Although a variety of methods are available to re-establish

Transcription

1 Colonic Interposition for Benign Disease Steven R. DeMeester, MD Although a variety of methods are available to re-establish gastrointestinal continuity after esophageal resection, the most commonly used esophageal substitute is the stomach. In situations where the stomach is not available either as a consequence of prior surgery or for oncologic concerns when the tumor involves a significant portion of the lesser curve and cardia, a colon interposition is an excellent alternative. The transverse colon based on the ascending branch of the left colic artery is a reliable esophageal substitute that has the benefit of a consistent blood supply and long length. Drawbacks to esophageal replacement with a colon graft compared with a gastric pull-up include the increased time and complexity and the necessity of three anastomoses (esophago-colo, gastro-colo, and colo-colo). In addition, use of a colon graft requires preoperative evaluation with colonoscopy or barium enema to exclude colonic mucosal abnormalities, and bowel preparation before the operation. While long-term functional results after a colon interposition can be excellent, there are technical details that are important to minimize potential pitfalls and maximize the long-term advantages of a colon graft, the major one being protection of the residual squamous esophageal mucosa from reflux-induced injury that can lead to the redevelopment of Barrett s esophagus and in rare instances esophageal adenocarcinoma. Preoperative Evaluation Preoperative evaluation of a patient for colon interposition must take into consideration the primary esophageal pathology but also the patient, the status of the colon, and the planned route of reconstruction. Evaluation of the patient begins with a careful history and physical examination. Specific questions regarding the patient s history should include a review of any chronic colonic symptoms as well as the presence of colonic pathology such as diverticulosis, Crohn s disease, ulcerative colitis, prior polyps, or malignancy. In From the Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, Los Angeles, California. Address reprint requests to: Steven R. DeMeester, MD, Associate Professor of Surgery, Department of Cardiothoracic Surgery, Keck School of Medicine, University of Southern California, 1510 San Pablo Street, Suite 514, Los Angeles, California sdemeester@surgery.usc.edu. addition, the patient should be questioned about prior colonic resection or history of an abdominal aortic aneurysm repair. In patients that have not had a recent colonoscopy, the colonic mucosa should be examined before use of the colon for esophageal replacement. At a minimum an air contrast barium enema should be obtained, but colonoscopy is preferred since it allows direct examination of the colonic mucosa and biopsy or removal of polyps or lesions. The role of virtual colonoscopy with computed tomographic scanning remains to be determined. The colon should be prepared before surgery, and my preference is to admit the patient into the hospital the day before surgery and cleanse the colon with 4 liters of Go-Lytely combined with oral Neomycin and metronidazole. Enemas are avoided to minimize the potential for mucosal edema in the colon. The most common portion of colon used for esophageal replacement is the transverse colon based on the ascending branch of the left colic artery from the inferior mesenteric artery (Fig. 1). Although the routine use of preoperative angiography to examine the colonic vasculature is controversial, I find it useful to prevent unnecessary dissection and wasted time in the operating room since anatomic variants of the colonic arteries are common, and in elderly patients a patent inferior mesenteric artery cannot be assumed to be present. Angiographic criteria favorable for a transverse colon graft include the presence of a patent inferior mesenteric artery, an intact marginal artery, a single middle colic trunk, and a separate origin of the right colic artery. Absolute requirements include a patent inferior mesenteric artery and marginal artery. 1 If a stenosis is present in the inferior mesenteric artery, the standard transverse colon graft should be avoided and an alternate vascular pedicle or graft used. Venous drainage of the colon parallels the arterial system. Typically the left colic vein joins the splenic and portal system, and the marginal vein also provides colonic venous drainage via the hemorrhoidal vein and inferior vena cava if it is left in continuity when the colon graft is divided. In the right colic system there is greater variation and often no dominant vein, and it has been suggested that marginal venous drainage may in part be responsible for the higher infarction and anastomotic leak rate reported to occur with use of the right colon for esophageal replacement /06/$-see front matter 2006 Elsevier Inc. All rights reserved. doi: /j.optechstcvs

2 Reconstruction after esophagectomy with a colon interposition Operative Technique For Left Colon Interposition Figure 1 Typical arterial and venous anatomy for the colon. The standard colon interposition is based on the ascending branch of the left colic artery from the inferior mesenteric artery. The middle colic vessels are divided and the region of the hepatic flexure is brought up for anastomosis to the residual esophagus in an isoperistaltic fashion. a artery; v vein. 233

3 234 S.R. DeMeester Figure 2 For a standard colon interposition the colon is mobilized from the retroperitoneal attachments and then the splenic flexure is brought up as far as the left colic and inferior mesenteric vessels will permit. A silk marking stitch is placed at this point, typically at about the level of the xiphoid in most patients. An umbilical tape is then used to mark the distance from the stitch on the colon to the tip of the left ear. This tape will then be used to determine the necessary length of colon proximal to the marking stitch for the graft to comfortably reach to the neck.

4 Reconstruction after esophagectomy with a colon interposition 235 Figure 3 After confirming the suitability of the vascular supply of the proposed graft (in this case a standard transverse colon graft based on the left colic vessels), the middle colic vessels are divided and the mesentery separated to allow the graft to become as straight as possible. It should reach comfortably to the neck since the length was determined with the umbilical tape (note the two silk marking stitches). a artery.

5 236 S.R. DeMeester Figure 4 Via an anterior gastrotomy a standard vein stripper has been passed up to the neck and the esophagus ligated securely around the large head of the vein stripper. The entire esophagus will be stripped out, and the esophagus has been completely divided. The interwoven nature of the esophageal vagal plexus makes stripping the only method that will preserve vagal integrity in a reliable fashion. In preparation for the stripping the gastroesophageal junction fat pad and anterior vagus nerve have been mobilized toward the patient s right and a highly selective vagotomy has freed up the lesser curvature and also mobilized the posterior vagus toward the right side of the patient. a artery; n nerve.

6 Reconstruction after esophagectomy with a colon interposition 237 Figure 5 The entire esophagus is stripped out of the mediastinum by pulling on the vein stripper. It should strip easily with a minimum of force. Not shown is an umbilical tape left tied to the esophagus that will traverse the mediastinum and guide the subsequent dilation of the mediastinal tract and the colon interposition.

7 238 S.R. DeMeester Figure 6 The esophagus has been stripped out and is now completely inverted out the anterior gastrotomy. The cardia is divided distal to the gastroesophageal and squamocolumnar junctions to be certain all Barrett s tissue has been excised and no squamous mucosa is left behind.

8 Reconstruction after esophagectomy with a colon interposition 239 Figure 7 The anterior gastrotomy has been closed, and the staple line from the division of the cardia is visible. The highly selective vagotomy is seen along the lesser curve with preservation of the antral and pyloric innervation.

9 240 S.R. DeMeester Figure 8 The colon interposition is passed up through the mediastinum behind the stomach. It is necessary to divide the uppermost short gastric vessels and posterior pancreatico-gastric vessels along the posterior fundus to create a passageway for the graft. The esophageal anastomosis is done with a single layer of 4-0 PDS sutures with the knots on the inside. The colo-gastric anastomosis is stapled to the posterior wall of the fundus. Not shown is the colo-colo anastomosis, which typically is located just below the colo-gastric anastomosis to minimize the amount of mesenteric dissection necessary after dividing the distal end of the graft.

10 Reconstruction after esophagectomy with a colon interposition 241 Figure 9 Patients with achalasia are candidates for a mucosal stripping vagal-sparing esophagectomy. Here an anterior myotomy has been made in the cervical esophagus and the mucosa has been circumferentially dissected, divided, and ligated securely around the large head of a vein stripper passed up from an anterior gastrotomy.

11 242 S.R. DeMeester Figure 10 The mucosa is stripped out of the esophagus leaving the muscular tube of the esophagus in place. This is most useful in patients with end-stage achalasia who have a very dilated esophagus. Mucosal stripping in this circumstance minimizes bleeding, which can be substantial if the entire esophagus is removed since the dilated achalasia esophagus can be supplied by very large aortic branches. Further, the old muscularis propria of the esophagus serves to keep the colon graft straight in the mediastinum and reduces the potential for redundancy.

12 Reconstruction after esophagectomy with a colon interposition 243 Figure 11 When the vagus nerves have been divided, the colon graft is sewn to the gastric antrum, and the upper two-thirds of the stomach are excised. The colo-antral anastomosis is done full length to the excised antral staple line, and often the colon is spatulated proximally along the anterior tinea to compensate for size discrepancy. The anastomosis is done in two layers of interrupted 3-0 silk sutures.

13 244 S.R. DeMeester Figure 12 (A) When the vagus nerves have NOT been preserved, a pyloroplasty is performed using a circular stapler. After manually dilating the pylorus with a clamp, head of a 21-mm circular stapler is passed through the pylorus, closed, and fired with gently downward pressure with a silk tie to push the anterior pyloric musculature into the stapler. The stapler is advanced through a gastrotomy along the lesser curve, which is excised when the stomach is divided at the antrum for anastomosis to the colon graft when the vagus nerves have not been preserved. (B) The endoscopic appearance of the pylorus after a stapled pyloroplasty procedure. An anterior defect in the pyloric ring has been created.

14 Reconstruction after esophagectomy with a colon interposition 245 Figure 12 Continued

15 246 S.R. DeMeester I use an upper midline abdominal incision, which typically extends below the umbilicus for esophagectomy with colon interposition. The first step is to dissect the omentum off the transverse colon and fully mobilize both the ascending and the descending colon, including the splenic and hepatic flexures and the cecum. The middle colic vessels are identified within the transverse mesocolon, and the middle colic artery is dissected to its origin from the superior mesenteric artery. Similarly, the middle colic vein is dissected to its junction with the superior mesenteric vein. If the gastroepiploic vein joins the middle colic vein, it must be preserved and the middle colic vein ligated distal to this junction. To determine the approximate length of colon necessary for reconstruction, I measure from the bottom of the left earlobe to the xiphoid with an umbilical tape and cut the tape to this distance. The left colon/splenic flexure region is brought up to the xiphoid until limited by the tethering effect of the left colic artery, and the antimesenteric border of the colon is marked at that location with a silk stitch (Fig. 2). This umbilical tape is then used to mark out the proposed colon graft starting from the site of the stitch near the splenic flexure and extending proximally toward the cecum. A second silk marking stitch is placed at the proximal limit of the umbilical tape, typically near the hepatic flexure or ascending colon just distal to the cecum. This portion of the colon will be brought up for anastomosis to the residual esophagus in an isoperistaltic fashion. Once the necessary length of colon for esophageal replacement is marked out, the vascular supply of the colon graft is assessed. The middle colic vessels are dissected down to their origin from the superior mesenteric artery and vein. It is critical to maintain communication between the right and left branches of the middle colic artery to provide adequate perfusion to the proximal portion of the proposed colon graft (near the hepatic flexure). In some cases the bifurcation of the right and left branches of the middle colic artery is so close to the superior mesenteric artery that a side-biting vascular clamp must be applied to the superior mesenteric artery to ligate the middle colic artery proximal to this bifurcation. When there are two middle colic arteries with separate origins from the superior mesenteric artery, the vascular supply of the proximal portion of the graft is compromised, and this section of colon must be carefully assessed for suitability. If the perfusion is marginal, consideration should be given to selecting an alternate vascular pedicle for the graft or supercharging the graft by performing a microvascular anastomosis between the middle colic vessels and suitable vessels in the neck. In most cases the need to divide more than two arteries or veins should prompt consideration of an alternate graft, or to use the colon based on alternate vessels. Once the anatomy of the middle colic vessels has been found to be acceptable, the artery is temporarily occluded with a fine bulldog vascular clamp. Vascular isolation of the proposed graft is completed by temporarily clamping the collateral circulation from the right and ileocolic vessels coursing within the mesentery between the cecum or ascending colon and the proximal extent of the proposed graft. At this point the vascular supply to the graft should be exclusively from the left colic vessels, and the adequacy can be assessed using palpation, inspection, and Doppler signal. Regardless of preoperative angiographic findings, the final decision regarding use of the colon as a graft is always made in the operating room after a careful inspection of the isolated graft. In a good graft, within several minutes of applying the clamps the small vessels adjacent to the wall of the colon in the proximal portion of the proposed graft will be visibly pulsatile. In the absence of visible pulsations in the vessels along the mesenteric border of the graft, Doppler examination should demonstrate a strong signal. If a strong signal is not present, consideration should be given to supercharging the graft or staging the reconstruction and leaving the colon in the abdomen to be inspected again in 48 hours. The adequacy of venous outflow should also be assessed, since venous hypertension can ultimately lead to arterial compromise and loss of the graft. If the vascular supply is adequate, the middle colic vessels are divided, and the colon is transected with a GIA stapler at the site of the proximal stitch. The vessels in the mesentery at the site of transection of the colon are ligated, and the remaining avascular portions of the transverse mesocolon are divided so that the colon graft can be straightened out as much as possible (Fig. 3). In rare circumstances a reversed transverse colon graft is used based on the middle colic vessels with the descending colon brought up for anastomosis to the esophagus. However, an isoperistaltic graft is always preferred. In most patients the graft is placed in the posterior mediastinum in the bed of the native esophagus, and this route tends to produce the best functional result. I bring the colon interposition up through the posterior mediastinum into the neck by suturing it to the funnel of an inverted Mousseau Barbin tube and wrapping the graft in a camera bag. This allows atraumatic transfer of the graft because tension is transferred to the bag, and the bag also protects the mesentery during passage through the mediastinum. It is critical to avoid twisting of the graft, and the mesenteric vessels should be located posterior and to the right of the graft. I prefer to anastomose the esophagus to the colon in an end-to-end fashion using a single layer of interrupted 4-0 monofilament sutures, although a stapled technique can also be useful for this anastomosis, particularly when there is a significant size discrepancy. All knots are placed on the inside with the exception of the final three or four sutures used to finish the anastomosis on the anterior surface. At the completion of the proximal anastomosis the camera bag is pulled out from the abdomen, thereby straightening out the colon graft and eliminating any redundancy. It is important to secure the colon to the left crus with several 2-0 silk sutures after it is pulled straight to prevent late redundancy and to avoid herniation of abdominal viscera into the mediastinum through the hiatus. The distal end of the colon graft is transected approximately 10 cm distal to the hiatus in preparation for the colo-gastric anastomosis. Care should be taken to transect the colon immediately adjacent to the bowel wall to avoid injury to the vascular pedicle of the graft. Both ends of the divided colon are mobilized just enough to permit performance of the coloantral and colo-colo anastomomoses. The colo-antral anastomosis is done with two layers of interrupted 3-0 silk sutures, and the entire length of the divided antrum is used for the anastomosis to minimize any retention in the distal colon graft. The colo-colostomy is done using a similar two-layer technique.

16 Reconstruction after esophagectomy with a colon interposition 247 Vagal-sparing Esophagectomy with Colon Interposition In the vagal-sparing procedure, the esophagus is stripped from the mediastinum using a vein stripper, allowing the vagal plexus in the mediastinum to be preserved. Since no mediastinal dissection is performed, it is an easier procedure than a trans-hiatal resection and can be done laparoscopically. After identifying the esophagus at the hiatus and placing vessel loops around the anterior and posterior vagal trunks, the first important step is to mobilize the gastroesophageal junction fat pad from the left toward the patient s right side. In so doing the anterior vagus trunk will be pulled safely away from the right side of the distal esophagus and cardia of the stomach. This then permits a highly selective vagotomy to be performed along the lesser curve of the stomach starting at the crow s foot in the antrum and extending proximally up to the distal esophagus. While relatively acid resistant, the intact, innervated stomach left with the vagalsparing procedure can generate sufficient acid to lead to ulcers in the colon near the colo-gastric anastomosis. The routine addition of a highly selective vagotomy and use of acid suppression medication when necessary has largely eliminated this problem. Once the vagal trunks have been freed from the distal esophagus, no further mediastinal dissection is performed. The next step is to open the left neck and expose the esophagus. A nasogastric tube is inserted by the anesthesiologist and 250 ml of dilute betadyne solution is irrigated into the esophagus to prepare the mucosa and reduce contamination during the esophageal stripping. In patients with Barrett s and high-grade dysplasia or intramucosal cancer the entire esophagus is stripped out, while for benign disease like achalasia, only the mucosa is removed and the muscular wall of the esophagus is left in place in the mediastinum. A 1-cm gastrotomy is created in the anterior wall of the stomach just distal to the gastroesophageal junction and the vein stripper is passed through the gastrotomy and up to the neck. The cervical esophagus is secured to the vein stripper with ties and endoloops to prevent the head of the vein stripper from pulling through and to insure that the esophagus inverts on itself, and then the esophagus is pulled out inside out through the gastrotomy (Figs. 4 to 7). A stapler is used to divide the cardia distal to the gastroesophageal junction to be sure that all Barrett s or squamous mucosa is removed, and the anterior gastrotomy is closed. After stripping out the esophagus, the mediastinal tract is dilated to prevent compression of the graft. An exception is when the esophagus is removed for end-stage achalasia. I use a Foley catheter with a 90-mL balloon and pull it from the abdomen up to the neck through the posterior mediastinum several times, starting with 30 ml of saline and adding more saline to the balloon each time. The colon graft is then wrapped in a camera bag for protection, brought posterior to the intact stomach via a window created by division of the proximal one to two short gastric and posterior pancreaticogastric vessels, and pulled up into the neck. A hand-sewn, single-layer esophago-colo anastomosis is performed, and the colon graft is straightened out by pulling the camera bag back out the abdomen. A stapled colo-gastric anastomosis is then performed to the posterior fundus of the intact, innervated stomach (Fig. 8). No pyloroplasty is necessary since the vagal innervation to the antrum and pylorus is preserved. Patients with end-stage achalasia are candidates for a mucosal-stripping vagal-sparing esophagectomy in which only the esophageal squamous mucosa is removed. The dilated, nonfunctional esophageal muscular wall is left in place and supports the graft in the mediastinum. The mucosal-stripping procedure is similar to that described above except in the neck a myotomy is created in the distal cervical esophagus and the mucosa is dissected circumferentially and divided, leaving the posterior muscular wall of the esophagus intact. The vein stripper is passed up from a gastrotomy near the gastroesophageal junction, and just the mucosa is ligated securely around the large head of the vein stripper. By pulling on the vein stripper the squamous esophageal mucosa is stripped out and the muscular wall of the esophagus is left in place along with the vagus nerves (Figs. 9 to 10). A TIA stapler is used to divide the gastric mucosa just distal to the gastroesophageal junction. A hole is created in the left lateral portion of the distal esophageal muscular wall and the colon graft is brought posterior to the stomach and up into the neck inside the residual muscular wall of the esophagus via the hole created distally. The esophago-colo and cologastric anastomoses are performed as described above. It is important that the mucosal stripping be done only in benign disease such as achalasia, and not for Barrett s. In any patient with premalignant mucosa the entire esophagus needs to be removed to be certain no mucosa is left behind. Non-vagal-sparing Esophagectomy If the vagus nerves have been divided or there is preoperative evidence of poor gastric emptying, then the colon should not be anastomosed to the intact stomach since significant problems with regurgitation are likely to develop. Instead, removing the proximal two-thirds of the stomach and anastomosing the colon to the antrum is a better choice and works very well. Over time the antrum regains a degree of function and acts as a pump to move material to the duodenum, while the colon graft takes on the former role of the stomach and acts as a reservoir. The longer the colon graft is in place, the better the function tends to be, so patience is warranted on the part of the patient and physician if there are troubling symptoms in the first 6 to 12 months after the procedure. I prefer an end-to-end hand-sewn anastomosis between the distal colon and antrum, utilizing the full length of the antral staple line after gastric transection (Fig. 11). In this fashion, colonic emptying is maximized and the potential for an anastomotic stricture is minimized. In patients where the whole stomach has been removed the colon can be connected to a Roux-en-Y limb of jejunum. When the vagus nerves have been transected, then a pyloroplasty is performed. I prefer a simple technique done with the circular stapler. The pylorus is manually dilated with a large clamp and then the anvil of a 21-mm circular stapler is passed through the pylorus. A 2-0 silk tie is used to push the anterior wall of the pylorus into the stapler, and the stapler is approximated and fired (Fig. 12A and B). Typically a wedge of the pyloric ring is removed, thereby

17 248 S.R. DeMeester disrupting the pylorus, and the staple line is completely internal (subserosal), eliminating the risk of a leak. Operative Technique for Right Colon Interposition The approach to the isoperistaltic right colon interposition is started similarly to the left colon. After excision of the omentum, the entire right colon and terminal ileum are mobilized from the retroperitoneum. The graft will be based on the middle colic vessels, and the first step is to stretch the transverse colon at the site of the middle colic vessels cephalad toward the xiphoid and then place a marking stitch in the antimesenteric border of the bowel at that point. The length of colon required is estimated by again using an umbilical tape cut to the distance between the left ear and the xiphoid. The site on the proximal colon or in some cases terminal ileum where the umbilical tape reaches is marked with a second silk stitch. The ileocolic, right colic, and ileal (if required) arteries are isolated and clamped with atraumatic bulldog clamps. The vascular supply based on the middle colic artery can now be assessed. In select circumstances a reversed right colon graft can be used based on the right and/or ileocolic vessels with division of the middle colic vessels using the region of the splenic flexure or proximal descending colon for the proximal anastomosis. Once the adequacy of the vascular supply has been confirmed, the appropriate vessels are divided and the graft is brought up to the neck as described above. Routes for Reconstruction Once the conduit has been prepared, the route of reconstruction must be selected and readied for the graft. There are two primary routes and two alternate, although seldom used, routes. In most cases the colon graft is positioned in the posterior mediastinum, in the bed of the excised esophagus. If the posterior mediastinum is unavailable because of delayed reconstruction or unwise to use because of residual disease in the chest, the graft is brought up substernally in the anterior mediastinum. When the colon is to be placed substernally, it is important to enlarge the thoracic inlet and minimize the acute angle created when the esophagus deviates from its normal course into the posterior mediastinum and turns superficially to pass under the sternum. We enlarge the thoracic inlet by removing the medial aspect of the left clavicle, the left half of the manubrium, and the medial portion of the first rib. Likewise the exit from the substernal tunnel should be inspected. If there is a very large left lateral segment of the liver, it may be necessary to remove some or all of it to prevent interference with the graft as it descends posteriorly to join the gastric remnant. Likewise, the diaphragm should be resected laterally for several centimeters on each side of the midline of the substernal window to prevent diaphragmatic obstruction of the graft. On occasion the pericardium creates an acute angle and it can be opened and closed transversely to eliminate any obstruction of the graft if necessary. Prior coronary artery bypass surgery makes creation of a substernal window hazardous and is a relative contraindication. A seldom-used option available when the posterior and anterior mediastinal routes are not available is the intrathoracic or pleural route. The left pleural space can be accessed either through the esophageal hiatus or through a small phrenotomy in the anterior aspect of the left diaphragm. The conduit can be brought up to the neck either anterior or posterior to the pulmonary hilum and then through the enlarged thoracic inlet following partial manubriectomy and claviculectomy as described above. A last option is the subcutaneous route. This is a potential space created above the sternum in the subcutaneous tissue. At the xiphoid, dissection with electrocautery is used to create a tunnel on the anterior aspect of the sternum. Similarly, at the sternal notch, the subcutaneous tissue is dissected free of the sternum. A tunnel three fingerbreadth s wide is necessary to create enough space for the colon interposition. By necessity, a ventral hernia is created at the level of xiphoid to allow the colon to exit the abdominal cavity and lie on top of the sternum. The graft is brought up via the subcutaneous tunnel into the neck. Postoperative Care Patients are routinely extubated at the completion of the operation and admitted directly to the intensive care unit. Continuous infusions of dopamine (3 g/kg/min) and nitroglycerin (5 to 20 mg/min) are used to aid graft perfusion and minimize venous congestion for 72 hours. Intravenous fluids and 5% albumin infusions are administered as needed to maintain intravascular volume. A thoracic epidural catheter placed before the operation is used for postoperative pain management and facilitates pulmonary toilet. Antibiotics are discontinued after routine perioperative coverage. Nasogastric suction is maintained until the drainage is minimal and bowel function has returned. We routinely obtain a contrast swallow study before starting oral intake to confirm anastomotic integrity and more importantly assess conduit emptying. Once an oral diet is initiated, patients are given strict instructions to eat or drink only when upright, and to stay upright for a minimum of an hour afterward to allow the graft to empty and to minimize the potential for an aspiration event. The threat of aspiration is real, and patients must be warned to avoid laying flat at all times, particularly if they have had anything to eat or drink recently. Results of Colon Interposition Despite recent improvements in perioperative management, postoperative morbidity following esophagectomy remains significant. Compared with a gastric pull-up colon interposition is a longer and more complex operation that entails three anastomoses, but I have not found significant differences in morbidity or mortality between the two procedures. Long-term problems with colon interposition include graft redundancy, aspiration and bile reflux/peptic complications, or dumping and postvagotomy diarrhea. 3 The most common indication for late reoperation is redundancy of the interposition. 4 To minimize this problem, it is important to pull the colon graft firmly into the abdomen and secure it with stitches to the left crus. However, the natural tortuosity of the colon and its thin wall render it susceptible to dilation along

18 Reconstruction after esophagectomy with a colon interposition 249 its course from extrinsic compression. Most commonly, redundancy is seen just above the hiatus. Redundancy leads to retention of food and liquid in the graft with regurgitation and an increased risk of aspiration. Reoperation with excision of the redundant portion and end-to-end colo-colostomy corrects the problem and is well tolerated since over time the vascular supply of the graft becomes quite hardy as long as the mesenteric pedicle is preserved. Rarely patients will have severe bile reflux and aspiration events unrelated to a redundant graft, and for these patients reoperation with roux-en-y colo-jejunostomy or duodenal switch procedure may ultimately be required. However, medical therapy with carafate and other bile binding agents and prokinetics including Dulcolax should be tried before considering revisional surgery. Dumping and postvagotomy diarrhea are relatively common early after surgery, but rarely are debilitating. However, a small percentage of patients suffer from severe dumping, and for these patients quality of life is significantly impaired. This is one of the major advantages of the vagal-sparing procedure, particularly since it is applicable to patients with benign disease or early cancer who have an excellent life expectancy and will be most devastated by protracted difficulty with dumping or diarrhea. To confirm that the vagalsparing procedure preserves vagal function and minimizes the risk of dumping and diarrhea, we compared a randomly selected group of patients who underwent one of three operations: vagal sparing esophagectomy with colon interposition; standard esophagectomy with colon interposition; and standard esophagectomy with gastric pull-up. 5 We found that after a vagal-sparing esophagectomy with colon interposition to the intact innervated stomach patients were able to consume a meal and maintain their body mass index significantly better than after procedures where the vagus nerves were divided. Further, the incidence of dumping and diarrhea was reduced in the vagal-sparing procedure. For patients with dumping and diarrhea refractory to dietary manipulation somatostatin injections are sometimes helpful. Conclusions Colon interposition is a challenging operation but remains an excellent option in patients where a gastric pull-up is not available or would be an oncologic compromise. Long-term function is excellent provided strict attention to operative detail is maintained. A colon interposition may offer benefits over a gastric pull-up in young patients that require esophageal replacement, particularly when performed as a vagalsparing procedure to the intact, innervated stomach. Because of the complexity, its use is perhaps best restricted to specialized centers that perform a high volume of esophageal surgery. References 1. Peters JH, Kronson JW, Katz M, DeMeester TR: Arterial anatomic considerations in colon interposition for esophageal replacement. Arch Surg 130(8): , discussion , Nicks R: Colonic replacement of the oesophagus. Some observations on infarction and wound leakage. Br J Surg 54: , DeMeester TR, Johansson KE, Franze I, et al: Indications, surgical technique, and long-term functional results of colon interposition or bypass. Ann Surg 208(4): , DeMeester SR: Colon interposition following esophagectomy. Dis Esophagus 14(3-4): , Banki F, Mason RJ, DeMeester SR, et al: Vagal-sparing esophagectomy: a more physiologic alternative. Ann Surg 236(3): , discussion , 2002