From the Guidelines
Colon interposition is usually reserved for patients who have undergone previous gastric surgery or other procedures that might have devascularized the stomach, and the left or transverse colon segments are preferred for reconstruction due to their reliable blood supply. When considering colon interposition after esophagectomy, it is essential to evaluate the potential blood supply to the colon segment to be used for reconstruction. According to 1, the gastric conduit is preferred for esophageal reconstruction, but colon interposition may be necessary in certain situations. The procedure should include careful preoperative evaluation of colonic vasculature using angiography or CT angiography to ensure adequate blood supply to the chosen segment.
- Key considerations for colon interposition include:
- Preoperative evaluation of colonic vasculature
- Selection of the left or transverse colon segments for reconstruction
- Preservation of the vascular pedicle during mobilization of the colon segment
- Postoperative monitoring for anastomotic leaks, strictures, and redundancy
- The potential benefits of colon interposition include durable long-term results with acceptable morbidity, although the procedure requires greater technical expertise and longer operative time compared to gastric pull-up, as noted in 1.
- In terms of specific surgical approaches, Ivor Lewis esophagogastrectomy and the McKeown esophagogastrectomy are the two standard options for transthoracic esophagogastrectomy, and transhiatal esophagogastrectomy may be used for lesions at any thoracic location, but with potential difficulties in dissection of large, middle esophageal tumors adjacent to the trachea, as discussed in 1.
- Minimally invasive esophagectomy strategies, including minimally invasive Ivor Lewis esophagogastrectomy and minimally invasive McKeown esophagogastrectomy, may be associated with decreased morbidity and shorter recovery times, but require further study to determine their long-term outcomes, as mentioned in 1.
From the Research
Colon Interposition for Esophagectomy: Potential Blood Supply and Recommendations
The potential blood supply for colon interposition after esophagectomy is a crucial factor in determining the success of the procedure. Several studies have investigated the arterial anatomy and venous drainage of the colon to identify the optimal graft for esophageal replacement.
- The study by 2 identified five angiographic features that are important for successful use of the left colon: a patient inferior mesenteric artery, a visible ascending branch of the left colic artery, a well-defined anastomosis between the middle colic and left colic systems, a single middle colic trunk prior to its division into right and left branches, and a separate origin of the right colic artery.
- The study by 3 described a modified technique for colon interposition using the right colon, which relies on the left colic artery for blood supply. This approach avoids the need for mobilization of the left flexure, which can damage arterial or venous collaterals.
- The study by 4 reported a case of salvage reconstruction using left colon interposition with microscopic supercharge and superdrainage anastomosis after failure of ileocolic interposition. This approach ensured augmented blood flow to the graft.
Recommendations for Colon Interposition
Based on the available evidence, the following recommendations can be made for colon interposition after esophagectomy:
- The left colon is a suitable graft for esophageal replacement, with a success rate of over 80% when screened by angiographic criteria 2.
- The right colon can also be used as a graft, with a modified technique that relies on the left colic artery for blood supply 3.
- The retrosternal route is associated with the lowest overall pooled morbidity and mortality, and left colonic conduits placed retrosternally are safest 5.
- Microscopic supercharge and superdrainage anastomosis can be used to ensure augmented blood flow to the graft, especially in cases of salvage reconstruction 4.
- Patients with an occluded or stenotic inferior mesenteric artery or variant middle colic arterial anatomy should undergo an alternate reconstruction 2.