Salvage esophageal reconstruction with colonic conduit: A single-center 25-year experience

Colonic interposition restores alimentary continuity after esophagectomy when a gastric conduit is unavailable, but its use has been limited by concerns about morbidity and functional outcomes. Hence, we aimed to assess our 25-year institutional experience, including perioperative outcomes, a subset with patient-reported outcomes, and a contemporary cohort treated with middle-colic microvascular "supercharging" to augment perfusion.

From January 2000 to June 2024, 99 patients underwent substernal colonic interposition. End points included perioperative outcomes, postoperative symptoms, assessed by Cleveland Clinic Esophageal Questionnaire (CEQ), and overall survival estimated by Kaplan-Meier method.

Median age was 61 [47, 73] years. Forty-eight (48%) patients had esophageal cancer. An inferior mesenteric artery-based transverse colon segment was used in 83 (84%). Sixteen (16%) underwent supercharge. Thirty-day mortality was 5%. One patient with supercharge (6.3%; 68% confidence interval, 2.3%-16%), and 36 without (43%; confidence interval, 38%-49%), developed a cervical anastomotic leak (P = .004). Among 18 patients with CEQ scores, most symptoms were experienced never or rarely; weekly postprandial diarrhea and bloating were the most common symptoms, reported by 10 (56%) and 9 (50%) patients, respectively. Median CEQ T scores for each symptom domain ranged from 42 to 56 after colon interposition versus 40 to 47 after gastric conduit. Overall survival with and without esophageal cancer was 25% to 66% at 10 years (P < .0001).

Colonic interposition historically carried substantial short-term morbidity attributable to sequelae of frequent anastomotic leaks. Presently, this can be mitigated with microvascular supercharge and a standardized multidisciplinary approach, warranting routine use. Contradicting conventional wisdom, long-term functional outcomes are similar to patients with a gastric conduit.