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A technique to improve vascularity in colon replacement of the esophagus
1Pediatric Surgical Department, Heidelberg University, Germany. ahmed.hadidi@kch.ma.uni-heidelberg.de
Insights
A novel technique of ligating middle colic vessels during gastrostomy improves colon replacement success in children with esophageal issues. This simple, 10-minute procedure enhances blood supply, minimizing complications and increasing success rates for esophageal reconstruction.
Area of Science:
- Pediatric Surgery
- Gastrointestinal Surgery
- Vascular Surgery
Background:
- Esophageal replacement in children with corrosive strictures or long gap atresia presents surgical challenges.
- Optimizing blood supply to the colon graft is crucial for successful esophageal reconstruction.
Purpose of the Study:
- To introduce a straightforward method to enhance outcomes of colon interposition for esophageal replacement in pediatric patients.
- To evaluate the efficacy and safety of ligating middle colic vessels to augment graft vascularity.
Main Methods:
- The technique involves ligating the middle colic artery during a gastrostomy operation to improve blood flow to the transverse colon segment used for esophageal replacement.
- Eleven children (6 male, 5 female) underwent this procedure between November 1999 and October 2002 for esophageal atresia or stricture.
- The vascular ligation was performed 1-3 months prior to the definitive colon interposition surgery, with follow-up ranging from 21 to 56 months.
Main Results:
- Children resumed gastrostomy feeding on day five and oral feeding by day eight, with all discharged by day 15.
- No wound infections, fistulas, or chest complications were observed.
- One patient developed a colo-esophageal anastomosis stricture, which was successfully revised.
Conclusions:
- Ligation of middle colic vessels during gastrostomy is a simple, time-efficient adjunct that enhances blood supply to the colon graft for esophageal replacement.
- This technique has demonstrably increased success rates and minimized morbidity in pediatric colon interposition surgeries.
- While principles of vascular augmentation are used elsewhere, its application in intestinal surgery for esophageal replacement is novel.
Objective:
The aim of this study was to present a simple method to improve the results of colon replacement of the esophagus in children with post-corrosive esophageal stricture or long gap esophageal atresia.
Technique:
At the gastrostomy operation, the abdomen and colon are explored and the segment of colon to be used for replacement is chosen. The trunk of the middle colic artery supplying the transverse colon is ligated and divided proximally to the marginal artery or, if another segment of the colon is chosen, the corresponding vessel is ligated.
Methods:
Between November 1999 and October 2002, 11 children had their middle colic vessels ligated during a gastrostomy operation. They were six boys and five girls. Five neonates had long gap esophageal atresia with or without fistula. The other 6 had long segment esophageal stricture due to swallowing caustic potash. Their ages ranged from one day to 40 months. The hospital stay ranged from 10 to 14 days. The interval between vascular ligation and the replacement was one to three months, depending on the general condition of the patient. The follow-up period was between 21 and 56 months.
Results:
After the definitive operation for colon replacement of the esophagus, the children resumed feeding through the gastrostomy on day five. They were fed by mouth from day eight and all had returned home by day 15.
Complications:
There was no wound infection, no fistula, or chest complications. One patient developed stricture at the colo-esophageal anastomosis two months after surgery. The esophageal anastomosis was excised six months after the colon interposition surgery and re-anastomosis was performed through the same neck incision, after which the patient was sent home seven days later.
Conclusions:
Ligation of the middle colic vessels during the gastrostomy operation increases the blood supply to the transverse colon through the left upper colic and marginal vessels. This adds an extra ten minutes to the gastrostomy operation. This technique has increased the success rate in colonic replacement and minimized morbidity in our unit. Although the principle is commonly used in plastic surgery in pedicled flap reconstruction and in pediatric surgery for high abdominal testis (Fowler Stephens procedure), to our knowledge, this has never been applied in intestinal surgery before.
