Surgical options in retrosternal oesophageal reconstruction.

BACKGROUND: Retrosternal oesophageal reconstructions with collar anastomoses can become necessary when the stomach is either unavailable for oesophageal replacement, or orthotopic reconstruction is deemed impractical. Our aim was to analyse our results regarding technical approaches and outcomes. MATERIALS AND METHODS: All patients undergoing primary and secondary oesophageal retrosternal reconstructions with collar anastomoses at our centre (2019-2023) were retrospectively analysed and individual surgical reconstruction options were presented. RESULTS: Overall, twelve patients received primary (n = 5; 42.7%) or secondary (n = 7; 58.3%) reconstructions; ten with colonic interposition and two with gastric pull-up. Male/female ratio was 4:8; median age 66 years (30-87). Charlson-Comorbidity-Score (CCS) was 5 (1-7); 8/12 patients (67%) had ASA-classification score ≥ 3. We observed no conduit necrosis, but one patient (8.3%) with a leakage of the oesophago-colonostomy which was successfully treated by endoscopic vacuum therapy. Four patients (33.3%) acquired nosocomial pneumonia. Additional drainages for pleural fluid collections were necessary in three patients (25%). Overall comprehensive-complication-index (CCI) was 26.2 (0-44.9). Length-of-stay (LOS) was 22 days median (15-40). There was no 90-days mortality. Overall, CCI during the follow-up (FU) period at median 26 months (16-50) was 33.7 (0-100). 10 out of 12 patients were on sufficient oral nutrition at 12 months FU. CONCLUSION: Primary and secondary oesophageal retrosternal reconstructions encompass diverse entities and typically requires tailored decision-making. These procedures, though rare, are feasible with acceptable complication rates and positive functional outcomes when performed in experienced hands.

Colonic interposition in esophagectomy: an ACS-NSQIP study.

INTRODUCTION: For patients with cancer or injury of the esophagus, esophagectomy with reconstruction using the stomach (gastric pull-up, GPU) or colon (colonic interposition, CI) can restore function but is associated with high morbidity. We sought to describe the differences in outcomes between the two replacement organs using a national database. METHODS: From ACS-NSQIP, patients who underwent GPU or CI between 2006 and 2020 were identified. Univariate analyses were performed on length of stay, complications, reoperation, readmission, and mortality. Variables with P ≤ 0.2 were included in the multivariate regression. Primary outcomes were 30-day reoperation, readmission, and mortality. Data were assessed using Chi-squared tests and logistic regression. RESULTS: There were 12,545 GPU and 502 CI patients. GPU patients were older with higher BMI, and more likely to be male (80.3% versus 70.3%, P < 0.0001) and white (77.8% versus 69.1%, P < 0.0001). More GPU patients had independent functional status and underlying bleeding disorders, but fewer other preoperative comorbidities than CI patients. On univariate analysis, CI patients had longer hospital stays (13 versus 10 days, P < 0.0001); more reoperations (23.9% versus 14.5%, P < 0.0001); a lower rate of discharge to home (70.9% versus 82.1%, P < 0.0001); and a higher mortality rate (6.2% versus 2.9%, P < 0.0001). On multivariate analysis, CI was associated with increased risk of reoperation but not with readmission or mortality. Reoperation was associated with CI, smoking, chronic wound, hypertension, higher ASA class, contaminated or dirty wound class, and longer operative time. Readmission was associated with female gender, hypertension, and longer operative time. Mortality was associated with age, metastatic cancer, preoperative sepsis, preoperative renal failure, malignant esophageal disease, higher ASA class, incomplete closure, and longer operative time. CONCLUSION: Colonic interposition, although a more difficult option with traditionally worse outcomes, should still be considered for patients requiring esophagectomy if the stomach cannot be used to restore continuity, as differences in outcomes appear to be due to underlying frailty of patients rather than the procedure.

The role of fluorescence angiography in colonic interposition after esophagectomy.

Colonic interposition is an alternative for gastric conduit reconstruction after esophagectomy. Anastomotic leakage (AL) occurs in 15-25% of patients and may be attributed to reduced blood supply after vascular ligation. Indocyanine green fluorescence angiography (ICG-FA) can visualize tissue perfusion. We aimed to give an overview of the first experiences of ICG-FA and AL rate in colonic interposition. This study included all consecutive patients who underwent a colonic interposition between January 2015 and December 2021 at a tertiary referral center. Surgery was performed for the following indications: inability to use the stomach because of previous surgery or extensive tumour involvement, cancer recurrence in the gastric conduit, or because of complications after initial esophagectomy. Since 2018 ICG-FA was performed before anastomotic reconstruction by administration of ICG injection (0.1 mg/kg/bolus), using the Spy-phi (Stryker, Kalamazoo, MI). Twenty-eight patients (9 female, mean age 62.8), underwent colonic interposition of whom 15 (54%) underwent ICG-FA-guided surgery. Within the ICG-FA group, three (20%) AL occurred, whereas in the non-ICG-FA group, three AL and one graft necrosis (31%) occurred (P=0.67). There was a change of management due to the FA assessment in three patients in the FA group (20%) which led to the choice of a different bowel segment for the anastomosis. Mean operative times in the ICG-FA and non-ICG-FA groups were 372±99 and 399±113 minutes, respectively (P=0.85). ICG-FA is a safe, easy and feasible technique to assess perfusion of colonic interpositions. ICG-FA is of added value leading to a change in management in a considerable percentage of patients. Its role in prevention of AL remains to be elucidated.

Indocyanine green enhanced near-infrared fluorescence imaging for perfusion assessment of colonic conduit for esophageal replacement: Utility of a novel technique.

Esophagectomy, followed by esophageal replacement using gastric/colonic conduits, is a complex surgical procedure with significant perioperative morbidity. The most significant and potentially life-threatening complication associated with esophageal replacement is conduit ischaemia, resulting in anastomotic leak and conduit necrosis. Ensuring adequate perfusion of the conduit remains the key to preventing conduit ischaemia. Indocyanine green (ICG) enhanced near-infrared fluorescence imaging is a novel technique which has been used for assessing bowel perfusion. While numerous studies have focused on ICG fluorescence imaging for assessment of gastric conduit perfusion after esophagectomy, data regarding its use for colonic conduits is limited to case reports. ICG fluorescence imaging can help in resolving intraoperative issues by predicting the adequacy of colonic conduit perfusion, thereby preventing postoperative morbidity. To the best of our knowledge, this is the first report in Indian literature describing the utility of ICG fluorescence imaging for assessment of perfusion of colonic interposition.

14 Years' experience of esophageal replacement surgeries.

BACKGROUND: Esophageal replacement is a challenge to the therapeutic skills of surgeons and a technically demanding operation in the pediatric age group. Various conduits and routes have been described in the literature, each with their specific advantages and disadvantages. We carried out this retrospective study to share our experience of esophageal replacement. METHODOLOGY: This study was conducted at the department of pediatric surgery The Children's Hospital and The Institute of Child Health, Lahore. The records of patients treated for esophageal replacement were reviewed. The patients under follow-up were called for clinical evaluation and assessed of long terms complications if any. RESULTS: A total of 93 patients with esophageal replacement were included in the study. Esophageal replacement was done with gastric transposition in 84 cases (90%), colon interposition in 7 cases (7.5%) including one case of redo colonic interposition, and jejunal interposition in 2 cases (2%). Routes of esophageal replacement were trans-hiatal in 71 (76%), retrosternal in 13 (14%), and trans-hiatal with thoracotomy in 9 (10%) patients. Postoperatively, all of the conduits maintained viability. Wound infection was seen in 10 (11%), wound dehiscence in 5 (5%), anastomotic leak in 9 (10%), anastomotic stenosis in 12 (13%), fistula formation in 4 (4%), aortic injury 1 (1%), dumping syndrome 8 (9%), reflux 18 (19%), dysphagia 15 (16%) and death occurred in 12 patients (13%). CONCLUSION: There are problems with esophageal replacement in developing countries. In this context, gastric conduit appeared as the best conduit for esophageal replacement, using the trans-hiatal route for replacement, in the authors' experience.

A case report of a retrosplenic colonic interposition: Preoperative computed tomography is essential for safe colonic resection.

Retrosplenic colonic interposition is a rare anatomical variant which involves an aberrant positioning of the colon between the spleen and the left hemidiaphragm. Cross-sectional imaging, particularly preoperative computed tomography, plays a critical role in identifying this variant. Recognition of a retrosplenic colonic interposition is essential in certain surgical procedures for ensuring appropriate management tailored to individual patient anatomy and minimizing complications. To our knowledge, this is the first case report describing retrosplenic colonic interposition during colonic resection.

Jejunocolic intussusception after colonic esophageal interposition-A case report.

The management of gastrointestinal complications in patients with complex medical history poses significant challenges to healthcare clinicians. A 42-year-old male patient was admitted to the emergency department with excruciating abdominal pain and signs of bowel obstruction. The patient had a previous history of schizophrenia and esophageal stricture, treated 6 years ago with colonic esophageal interposition. From the computed tomography scan, intussusception of the jejunum in the colonic graft was revealed, which resolved spontaneously after a few hours probably due to the oral contrast. Although, colonic esophageal interposition is a life-saving procedure for long-esophageal strictures, there are rare complications that are still not clearly reported. Jejunocolic intussusception should raise awareness of the clinicians, as one of the potential complications of colonic esophageal interposition.

Unveiling the Chilaiditi Syndrome: A Case Report and Management Implications.

The Chilaiditi syndrome is when the radiologic Chilaiditi sign, defined by the interpositioning of the colon between the liver and diaphragm, becomes complicated by clinical symptoms such as respiratory insufficiency or bowel obstruction. We present the case of a 70-year-old male with a history of depression, anxiety, gastroesophageal reflux disease (GERD), and post-polio syndrome, who presented with left shoulder pain, chronic weakness, and dizziness. Initial evaluation revealed hypotension and elevated lactic acid, attributed to dehydration. Further imaging identified a Chilaiditi sign, thus raising suspicion of small bowel obstruction and the Chilaiditi syndrome. Despite conservative management, the patient continued to experience elevated lactic acid levels, prompting a computed tomography (CT) angiogram to rule out bowel ischemia. No acute intra-abdominal pathology was identified, and the patient improved with hydration and bowel rest. This case highlights the challenges in diagnosing and managing the Chilaiditi syndrome in the setting of chronic comorbidities.

A Novel Organoid-Based Strategy Using Hybrid Colon Interposition for Short Bowel Syndrome: A Mini Review of In Vivo Models and Possible Human Candidates.

This comprehensive review focuses on advances in surgical techniques and in vivo animal models for treating short bowel syndrome (SBS) with intestinal organoids. Notably, this review discusses a novel method involving the replacement of the epithelium of large intestinal tissue with small intestinal organoids, which improves function and prognosis when grafted back into the small intestine. This study not only underscores the importance of integrating organoid technology and surgical techniques to improve the outcomes of patients with SBS but also acknowledges the challenges that lie ahead, including achieving functional organoids with peristaltic movement and vascularization.

Chilaiditi Syndrome: A Case Report, Literature Review, and Proposition of a Novel Management Staging System.

Chilaiditi's sign refers to colonic interposition between the liver and the diaphragm in the right subphrenic space secondary to the relaxation of the suspensory ligaments of the right colic flexure. The diagnosis of Chilaiditi's sign is based on radiological findings with the following three criteria: 1) The right hemidiaphragm must be adequately elevated above the liver by the intestine, 2) the bowel must be distended by air to illustrate pseudo-pneumoperitoneum, and 3) the superior margin of the liver must be depressed below the level of the left hemidiaphragm. In this report, we present the case of a 49-year-old female presenting with signs and symptoms suggestive of Chilaiditi syndrome managed with laparoscopic surgery. We also present a literature review with a summary of previous studies and propose a novel management staging system for this syndrome.

Caustic ingestion leads to pneumonectomy and right colonic interposition, a unique case report.

INTRODUCTION: Corrosive ingestion forms serious problem, with various outcomes depending on the time of diagnosis and treatment. We report here a case with rare and dangerous complications. PRESENTATION OF CASE: A two-year-old girl came to our hospital, complaining of solids' dysphagia. Retrieving her medical history showed that she had ingested a corrosive liquid accidentally. Without knowing the nature of the ingested agent, the local doctor removed it, using nasal gastric tube. This procedure induced vomiting, which in turn led to more damage. She stayed in the area's hospital for 40 days with just supportive treatment. The radiological investigations suggested severe stenosis. The dilation was done, but the patient did not respond after three months of treatment. Therefore, a gastrostomy was done. The esophagus replacement was inevitable, but the parents refused the surgical approach. Three months later, she returned to our hospital complaining of a productive cough. The radiological investigations suggested destruction in the left lung with a high suspicion of tracheoesophageal fistula. The treatment was through a surgical approach by removing the damaged lung tissue and closing the tracheoesophageal fistula. The patient got better after a month of the surgery, which allowed us to replace the esophagus and close the tracheoesophageal fistula. DISCUSSION: corrosive treatment varies a lot, depending on the patient's situation. Accurate treatment prevents severe and unexpected complications. CONCLUSION: More stringent instructions should be enacted among medical providers, corrosive agents' producers, and the public to be more careful when dealing with corrosive chemicals.

Esophageal Replacement by Colonic Interposition for the Surgical Management of Acute Necrotic Gastric Volvulus: A Case Report.

Acute gastric volvulus, a condition where the stomach rotates around itself, is a rare clinical entity that requires prompt identification and immediate intervention to prevent life-threatening complications. Upon diagnosis, an emergent exploratory laparotomy is the procedure of choice, especially if complications, such as obstruction, ischemia, or perforation, are present. Management techniques and surgical corrections vary depending on the degree of obstruction, the consequent damage to surrounding structures, and the functional reservoir. We present a case of acute gastric volvulus with extensive esophageal and gastric necrosis requiring total gastrectomy and partial esophagectomy. We discuss the patient's operative management requiring colonic interposition with esophagocolonic anastomosis to reconnect this patient's gastrointestinal tract.

Long-term follow-up after retrosternal ileocolic esophagoplasty in two cases of long-gap esophageal atresia: why it is still a valid option as a rescue strategy.

Introduction: Esophageal replacement surgery in children is sometimes necessary for long-gap esophageal atresia. Ileocolic esophagoplasty in the retrosternal space can serve as a good alternative technique in case of hostile posterior mediastinum. We present two cases of successful ileocolic transposition performed at 6 months of age. Methods: Esophageal replacement was performed through a midline laparotomy incision associated with a left cervical approach. The ileocolic transplant was pediculized on the right superior colic artery after ligating the right colic and ileocolic vessels. A retrosternal tunnel was created, and the ileocolic transplant pulled through it to reach the cervical region. Proximally, esophageal-ileal anastomosis and, distally, colonic-gastric anastomosis were performed. Ileocolic continuity was repaired. Results: There were no early postoperative complications. In both cases, the patients presented oral feeding difficulties during the first 6 postoperative months. Thereafter, full oral feeding was achieved, and both patients were clinically asymptomatic during the following 18 and 20 years, respectively, with satisfactory oral radiological assessments, showing no redundancy or inappropriate growth of the graft and no anastomotic stricture. Currently, these patients do not complain of dysphagia, pathological reflux, or respiratory symptoms. Conclusion: When native esophagus preservation in long-gap esophageal atresia is estimated unfeasible, ileocolic transposition in the retrosternal space might be considered a good and safe option, particularly in those difficult cases after multiple previous surgical attempts and mediastinitis. This technique is putatively associated with a beneficial anti-reflux effect, thanks to the presence of the ileocecal valve, in preventing cervical peptic esophagitis. Long-term follow-up confirms that the transposed colon in the retrosternal space did not suffer any abnormal modification in size and growth.

Chilaiditi Sign in a Patient With Acute Coronary Syndrome: A Case Report.

Chilaiditi sign is a radiographic finding where part of the colon is found to be between the diaphragm and liver. Chilaiditi syndrome is characterized by symptoms such as chest or abdominal pain and shortness of breath once Chilaiditi sign is found on imaging. Chilaiditi sign is typically diagnosed by CT angiography (CTA) scan although it can also be seen on X-ray imaging at times. In most cases, Chilaiditi sign does not require acute intervention, as will be seen in our patient; however, it is important to include it in the differential diagnosis when a patient presents with characteristic symptoms. We present a case of a 71-year-old female who presented with chest pressure and shortness of breath due to acute coronary syndrome; however, she was found to have Chilaiditi sign, which was diagnosed by CTA chest.

Functional, nutritional, and developmental assessment of gastric transposition and colonic interposition: Long-term follow-up outcome analysis.

PURPOSE: The choice of Esophageal replacement (ER) depends on surgeons' preference and patients' anatomical condition. A cross-sectional study was done to compare the long-term outcomes of two methods of ER, Gastric transposition (GT) and Colonic interposition (CI). METHODS: Children who had undergone ER from January 1997 to December 2017 with a minimum of two-year post-ER follow-up were evaluated by anthropometry, hepatobiliary scintigraphy, gastroesophageal reflux study, gastric emptying test, pulmonary function test and blood tests. RESULTS: Twenty-six (Male:female=17:9) children were recruited. The median age at ER was 13 months (interquartile range 9-40 months) and mean follow-up post-ER was 116.7 ± 76.4 months (range 24-247 months). GT:CI was done in 15(57.7%):11(42.3%) cases. A greater number of abnormal oral contrast studies (p = 0.02) and re-operations (p = 0.05) were documented as baseline characteristics with CI group. The presence of gastroesophageal reflux 9/23(39.1%), duodenogastric reflux 6/24(25%), delayed gastric emptying 6/25(24%), abnormal pulmonary function test 14/22(63.6%) were documented during the study period. However, there was no significant(p>0.05) difference in nutritional, developmental and functional outcomes of both operative methods of ER in the study. CONCLUSION: Assessment of nutritional, developmental and functional parameters in children after ER reveals good long-term results. There was no significant difference in CI and GT. LEVEL OF EVIDENCE: Comparative study; II.

Long term outcome of a subcutaneous colonic interposition after pharyngo-laryngectomy for strictures of the larynx and hypopharynx resulting from caustic ingestion: A case report.

INTRODUCTION: Caustic agents, also called corrosive agents, could be acids or alkali in nature. If ingested, these agents can injure any part of the aerodigestive tree. Extent of injury depends on the type, concentration, duration of exposure and volume of caustic agent ingested. Serious complications after caustic agent ingestion can occur both in the short term such as hollow viscus perforation and death and in the long term such as stricture formation causing obstruction and lifetime risk of development of carcinoma. PRESENTATION OF A CASE: This is a case of a 25-year-old female who ingested an unknown substance resulting to a severe stricture of the larynx, hypopharynx, esophagus and pyloroantral region of the stomach. Six months after her tracheostomy and tube jejunostomy, she sought further medical attention in our institution due to inability to swallow food and saliva. She underwent pharyngolaryngectomy (PL) with the strictured esophagus and stomach left in-situ due to extensive adhesions. The subcutaneous colonic interposition reestablished the alimentary continuity by providing enough length for tension-free anastomosis and a more direct route for cervical anastomosis. DISCUSSION: Stricture formation is one of the most challenging late complication of corrosive injury. It results from scar formation in response to inflammation of the aerodigestive tract. Key factors in managing caustic strictures include safety of strictured segment resection, choice of replacement organ for reconstruction and route of conduit. CONCLUSION: Timing of surgery and proper selection the surgical procedure for complications of caustic ingestion can result in excellent long term outcomes.

Chilaiditi Syndrome Presenting as Partial Colonic Obstruction.

Chilaiditi sign is a rare incidental radiographic finding where bowel is interposed between the diaphragm and the liver, often seen as air under the right hemidiaphragm. A majority of patients with Chilaiditi sign are asymptomatic and remain so throughout their lifetime. Chilaiditi sign is recategorized as Chilaiditi syndrome if it becomes symptomatic and is a very rare etiology of bowel obstruction. As bowel obstruction confers a huge financial burden to the health care system, studies of even the rarer etiologies are of significant value. Particularly in the case of Chilaiditi syndrome, the free air under the right hemidiaphragm can lead physicians to prematurely conclude pneumoperitoneum, which would require an emergent surgical evaluation. It is through the incorporation of a broad differential and clinical presentation that physicians can decrease the inappropriate allocation of hospital resources and unnecessary surgical procedures; additionally, keeping Chilaiditi syndrome on the differential may prevent unnecessary surgical intervention, cost to the patient, and downstream complications. Bowel obstruction secondary to Chilaiditi syndrome is most commonly treated with conservative management including intravenous fluids, bowel rest, decompression, and laxatives. If the symptoms worsen and progress to full bowel obstruction, surgical intervention has shown great efficacy. We report a case of a 69-year-old male who presented to the emergency department for progressively worsening abdominal pain, nausea, and vomiting incidentally found to have colonic interposition with mild colonic dilatation on computed tomography (CT) imaging. The patient was diagnosed with bowel obstruction secondary to Chilaiditi syndrome and treated non-surgically with rapid recovery.

The Application of Two-Stage Operation for High-Risk Patients with Oesophageal Cancer Following Gastrectomy.

BACKGROUND: Oesophageal replacement by colonic interposition remains a major challenge due to its complexity and high incidence of complications; here we applied the two-stage operation strategy to oesophageal replacement by colonic interposition in high-risk oesophageal cancer patients following gastrectomy. METHODS: We performed a retrospective analysis on the data of patients with a history of distal gastrectomy who underwent one-stage and two-stage oesophageal replacement by colonic interposition from February 2012 to February 2020, and explored the relationship between the staging strategy and postoperative outcomes. RESULTS: The clinical data of 93 patients were collected and analysed. There were no significant differences in the patients' characteristics between the two groups (all p > 0.05), except for comorbidities and Charlson Comorbidity Index (all p < 0.05). The Clavien-Dindo score between the two groups was also not significantly different (p > 0.05). The logistic regression models revealed that patients who had received preoperative therapy had a higher Clavien-Dindo score (p < 0.05), but the stage strategy did not (p > 0.05). CONCLUSIONS: The two-stage operation is feasible in high-risk patients who need to undergo colonic interposition for oesophageal replacement. At the same time, it lowers the technical threshold of colonic interposition for oesophageal replacement, increasing this surgical technique's acceptability.

Chilaiditi syndrome in a Nepalese girl - A potential mislead!

INTRODUCTION: Chilaiditi's Sign (CS) is a radiological finding on an abdominal radiograph due to colonic interposition between the liver and the diaphragm giving a false impression of free intra peritoneal air. When accompanied by abdominal symptoms, a syndrome with the same name is diagnosed. As elusive a finding, it can be a source of diagnostic misinterpretation causing an alarming illusion of a deceptive emergency. CASE PRESENTATION: We report a four-year-old girl presenting with an acute abdomen in a background of long-standing constipation and an illusory radiograph suggesting left-sided, free sub diaphragmatic air. Further imaging with a CECT confirmed mesenteric lymphadenitis without free peritoneal air and chronic constipation as a cause of symptoms. Expectant management resulted in gradual clinical improvement. DISCUSSION: Chilaiditi's syndrome or CS is more often described in adults and more frequently over the right side, nevertheless, can occur in children too. Knowledge of its occurrence can avoid unnecessary surgical intervention. CONCLUSION: While evaluating a child with acute abdomen, if the finding of a radiographic free sub diaphragmatic air is discordant with clinical signs, further imaging to rule out CS is important to avoid unnecessary exploration.

Beware of gastric tube in esophagectomy after gastric radiotherapy: A case report.

BACKGROUND: Gastric tube formation and pull-up is the most common technique of reconstruction following esophagectomy for esophageal cancer. If previous treatment with radiotherapy for gastric mucosa-associated lymphoid tissue (MALT)-lymphoma restricts suitability of the stomach for anastomosis to the esophagus is unknown. CASE SUMMARY: A 57-year-old man underwent sequential chemotherapy and radiotherapy for gastric MALT-lymphoma seven years prior to diagnosis of esophageal adenocarcinoma. Esophagectomy without neoadjuvant treatment was recommended by the multidisciplinary tumor board due to early tumor stage [uT1 (sm2) uN+ cM0 according to TNM-classification of malignant tumors, 8th edition] without lymph node involvement. Minimal invasive esophageal resection with esophagogastrostomy was performed. Due to gastric tube necrosis with anastomotic leakage on the twelfth postoperative day, diverting resection with construction of a cervical salivary fistula was necessary. Rapid recovery facilitated colonic interposition without any complications six months afterwards. CONCLUSION: This case report may represent the start for further investigation to know if it is reasonable to refrain from esophagogastrostomy in patients with a long interval between gastric radiotherapy and surgery.