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Esophageal replacement using the colon: is it a good choice?
S A Ahmad1, K G Sylvester, A Hebra
1Department of Surgery, University of Pennsylvania School of Medicine, Philadelphia, USA.
Insights
Colon interposition is a viable option for esophageal replacement in children, though additional procedures may be needed for optimal outcomes. Careful long-term follow-up is essential for managing potential late complications.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Thoracic Surgery
Background:
- Esophageal replacement is a complex procedure for children with esophageal atresia or strictures.
- Colon interposition has been utilized for decades, with various techniques and outcomes.
Purpose of the Study:
- To evaluate the long-term outcomes and complications of colon interposition for esophageal replacement in a pediatric population.
- To assess the efficacy of different surgical approaches and identify factors influencing functional results.
Main Methods:
- Retrospective review of 38 pediatric patients who underwent esophageal replacement between 1962 and 1993.
- Analysis of surgical techniques (right vs. left colon, substernal vs. transthoracic placement), early and late complications, and functional outcomes.
- Long-term follow-up data were collected for 20 patients (53%) over a mean of 12 years.
Main Results:
- Colon interposition, primarily using the right colon (61%), was performed for esophageal atresia and strictures.
- Early complications included cervical anastomotic leaks (29%) and pneumonia. Late complications involved strictures and graft failures (18%).
- Despite complications, 14 patients (70% of those with follow-up) had excellent results, while 17 (45%) required additional procedures.
Conclusions:
- Colon interposition remains a suitable option for pediatric esophageal replacement, offering good functional outcomes in the majority of cases.
- While early complications like anastomotic leaks can occur, they rarely persist long-term.
- Redundant grafts and poor emptying are potential late issues, underscoring the need for vigilant long-term patient monitoring and management.
Abstract:
Thirty-eight children (2 months to 26 years of age) underwent esophageal replacement at our institution between 1962 and 1993. Twenty-four patients had esophageal atresia, with the replacement performed at a mean age of 17 months. The remaining patients (37%) had strictures and were older (mean, 7.4 years). Replacement procedures involved the right colon in 61% of cases and the transverse left colon in the others (39%). Sixty-three percent were placed substernally and 37% were done in transthoracic fashion. The average length of stay in the hospital was 34 days (range, 11 to 256 days.) Early complications (within 30 days) included cervical anastomotic leaks (11 patients; 29%) pneumonia (4), would infection (2), pneumothorax/hemothorax (3), wound dehiscence (1), prolonged ventilation (2), vocal cord paralysis (1), Horner's syndrome (1), pancreatitis (1), and perforated graft (1). Despite the incidence of early leaks, only two persisted long-term (more than 3 months). Other late complications included significant proximal strictures (5), and cologastric strictures developed in five patients. Seven cases were considered graft failures (18%), and all of these eventually require graft replacement. Additional problems included redundant graft requiring revision (4) and dumping syndrome (2). There were six cases of intestinal obstruction caused by adhesions. Four of these involved intrathoracic obstruction of the graft and two involved small bowel obstruction. There was only one death, which occurred late and was not related to the primary disease or procedure. Long-term follow-up data were available for 20 patients (53%). The follow-up period ranged from 1 to 33 years (mean, 12 years). Fourteen had excellent results after the initial interposition, being able to eat and function well without any further intervention. Seven patients (18%) have had poor results and 17 (45%) required additional procedures to obtain good functional results. In our experience, the colon continues to be a good option for esophageal replacement, but additional procedures frequently are necessary to optimize the functional outcome. Good results can be expected in the majority of cases, but late problems (ie, redundant colon and poor emptying) are not unusual, and careful follow-up is essential in the management of such patients.