Coloplasty: an alternative to Gastric pull-up in benign diseases of Esophagus

Dr. Nitin R Nangare; Dr. Dhairyashil B Patil

Volume : X, Issue : I, January - 2020

Coloplasty: an alternative to Gastric pull-up in benign diseases of Esophagus

Dr. Nitin R Nangare, Dr. Dhairyashil B Patil

Abstract :

Restoration of swallowing in a patient with dysphagia due to nondilatable corrosive stricture of esophagus remains a surgical challenge. Organs available for replacement are stomach, jejunum, or colon. Jejunum is useful to replace a small segment, whereas stomach and colon are required for a long–segment replacement. In cases where the stomach is also injured, colon remains the only option. The route of colonic interposition has also been a subject of debate over the years. The choice of the colon as an esophageal substitute results primarily from the unavailability of the stomach. However, given its durability and function, colon interposition keeps elective indications in patients with benign or malignant esophageal disease who are potential candidates for long survival. The choice of the colonic portion used for esophageal reconstruction depends on the required length of the graft, and the encountered colonic vascular anatomy, the last being characterized by the near–invariability of the left colonic vessels, in contrast to the vascular pattern of the right side of the colon. Accordingly, the transverse colon with all or part of the ascending colon is the substitute of choice, positioned in the isoperistaltic direction, and supplied either from the left colic vessels for long grafts or middle colic vessels for shorter grafts. Technical key points are: full mobilization of the entire colon, identification of the main colonic vessels and collaterals, and a prolonged clamping test to ensure the permeability of the chosen nourishing pedicle. Transposition through the posterior mediastinum in the esophageal bed is the shortest one and thereby offers the best functional results. When the esophageal bed is not available, the retrosternal route is the preferred alternative option. The food bolus traveling mainly by gravity makes straightness of the conduit of paramount importance. The proximal anastomosis is a single–layer hand–fashioned end–to–end anastomosis to prevent narrowing. When the stomach is available, the distal anastomosis is best performed at the posterior part of the antrum for the reasons of pedicle positioning and reflux prevention, and a gastric drainage procedure is added when the esophagus and vagus nerves have been removed. In the other cases, a Roux–en–Y jejunal loop is preferable to prevent bile reflux into the colon. To construct a colon interposition graft that is long enough, we examined a procedure in which the colon is transected proximally at the site of the cecum and the right colic artery is transected, in addition to ligation of the middle artery. Here we examined the series of 20 procedures for post–corrosive esophageal strictures treated with retrosternal colonic interpositions.