European perspective in Thoracic surgery-eso-coloplasty: when and how?

Abstract

Colon interposition has been used since the beginning of the 20(th) century as a substitute for esophageal replacement. Colon interposition is mainly chosen as a second line treatment when the stomach cannot be used, when the stomach has to be resected for oncological or technical reasons, or when the stomach is deliberately kept intact for benign diseases in young patients with long-life expectancy. During the surgery the vascularization of the colon must be carefully assessed, as well as the type of the graft (right or left colon), the length of the graft, the surgical approach and the route of the reconstruction. Early complications such as graft necrosis or anastomotic leaks, and late complications such as redundancy depend on the quality of the initial surgery. Despite a complex and time-consuming procedure requiring at least three or four digestive anastomoses, reported long term functional outcomes of colon interposition are good, with an acceptable operative risk. Thus, in very selected indications, colon interposition could be seen as a valuable alternative for esophageal replacement when stomach cannot be considered. This review aims at briefly defining "when" and "how" to perform a coloplasty through demonstrative videos.

Keywords: Esophageal surgery; benign esophageal disease; colon interposition; esophageal cancer; esophageal motility dysfunction.

Figure 1

Vascularisation of the colon applied to surgery. (A) Right colon vascularisation based on the superior mesenteric artery: [1] ileo-colic artery; [2] right colic artery; [3] media colica; (B) left colon vascularisation based on the inferior mesenteric artery: [4] IMA; [5] drummond marginal artery. IMA, inferior mesenteric artery.

Figure 2

Transillumination of the left colic vasculature.

Figure 3

Mobilisation of the colon. The colon is mobilised from the right hepatic flexure to the caecum, then from the left flexure to the sigmoid colon. When it is completely freed, the vessels are identified using transillumination (43). Available online: http://www.asvide.com/articles/966

Figure 4

Clamping of the colic arterial vessels. The length of available colon is measured, as is the length needed. The good arterial outflow of the transplant is tested using atraumatic clamps. Here the right collateral arcade is clamped (44). Available online: http://www.asvide.com/articles/967

Figure 5

Simulation of the graft vascularisation with the inferior mesenteric artery. The right colic artery, the middle colic artery and the marginal arteries are occluded with atraumatic clamps. The arterial outflow and the venous drainage through the left colic vessels are checked for at least 10 minutes.

Figure 6

The left colon transplant is freed and pedicled on the left colic vessels. (A) The proximal colon is transected; (B) the middle colic artery is transected; (C) the length of the colic transplant is checked; (D) the distal colon is transected.

Figure 7

The colic transplant is brought to the neck through a retro-sternal route. The upper thoracic inlet and the retro-sternal space are divided with blunt dissection. A loop is passed through the retro-sternal space from the cervicotomy to the hiatus. After it has been attached to the colonic transplant, it will be used to pull the colon to the neck. This whole step must be done precautiously in order not to compromise the colonic transplant (48). Available online: http://www.asvide.com/articles/968

Figure 8

Preservation of the stomach during a colon interposition. The colo-gastric anastomosis is performed at the posterior side of the antrum and is associated with a pyloroplasty.

Figure 9

Roux en Y loop. After a gastrectomy, two more anastomoses are needed when performing a colon interposition: a colo-jejunostomy and a jejuno-jenal anastomosis.

Figure 10

Eso-colic anastomosis. (A) Hand-sewn cervical anastomosis; (B) mechanical intra-thoracic anastomosis.

Figure 11

Hand-sewn cervical eso-colic anastomosis. The posterior part of the anastomosis is performed first. A resorbable 3.0 stitch is used for the first layer, and a slowly resorbable one for the second. After the naso-gastric tube has been placed through the colonic transplant, the anterior wall of the anastomosis is performed in the same way (53). Available online: http://www.asvide.com/articles/969