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ORIGINAL ARTICLE
Year : 2016  |  Volume : 12  |  Issue : 7  |  Page : 212-216

Application of colon interposition among the esophageal cancer patients with partial gastrectomy


1 Department of Thoracic Surgery, The First Hospital Affiliated to Huzhou University School of Medicine, Huzhou, Zhejiang, China
2 Department of Thoracic Surgery, Zhejiang Provincial Cancer Hospital, Hangzhou, Zhejiang, China
3 Department of Thoracic Surgery, Zhejiang Hospital, Hangzhou, Zhejiang, China

Date of Web Publication21-Feb-2017

Correspondence Address:
Qiuqiang Chen
Department of Thoracic Surgery, The First Hospital Affiliated to Huzhou University School of Medicine, 158 Guangchang Road, Huzhou, Zhejiang, 313000
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/0973-1482.200602

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 > Abstract 

Background: Esophageal reconstruction with colon interposition is an alternative solution for the esophageal cancer patients who have partial gastrectomy. The aim of this study was to investigate the therapeutic effects of colon interposition among the esophageal carcinoma patients with partial gastrectomy.
Materials and Methods: Under institutional review board approval, 32 esophageal carcinoma patients with a history of partial gastrectomy were included in this study. All the patients had been diagnosed and confirmed squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma by histopathological examination. Surgical approaches, complications and therapeutic results were analyzed in the current study.
Results: Thirty-two esophageal carcinoma patients (29 men, 3 women, median age 63.2 years) were included in this study. Isoperistaltic colon interposition was carried out on 14 patients; their 1-year and 2-year survival rate was 92.9% and 78.6%, respectively. Antiperistaltic colon interposition was carried out on 18 patients; their 1-year and 2-year survival rate was 88.9% and 77.8%, respectively. In which, cervical anastomotic leakage was observed on six patients.
Conclusion: Colon interposition is an ideal surgical approach for the esophageal carcinoma patients who had partial gastrectomy. Isoperistaltic colon interposition is preferred, but antiperistaltic colon interposition has the advantage that a longer colon can be used.

Keywords: Colon interposition, esophageal carcinoma, gastrectomy


How to cite this article:
Chen Q, Mao W, Yu H, Liang Y, Wang J, Chen G. Application of colon interposition among the esophageal cancer patients with partial gastrectomy. J Can Res Ther 2016;12, Suppl S3:212-6

How to cite this URL:
Chen Q, Mao W, Yu H, Liang Y, Wang J, Chen G. Application of colon interposition among the esophageal cancer patients with partial gastrectomy. J Can Res Ther [serial online] 2016 [cited 2021 Mar 1];12:212-6. Available from: https://www.cancerjournal.net/text.asp?2016/12/7/212/200602


 > Introduction Top


Ulcers are the most common cause of hospitalization for upper gastrointestinal bleeding. Thus, there are many patients who underwent partial gastrectomy due to bleeding, perforation, stenosis, or carcinoma that are complicated by gastric ulcer or duodenal ulcer. Therefore, in recent years, we have treated some esophageal carcinoma patients with a history of partial gastrectomy. This patient type of esophageal carcinoma with partial gastrectomy was also reported in Japan.[1],[2] Colon interposition has been used at the beginning of the 20th century as a substitute for esophagus. This surgery is mainly chosen as a second line treatment when the stomach cannot be used, such as the esophageal carcinoma patients with previous partial gastrectomy. Although this surgical approach is a second line treatment for the patients whose stomach cannot be used for any reasons, which led to the length of the stomach is too short. Under these circumstances, colon interposition becomes a relatively ideal treatment for these patients, because it not only meets the needs of radical resection of esophageal carcinoma, but also provides graft of sufficient length to connect to cervical esophagus.[3],[4],[5],[6],[7],[8] Therefore, the clinical data was collected from 32 esophageal carcinoma patients with a history of partial gastrectomy who received colon interposition in our hospitals between January 2000 and December 2014, the retrospective analysis was also carried out and reported as follows.


 > Materials and Methods Top


Patients' information

All the 32 cases in the current study have a history of partial gastrectomy. In which, 29 cases are male and three cases are female with an age range of 42–76 (mean age is 63.2 years old). All the patients were confirmed by histopathological examination with the diagnosis of squamous cell carcinoma, adenocarcinoma, or adenosquamous carcinoma. The carcinomas were located at the upper thoracic portion in 2 cases, middle thoracic portion in 19 cases, and lower thoracic portion in 11 cases. Two cases were multi-center gastric stump carcinoma at the middle portion of esophagus. The carcinoma size were 3–4 cm in 11 cases, 5–8 cm in 16 cases, and larger than 8 cm in 5 cases (average size was 5.2 cm). The period between partial gastrectomy and diagnosis of esophageal carcinoma was <5 years in 1 case, 5–10 years in 10 cases, 11–20 years in 19 cases and >20 years in 2 cases, the average period was 13 years. Gastrectomy was performed due to gastric ulcer in 26 cases, benign tumor or gastric cancer in 6 cases. Among the 32 cases, Billroth II digestive tract reconstruction was performed in 20 cases, while Billroth I digestive tract reconstruction was performed in 12 cases. All the clinical information including location and tumor, node, metastasis stage was summarized in [Table 1].
Table 1: Classification of the 32-esophageal carcinoma patients

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Preoperative evaluation

Preoperative evaluation mainly consists of oncology evaluation. We analyzed the following circumstance of the patients who underwent partial gastrectomy including clinical staging of the esophageal carcinoma, relationship between the carcinomas and surrounding vessels, and availability of the colon graft.

Surgical approaches

In this study, five cases were performed by 2-incision radical resection of esophageal carcinoma on the right chest; 27 cases were performed by 3-incision radical resection of esophageal carcinoma. Involved partial esophagus, gastric stump, and lymph nodes were all removed, and colon interposition was performed for esophagus replacement on all above cases. Meanwhile, esophagus-colon end-to-end or end-to-side anastomoses were successfully carried out.

Intra-abdominal operations

(1) Midline incision on upper abdomen and preanastomotic colon or postanastomotic colon was performed on the patients who received Billroth II digestive tract reconstruction. Gastric stump and gastrointestinal anastomosis were removed, and jejunum-jejunum end-to-end anastomosis was performed. Brown anastomosis could be added depending on whether the stoma was obstructed or not. If the stoma was unobstructed, the Brown anastomosis could be kept, and the stump will be closed. In this study, the gastric stump from the patients who received Billroth I digestive tract reconstruction was removed, and the duodenum stump was also closed. Lymph nodes dissection was carried out for both above situations when necessary. (2) Selection of the colons: Priority of choosing right colon or left colon was determined by their blood supply. Isoperistaltic colon interposition was performed when choosing right colon and antiperistaltic colon interposition was performed while choosing left colon. In this study, isoperistaltic colon interposition was performed on 14 cases and antiperistaltic colon interposition was performed on 18 cases. End-to-end anastomosis was all completed manually.

Intrathoracic operations

Right posterolateral thoracic incision was performed first, the esophagus was divided, and the carcinoma was then removed. Meanwhile, the lymph nodes were dissected. Laryngeal nerves were protected very carefully. The colon was connected with esophagus using trans-retrosternal route on six cases because their thoracic aorta were invaded by carcinoma, and the colon was connected with esophagus in thoracic cavity in five cases.

Cervical surgery

In this study, colon and esophagus anastomosed at cervical trans-esophageal-bed was completed on 21 cases, trans-retrosternal anastomosis was conducted on 6 cases. Incision at the anterior border of left sternocleidomastoid muscle was made; the colon and esophagus were then connected through trans-retrosternal or transesophageal bed routes. In which, end-to-end anastomosis was manually conducted on 18 cases, and end-to-side anastomosis was completed by circular stapler on 9 cases. It was double-checked that there were no intestinal volvulus, tension-free on anastomosis. Meanwhile, the laryngeal nerve was carefully protected. However, five cases still suffered from hoarse voice that was caused by injured laryngeal nerve after the examination by laryngeal endoscope. During the surgeries, rapid pathological diagnoses were obtained including the incisal margins of both upper and lower ends of the specimens from esophagus and stomach.


 > Results Top


Surgical results

Most of the operations had been completed very smoothly. Unfortunately, cervical anastomotic leakage was still found on six patients 5–10 days after operation. In which, three cases existed from the approach of isoperistaltic colon interposition, and three cases existed from the approach of antiperistaltic colon interposition. Anastomotic leakage from antiperistaltic colon interposition resulted in fistula that connected to thoracic cavity was found on a case; it was confirmed by contrasted imaging examination. All the patients with anastomotic leakage or fistulas received conservative managements were all finally cured. Meanwhile, five cases suffered from lung infection and two cases suffered from incision infection were found at the sites of chest or abdomen. All above patients were eventually cured. These complications were summarized in [Table 2].
Table 2: Postoperative complications

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Follow-up results

All the patients were followed up from 6 to 120 months. Among the patients, six cases were out of communication for some reason. The results showed that the shortest survival period was 2 months, the longest survival period was 108 months (9 years), and the mean survival period was 36.9 months [Figure 1]. Dilation of the interpositioned colon at different levels was found from ten patients who received antiperistaltic colon interposition 1 year after the surgery. This colonic dilation was confirmed by following-up examination with barium swallow imaging examination. Meanwhile, no obvious colonic dilation was found from the patients who received isoperistaltic colon interposition. Difficulty or discomfort swallowing (dysphagia) at different levels, refluxes during night, eructation, and bad breath (malodor) were found from the patients who received antiperistaltic colon interposition. All these symptoms disappeared in most of the patients half to a year after the surgery.
Figure 1: Survival curve of the 32-esophageal carcinoma patients with partial gastrectomy after colon interposition

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 > Discussion Top


Colon interposition is a complex operation, with specific indications. Over time the indications of colonic interposition have been changed. Colon interposition is nowadays reserved for the selected patients with esophageal cancer when the stomach is unavailable.[9] According to our experience, we have a few topics discussed here.

Esophageal reconstruction

There are many methods of digestive tract reconstruction after esophagectomy among the patients with esophageal carcinoma. These methods include gastric-, jejunal- and colonic replacement for esophagus. Currently, gastric replacement is very popular and commonly used. However, colonic replacement is used less, because the surgery is relatively difficult, time-consuming, and high risk of serious postoperative complications including colon necrosis, anastomotic fistula, and anastomotic stenosis.[10],[11],[12] Anyhow, the most ideal operation would be colonic replacement after gastrectomy. This method not only meets the needs of radical resection of esophageal carcinoma include resecting the full length of thoracic portion, abdominal portion of esophagus and involved lymph nodes, but also provides the graft with sufficient length while connecting to cervical esophagus.

Jejunal or colonic replacement

For the patients who received Billroth I operation, except peritoneal adhesion at various levels, the option of choosing jejunal or colonic replacement has no difference with other patients. Therefore, jejunal replacement might be a better choice. However, if the anastomosis is at the cervical portion, that will result in anastomosis tension because of the limited jejunum length. In this case, we usually consider colonic replacement. Compensatory dilation at different levels was found at the jejunum proximal close to the stomach-jejunum stoma from the patients who received Billroth II operation. For these reasons that jejunum has been used previously and the adhesion has to be separated, etc., thus, jejunal replacement becomes more difficult. Alternatively, colonic replacement will be preferred. Changes of the transverse colon at different levels were noticed from the patients who received Billroth II precolonic anastomosis and retrocolonic anastomosis. Less influence on the transverse colon was found from the patients who received retrocolonic anastomosis. Apparently, more influence was found from the patients who received precolonic anastomosis. These were probably caused by (1) peritoneal adhesion after gastrectomy increased the difficulty of colonic replacement operation; (2) Peritoneal adhesion and transverse colon is squeezed by stomach-jejunum stoma, this may lead to the crispation of transverse colon, and thinner of left colic artery branches, which can led to insufficiency of blood supply and reduction of the interpositioned transverse colon length in some patients after gastrectomy. These correlate with the interval between the gastrectomy and the operation of esophageal carcinoma.

Option of choosing trans-esophageal bed or trans-retrosternal route

Trans-esophageal bed route has been chosen for most of the patients in this study exclude (1) resection of the esophageal-bed lymph nodes was unsatisfactory; (2) local serious invasion of the esophageal carcinoma that palliative resection was carried out; (3) the patients' conditions can not tolerate surgery including old age, severe bleeding that the esophagectomy can not be performed. Under these circumstances, trans-retrosternal route will be more suitable.[13] In this study, six cases were performed trans-retrosternal esophagus-colon anastomosis, and a case was found anastomotic leakage. We believed that trans-retrosternal route is conducive to esophageal bed radiation therapy postoperation. Even if the carcinoma relapses later, it would not interfere patient's eating. Moreover, the following attentions should be paid to during cervical colon anastomosis: (1) enough retrosternal space should be kept to avoid compression of the colon, which could lead to stenosis, obstruction or even fistula; (2) make sure that there is no intestinal volvulus; (3) sternohyoid muscle should be partially resected to avoid possible compression of the esophagus or colon; (4) the stoma between esophagus and colon should be placed higher so as to avoid large cervical-to-retrosternal angle, which can potentially interrupt emptying.

Option of isoperistaltic colon interposition or antiperistaltic colon interposition

We found that the higher incidences of hiccup and eructation were from the patients with antiperistaltic colon interposition. In addition, the more serious dilation of interpositioned colon was found from the patients with antiperistaltic colon interposition than that from the patients with isoperistaltic colon interposition a year after the surgery. This was confirmed by the examination of barium swallow imaging. This issue might be caused by the antiperistalsis of the colon, which leads to the refluxes of contents and food after its function restoration. Obviously, the gastrointestinal function from the patients with isoperistaltic colon interposition was much better than that from the patients with antiperistaltic colon interposition, since less refluxes inflammation occurring from the former.[14] Thus, isoperistaltic colon interposition is strongly recommended.[15] Alternatively, there is usually longer colon graft available from left colon.

Option of anastomosing techniques

Manual anastomosis was usually applied in our hospitals, and circular stapler has also been used in recent years on five cases, no stenosis or fistulas were found. Definitely, the stapler is more convenient and timesaving during operation. However, in the cases with esophagus-colon anastomosis, the colonic stump should be closed in the way of end-side anastomosis. Thus, longer colon segment for stapling is needed than that for manual anastomosis. Therefore, it depends on the patient's condition, the surgeon's experience, and the length of interpositioned colon whether the anastomosis should be performed manually or by stapling.

Therapeutics of anastomotic leakage/fistula

Anastomotic leakage or fistula is not only the most common and most serious complication when performing colonic replacement for esophagus, but also the major psychological barrier for both the doctors and patients when the decision making of a colonic replacement for esophagus. Its incidence is as high as 15.7%–43.7%.[16] In our study, cervical anastomotic fistulas were found in 6 of the 32 patients, with an incidence of 18.8%. Anastomotic fistulas usually occur around a week after surgery. We paid special attentions to this issue ever since 4 days postoperation. Once the inflammation symptoms including red and swollen in the neck area was found, B-ultrasound examination was performed to check any potential effusion around the stoma, or several stitches need to be removed. For the patients with suspicious fistula, iohexol contrast imaging was carried out. Routine procedures were performed once the fistula was confirmed. One case was found that the fistula was connected to the left thoracic cavity. To treat it, two drainage tubes were placed, one was for diluted povidone-iodinerinse, and another was for vacuum aspiration. Closed drainage of thoracic cavity with low negative pressure was also applied. We demonstrated that all these procedures resulted in satisfactory effects.


 > Conclusion Top


We believed that colon interposition is an ideal strategy for the treatment of esophageal carcinoma patients with a history of partial gastrectomy. Isoperistaltic colon interposition is recommended because the gastrointestinal function recovered better in the patients with isoperistaltic colon interposition than those with antiperistaltic colon interposition. However, antiperistaltic colon interposition becomes more popular in clinic due to the availability of longer colon graft. As the options of choosing trans-esophageal bed or trans-retrosternal routes, and the anastomosis should be performed manually or by stapling, it will be depends on the patient's condition and the surgeon's skills and experience.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
 > References Top

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Hino H, Shiozaki A, Fujiwara H, Komatsu S, Ichikawa D, Okamoto K, et al. Intrathoracic supercharge technique for esophageal reconstruction using colon interposition via a retrosternal route. Esophagus 2012;9:234-8.  Back to cited text no. 2
    
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