Operations to Replace or Bypass the Esophagus: Colon or Jejunum Interposition; Gastric Pull-Up

Abstract

Using the colon (or jejunum) to replace resected segments of the esophagus permits the surgeon to preserve intact a functioning stomach. Performing the cologastric anastomosis 8–9 cm down from the gastric cardia will generally minimize gastrocolic reflux. Achieving a sufficient length of viable colon is, with rare exceptions, a relatively simple task. One drawback to using the colon as a substitute esophagus is the risk of impairing the venous blood flow either by injuring the veins in the colon mesentery or impairing venous return by leaving an inadequate aperture in the diaphragm or at the apex of the thorax for the colon and its mesentery. Under these conditions venous infarction can occur. Following careful surgery, this complication should be quite rare. Belsey experienced one colon infarct in 92 left colon interposition operations. This complication appears to be more common when the right colon is used as opposed to the left colon (Wilkins). When performed for benign disease, the left colon interposition is a safe operation. Belsey reported a 4.3% mortality, but no anastomotic leaks. Skinner, in discussing a paper by Mansour, Hansen, Hersh, Miller, and others, stated that they had had no hospital deaths in 40 consecutive operations for colon interposition after the resection of non-dilatable benign strictures of the esophagus. Also, Skinner’s long-term functional results following the use of the left colon interposition have been good. Belsey, after following his patients for 1–6 years, reported 81% good and 17% satisfactory results. Wilkins followed a group of 21 patients for 5–24 years and reported excellent functional results. Glasgow, Cannon, and Elkins also reported good or excellent results and no operative deaths following 17 left and 1 right colon interposition operations for benign esophageal disease. These patients had been followed for 1–6.5 years. Good results following colon interposition in children were reported by Kelly, Shackelford, and Roper.