Arterial anatomic considerations in colon interposition for esophageal replacement
J. H. Peters, J. W. Kronson, M. Katz and T. R. DeMeester
Department of Surgery, University of Southern California School of Medicine, Los Angeles, USA.
BACKGROUND: Little has been written regarding the arterial anatomy
predictive of success following esophagectomy and colon interposition.
DESIGN: Retrospective review. SETTING: University teaching hospital.
PATIENTS: Twenty-five patients undergoing planned left colon interposition.
INTERVENTION: Colon interposition was performed via an isoperistaltic left
colon graft based on the ascending branch of the left colic artery. MAIN
OUTCOME MEASURES: Five angiographic features were considered important to
successful use of the left colon: (1) a patient inferior mesenteric artery,
(2) a visible ascending branch of the left colic artery, (3) a well-defined
anastomosis between the middle colic and left colic systems, (4) a single
middle colic trunk prior to its division into right and left branches, and
(5) a separate origin of the right colic artery. Venous drainage via a
patent marginal vein, inferior mesenteric vein, and superior hemorrhoidal
veins was preserved in all patients. RESULTS: Left colon interposition
could be performed in 21 (84%) of 25 patients. Eighty percent of the
patients (20/25) had at least four of the five criteria thought necessary
for optimal graft perfusion. Three or fewer criteria were present in five
patients, three of whom underwent gastric interposition. The inferior
mesenteric artery was patent in all patients except one who required a
right colon interposition. Ninety-two percent (23/25) demonstrated an
adequate ascending left colic artery. The superior-inferior mesenteric
artery anastomosis was seen in 52% (13/25). A single-trunked middle colic
artery was present 80% (20/25) of the time. A single incidence of graft
necrosis occurred secondary to venous insufficiency. Ninety-six percent of
patients (24/25) were able to swallow without difficulty at the time of
discharge from the hospital. CONCLUSIONS: Replacement of the esophagus with
colon can be successful in over 80% of patients screened by angiographic
criteria. Patients with an occluded or stenotic inferior mesenteric artery
or variant middle colic arterial anatomy should undergo an alternate
reconstruction.
