Salvage esophageal reconstruction with colon interposition: a 20 year experience.

Purpose: Esophageal replacement with the colon interposition is utilized by thoracic surgeons in salvage scenarios when stomach is not available as a viable conduit. In this study, we describe the indications, pre-operative comorbidities, evolution of the technique and post-operative outcomes after colon interposition for the past 2 decades at our institution.

Methods: Eighty-nine patients underwent a colon interposition between 2000 and 2020. Median age was 59 years and 71% were male. Prior Esophagogastrectomy for esophageal cancer (n=42) and failed Nissen fundoplication (n=19) were the two most common indications. In all patients, the stomach was unavailable for reconstruction. Pearson chi square test was done using STATA to analyze the association between preoperative comorbidities and postoperative outcomes in these patients.

Results: Most patients (84/89) undergoing a colon interposition had delayed reconstruction with a median time 1.5 years. Iso-peristaltic left colon was used as the conduit in 62 patients (69.7%) Supercharging using IMA was done in 3 patients recently. The median operative time was 381 minutes. The perioperative mortality rate was 6.74% with 6 in-hospital deaths with the mortality decreasing to 4.8% (2 out of 42 patients) in the past 10 years. The median length of stay at the hospital was 18 days. Anastomotic leak (34.8%, n=31) was the most common perioperative complication. The 30-day readmission rate was 34.8% (n= 31). The most common re-intervention within 30 days was Neck re-exploration and debridement. The median follow-up was 4 years for surviving patients and the overall survival rate at 5 years was 54%. The 5 year survival was 74% for non-cancer diagnosis and 24% for cancer diagnosis. During long term follow-up, 49 (55.1%) patients had developed dysphagia due to stricture and 41 (46.1%) underwent single or multiple dilations. Interestingly among preoperative comorbidities, Diabetes mellitus was associated with increased risk of anastomotic leaks (p = .009). Wound infections was significantly associated with increased risk of readmissions in the perioperative period (p = .001).

Conclusion: Colon interposition by sub-sternal route is a highly complex procedure with high morbidity but acceptable mortality to salvage patients without a viable gastric conduit. During the course of 20 years, our technique has evolved resulting in decreased mortality and morbidity. Given the short term and long-term issues, the procedure is best performed in high volume centers with appropriate multi-disciplinary expertise to salvage complications and manage sequelae.

Identify the source of the funding for this research project: No extramural funding was utilized.