1. Esophageal Replacement With Colon Interposition
Tom R. DeMeester 
Operative Techniques in Cardiac and Thoracic Surgery 
Volume 2, Issue 1, Pages (February 1997)
DOI: /S (07)
Copyright © 1997 Elsevier Inc. Terms and Conditions

2. 1
The colon is usually prepared through an upper midline abdominal incision. The omentum is dissected off the transverse colon, the splenic and hepatic flexures are taken down, and the ascending and descending colon are mobilized to the midline so that the whole colon from the sigmoid to the cecum is free on its mesentery. This is done carefully to prevent injury to any mesenteric vessels. By stretching the mesentery in a cephalad direction the ascending branch of the left colic artery can be easily identified as it forms a natural pedicle ascending in the direction of the splenic flexure adjacent to the ligament of Treitz.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

3. 2
The length of the colon graft is measured by tethering the colon as much as possible in a cephalad direction on the natural pedicle made by the ascending branch of the left colic artery. The apex of the colon will usually reach up to or slightly above the xiphoid. A marking stitch is placed on the antimesenteric border of the colon directly opposite the tethering artery. The distal part of the colon is usually somewhat redundant if the tethering artery is the limiting factor. The distance from this point, usually at or above the xiphoid, to the angle of the jaw is measured liberally with an umbilical tape. The same distance is then measured from the marking stitch proximally along the transverse and ascending colon and marked with a second marking stitch. This corresponds to the proximal anastomotic site. The second marking stitch will usually lie to the right of the right branch of the middle colic artery (see Fig 1). The marginal artery and vein are ligated at the point of the second marking stitch. Because of the poorly developed peripheral arcade between the right and left branches of the midcolic artery, the midcolic artery and vein are ligated proximal to their right and left branches (see Fig 1).
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

4. 3
Ligation of the midcolic artery may require excision of a button of the superior mesenteric artery and vein and suturing the margins together in order to maintain patency between the left and right branches which ensures blood flow to the most proximal portion of the graft. Before ligation and division of any vessels it is wise to occlude them with a small bulldog clamp and to check the adequacy of blood flow to the proximal end of the graft by palpating pulses or assessing doppler flow. Similarly, the patency of the venous outflow is assessed by observing for signs of venous hypertension. If the arterial inflow and venous outflow appear to be adequate, the vessels may be divided, including those small end arteries and veins to the colon at the point of its transection. The transection of the colon itself is delayed until later in the operation.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

5. 4
The site of the proximal anastomosis is prepared in the neck through an incision along the left sternocleidomastoid muscle (see dotted line). A left neck approach is preferred for the following reasons: the cervical esophagus takes a slight jog to the left; the right recurrent laryngeal nerve lies slightly more lateral to the esophagus than the left nerve and subsequently is less prone to injury when encircling the esophagus from the left; and if there is an aberrant recurrent laryngeal nerve, it usually occurs on the right side.
If the substernal route is chosen, the left half of the manubrium, the medial end of the first rib, and the sternal head of the left clavicle are resected to enlarge the thoracic inlet (shaded area). This is done carefully so as to not enter the pleura or destroy the internal mammary artery and vein, which may be used later as a source of blood supply for a free jejunal transfer should there be a failure. The left clavicle is divided just lateral to its sternal head by passing a Gigli's saw just underneath it at the angle made with the first rib. The bone is sawed as close as possible to this angle to preserve the costoclavicular ligament to anchor the remaining clavicle to the first rib. If a long segment of functional native proximal esophagus is available, resection of a portion of the clavicle/first rib/manubrium may not he necessary because bolus transport into the thorax is facilitated by the normal contracting proximal esophagus. If the substernal route is chosen, a tunnel can usually be created safely using blunt technique so long as there has not been previous scarring in the anterior mediastinum. If scarring is present, a median sternotomy may be necessary.
Caustic injuries deserve special consideration regarding the site of the proximal anastomosis. If the cervical esophagus is destroyed and a pyriform sinus remains open, the anastomosis can be made to the lateral hypopharynx through an anterior suprahyoid approach. When there is scarring of the hypopharynx and loss of both pyriform sinuses, an extensive pharyngoplasty is required. This almost always requires a partial resection of the hyoid and thyroid cartilage in order to perform the anastomosis. Preserving the larynx in this situation is a challenging problem.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

6. 5
After the site of the proximal anastomosis has been prepared, the colon graft is reexamined to evaluate the status of its vascular supply. If there is any doubt about the adequacy of the arterial supply or venous outflow of the graft, a decision is made to delay the reconstruction. To do this requires moving the small bowel through an incision in the transverse mesocolon so that it lies cephalad and anterior to the transverse colon. The mobilized colon is placed underneath the small bowel and fixed to the right inferior abdominal wall so that it will not adhere to the denuded posterior peritoneal surfaces left behind by its mobilization. This surrounds the colon graft with small bowel and makes subsequent mobilization of the colon easier. A cervical end esophagostomy is constructed. A feeding jejunostomy is inserted to allow for continued nutritional support.
If the decision is made to proceed with the colon interposition, the colon is transected with a GIA stapler at the proximal marking stitch (see Fig 1). The distal division is delayed until later in the operation. The colon is then laid on the anterior chest wall to assure that the mesentery is not twisted.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

7. 6
The proximal end of the graft is then sutured inside the funnel of an inverted Mousseau-Barbin tube (Porges Catheter Corp., New York, NT). A plastic bowel bag is wrapped around the graft and funnel and moistened generously with water to allow an atraumatic passage of the colon through a posterior or substernal tunnel. Tension is applied to the bag rather than the graft. This allows pulling the colon up into the neck with minimal friction and prevents tearing of the mesentery. Its course should be posterior to the stomach, if left intact, and through the esophageal hiatus for posterior mediastinal grafts and through the gastrohepatic ligament into the substernal tunnel for substernal grafts.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

8. 7
The proximal anastomosis is performed by division of the esophagus at the planned level. The staple line of the proximal colon is excised and the esophagocolic anastomosis performed in a single layer fashion using permanent 4–0 monofilament interrupted sutures. All knots are tied on the inside except for the final four or five anteriorly which are placed using a modified Gambee technique (see insert). (A) The anastomosis of the cervical esophagus to a posterior placed colon. (B) The anastomosis of the cervical esophagus to a colon placed in the substernal position.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

9. 8
The colon is placed on sufficient stretch to prevent redundancy but not so much so as to put excessive tension on the anastomosis. It is anchored in its straightened position by sutures to the left crura margin of the hiatus or the left margin of the opening in the diaphragm into the substernal tunnel. This is done because the straighter the colon, the better its postoperative function. The colon is not sutured circumferentially around the hiatus of the diaphragm opening because of the tendency to bow string the colon transversely and produce a functional obstruction. It is important to avoid kinking the vessels to the colon graft on the edge of the diaphragm at the entry into the substernal tunnel when using the substernal route. This may require a 2- to 3-cm longitudinal incision into the pericardium above and below the acute edge and closing it in a transverse plane similar to a Heineke-Mikulicz pyloroplasty. This converts the acute angle formed by the diaphragm and pericardium into a gentle rounded one.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

10. 9
The distal end of the colon graft is then transected 10 cm below the diaphragmatic opening. At the site of division, the colon is freed from its mesentery for a distance of 2 cm along its mesenteric border by dividing the small end vessels while taking care not to injure the marginal artery. The colon is transected without dividing the mesentery other than just along its mesenteric border. This preserves additional blood supply from the marginal artery via the sigmoid arteries and venous drainage through the hemorrhoidal and sigmoid veins.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

11. 10
If the stomach has been denervated, a proximal two-thirds gastrectomy is performed and the distal end of the colon graft is anastomosed to the remaining one third of the stomach and the loss of the gastric reservoir is replaced by the interposed colon. Retaining a vagotomized proximal stomach leads to gastric atony, delayed gastric emptying, and excessive regurgitation. The anastomosis is performed in a double-layer fashion using interrupted 3–0 silk suture. A pyloromyotomy should be done. Colonic continuity is reestablished by bringing the previously mobilized right colon over to the distal end of the divided colon graft and performing an end-to-end double-layer anastomosis using interrupted 3–0 silk sutures. The descending and sigmoid colon mesentery are not divided. This preserves as much arterial supply and venous drainage to the colon graft as possible via the sigmoid arteries and hemorrhoidal veins. The mesentery of the right colon is sutured to the mesentery of the descending colon to avoid an internal hernia. When finished, the colocolic and the gastrocolic anastomosis lie in close proximity to each other.
An intramural feeding jejunostomy tube is routinely inserted 25 cm distal to the ligament of Treitz. This allows for early postoperative nutrition that can be tapered as adequate oral intake is resumed.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

12. 11
If a vagal-sparing esophagectomy can be performed, the stomach is preserved and the distal end of the colon graft is anastomosed to the posterior surface of the stomach at a point one-third the distance between the tip of the fundus and the pylorus. The anastomosis is performed using a GIA stapler by inserting one staple head through a small gastrotomy in the posterior wall of the stomach and the other through a small colotomy in the antimesenteric wall of the colon graft (A). The stapler is closed bringing the colonic and gastric walls together (B) and fired creating a longitudinal anastomosis between the stomach and colon (C). The joined gastrotomy and colotomy are spread apart laterally (D) and the stomach and colon are joined together with a T-60 stapler forming a triangular anastomosis (E).
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

13. 11
If a vagal-sparing esophagectomy can be performed, the stomach is preserved and the distal end of the colon graft is anastomosed to the posterior surface of the stomach at a point one-third the distance between the tip of the fundus and the pylorus. The anastomosis is performed using a GIA stapler by inserting one staple head through a small gastrotomy in the posterior wall of the stomach and the other through a small colotomy in the antimesenteric wall of the colon graft (A). The stapler is closed bringing the colonic and gastric walls together (B) and fired creating a longitudinal anastomosis between the stomach and colon (C). The joined gastrotomy and colotomy are spread apart laterally (D) and the stomach and colon are joined together with a T-60 stapler forming a triangular anastomosis (E).
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

14. 12
The colonic continuity is reestablished by an end-to-end colocolostomy.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions

15. 13
When finished, the interposed colon reestablishes gastrointestinal continuity between the cervical esophagus and the vagal innervated stomach. This type of reconstruction is particularly suited for esophagectomies performed for advanced achalasia, benign stricture that cannot be dilated, and an esophagus destroyed by ingesting caustic agents.
Operative Techniques in Cardiac and Thoracic Surgery 1997 2, 73-86DOI: ( /S (07) )
Copyright © 1997 Elsevier Inc. Terms and Conditions