Colon Interposition for Staged Esophageal Reconstruction

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Presentation transcript:

Colon Interposition for Staged Esophageal Reconstruction Andrew C. Chang, MD Operative Techniques in Thoracic and Cardiovascular Surgery Volume 15, Issue 3, Pages 231-242 (September 2010) DOI: 10.1053/j.optechstcvs.2010.08.003 Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 1 Potential locations for the colon interposition conduit during esophageal reconstruction include: (A) retrosternal or anterior mediastinal; (B) posterior mediastinal or orthotopic. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 2 Surface anatomy and possible locations for placement of an end esophagostomy. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 3 Completed Roux-en-Y colojejunal anastomosis with feeding jejunostomy. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 4 Vascular supply to the colon with potential points of division for the interposition conduit. a. = artery; v. = vein. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 5 Assessment of the marginal artery. After serial occlusion of the middle colic vessels (A), a Doppler flow probe (B) is used to assess for pulsatile arterial flow within the marginal artery. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 6 Mobilization of an anterior thoracic end esophagostomy (A), beginning with circumferential incision of the stoma (B) and mobilization of the remaining upper and cervical esophagus (C). Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 7 Excision of the left sternoclavicular joint, including the posterior prominence of the clavicular head, opens the thoracic inlet and limits compression of the esophageal substitute as it passes through the anterior mediastinal or left paramediastinal space. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 8 Once the colon conduit is passed through the mediastinal space, any redundant colon is reduced gently back into the peritoneal cavity (A) to prevent kinking or twisting of the intrathoracic portion. The colojejunal anastomosis is performed first (B) to prevent any distension by mucosal secretions within the interposition conduit. The colojejunal anastomosis is placed in a retrocolic position (C). Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 9 A Wützel feeding jejunostomy is placed in the afferent (biliary drainage) limb and passed across the jejunal anastomosis, to limit potential distal obstruction of the colojejunal anastomosis. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions

Figure 10 A side-to-side semistapled esophagocolic anastomosis is completed. After (A) making a vertical colotomy, (B-C) 3-0 polyglycolic stay sutures are placed and a linear stapler is deployed, with the larger cartridge passed into the esophagus. (D-E) The remaining anterior “hood” of the esophagocolostomy is closed in two layers. Operative Techniques in Thoracic and Cardiovascular Surgery 2010 15, 231-242DOI: (10.1053/j.optechstcvs.2010.08.003) Copyright © 2010 Elsevier Inc. Terms and Conditions