the substernal colon, reconstruction with a free segment of autogenous jejunum was undertaken. The defect between the pharynx and the substernal colon was 20 cm long, and a comparable segment of je junum was isolated 60 cm distal to the ligament of Treitz. The mesentery and bowel were resected, and the vascular Fig. 3. Photograph of 22-cm segment of jejunum isolated on its pedicle was isolated (Fig. 3). Concomitantly, the external vascular pedicle before transfer. carotid artery and the internal jugular vein were dissected, while the segment of jejunum was allowed to perfuse on its vascular pedicle; thus, the ischemia time was minimized. After the recipient vessels were prepared, the jejunal pedi- Fig. 4. Jejunal segment has been transferred to head and neck area, and proximal bowel anastomosis has been completed. Arrows denote remnant of substernal colon. Fig. 5. Proximal and distal bowel anastomoses have been completed, and segment of jejunum has been revascularized.

4 200 ESOPHACEAL RECONSTRUCTION Mayo Clin Proc, March 1984, Vol 59 transient obstruction of the gastric outlet, which resolved with flexible endoscopic balloon dilation of the pylorus through the gastrostomy site. This permitted the resumption of feeding through the gastrostomy tube. Subsequent contrast radiographic examination objectively demonstrated patency of the esophageal reconstruction from the mouth to the stomach. An oral diet was taken with great difficulty initially; however, by the 30th postoperative day, the patient was consuming a general diet and had complete control of salivary secretions. One month postoperatively, the patient noted slight drainage of ingested material through the healed upper sternal incision. A cutaneous fistula was found to be communicating with the jejunocolonic anastomosis; however, with debridement and drainage, this spontaneously closed. His subsequent course was gratifying. At 18 months postoperatively, the patient had gained 15.9 kg (35 pounds) and was eating a general diet. Barium swallow roentgenograms showed rapid flow from the oropharynx into the jejunal and colonic segments with filling of the stomach (Fig. 7 and 8). f/> / 1 DISCUSSION In 1907, Carrel 2 reported transfer of a free jejunal segment in a dog. He had brought a section of jejunum into the head and neck area and had vascularized it by using the carotid and jugular vessels. In 1959, Seidenberg and associates 3 reported the first clinical case in which a patient had reconstruction of the cervical portion of the esophagus with a free jejunal graft. Other reports of use of this technique appeared in the 1960s and early 1970s. 4 ' 8 A major problem, however, was the high incidence of vascular thrombosis when the procedure involved small vessels. It was not until the late 1960s that advances in microvascular surgical techniques allowed substantial improvements in patency rates of small vessels. Once Fig. 6. Diagram showing reconstruction of hypopharynx and esophagus with a free jejunal segment anastomosed to previous colon interposition. cle was interrupted, and the free intestinal graft was brought into the neck and isoperistaltic orientation was maintained. The proximal end of the jejunum was anastomosed end to side with the pharynx by using interrupted 3-0 Vicryl sutures (Fig. 4). The microvascular anastomoses were then performed under the operating microscope with use of 8-0 nylon sutures on a BV-3 needle. On release of the microvascular clamps, the bowel regained its normal color and peristaltic activity. Finally, continuity was restored with an end-to-end jejunocolostomy at the midmanubrial level (Fig. 5 and 6). The upper cervical portion of the free jejunal graft was covered with a split-thickness skin graft. Initially, the patient had difficulty swallowing; he continued to expectorate saliva into a cup and was unable to ingest water without aspiration. This difficulty was considered to be related to edema of the free jejunal segment. This condition was further complicated by unexplained Fig. 7. Barium swallow roentgenograms 1 Vi years after reconstruction with free jejunal transplant. Black arrows denote proximal jejunal anastomosis to hypopharynx; white arrowheads identify distal jejunal anastomosis to colon.

5 Mayo Clin Proc, March 1984, Vol 59 ESOPHAGEAL RECONSTRUCTION 201 curved, and a second microvascular anastomosis may be necessary. The benefits of using a free intestinal graft in salvaging a colon interposition that has failed include the need for only a single-staged procedure, the provision of a rich blood supply in a scarred operative site, and the maintenance of peristaltic activity in the isolated jejunal segments. The use of free intestinal transfers and microsurgical techniques seems to be well suited for the patient who has had multiple previous procedures that have failed. Fig. 8. Barium swallow roentgenogram, showing remnant of colon interposition with flow into stomach. suture material and instruments were developed for use in conjunction with the microscope, predictable patency rates in excess of 90% were obtainable. As microvascular surgical procedures rapidly expanded in the 1970s, free intestinal transfers became more common. 9 Several series of patients have now undergone esophagolaryngectomy and reconstruction of the cervical part of the esophagus by means of a free intestinal transfer. 10 " 13 In 1980, Chang and associates 14 described a series of patients who had undergone esophageal reconstruction with free jejunal grafts; in two of these patients, previous colon interpositions had resulted in partial necrosis in the neck area. Patch grafts of free vascularized jejunum were used to repair isolated areas of colonic stenosis in the neck. One of the limitations of this procedure is the length of bowel that can be transplanted on a single vascular pedicle. Any segment longer than 18 to 22 cm becomes REFERENCES 1. Postlethwait RW: Surgery of the Esophagus. New York, Appleton- Century-Crofts, Carrel A: The surgery of blood vessels, etc. Johns Hopkins Hosp Bull 18:18-28, Seidenberg B, Rosenak SS, Hurwitt ES, Som ML: Immediate reconstruction of the cervical esophagus by a revascularized isolated jejunal segment. Ann Surg 149: , Roberts RE, Douglass FM: Replacement of the cervical esophagus and hypopharynx by a revascularized free jejunal autograft: report of a case successfully treated. N Engl) Med 264: , Hiebert CA, Cummings CO Jr: Successful replacement of the cervical esophagus by transplantation and revascularization of a free graft of gastric antrum. Ann Surg 154: , Jurkiewicz MJ: Vascularized intestinal graft for reconstruction of the cervical esophagus and pharynx. Plast Reconstr Surg 36: , Black PW, Bevin AG, Arnold PG: One-stage palate reconstruction with a free neo-vascularized jejunal graft. Plast Reconstr Surg 47: , Nakayama K, Yamamoto K, Tamiya T, Makino H, Odaka M, Ohwada M, Takahashi H: Experience with free autografts of the bowel with a new venous anastomosis apparatus. Surgery 55: , McKee DM, Peters CR: Reconstruction of the hypopharynx and cervical esophagus with microvascular jejunal transplant. Clin Plast Surg 5: , Hester TRJr, McConnel FMS, Nahai F, Jurkiewicz MJ, Brown RG: Reconstruction of cervical esophagus, hypopharynx and oral cavity using free jejunal transfer. Am J Surg 140: , Gluckman JL, McDonough J, Donegan JO: The role of the free jejunal graft in reconstruction of the pharynx and cervical esophagus. Head Neck Surg 4: , Robinson DW, MacLeod A: Microvascular free jejunum transfer. Br J Plast Surg 35: , Meyers WC, Seigler HF, Hanks JB, Thompson WM, Postlethwait R, Jones RS, Akwari OK, Cole TB: Postoperative function of "free" jejunal transplants for replacement of the cervical esophagus. Ann Surg 192: , 1980 '. 14. Chang T-S, Hwang O-L, Wang W: Reconstruction of esophageal defects with microsurgically revascularized jejunal segments: a report of 13 cases. J Microsurg 2:83-94, 1980