The use of ileocolic segment for esophageal replacement in children.

AIMS: To evaluate and describe the procedure and outcome of ileocolic replacement of esophagus.
MATERIALS AND METHODS: We review 7 children with esophageal injuries, who underwent esophageal replacement using ileocolic segment in Christian Medical College, Vellore, India between 2006 and 2014.
RESULTS: The ileocolic segment was used in 7 children with scarred or inadequate esophagus. There were 4 girls and 3 boys, who underwent esophageal replacement using isoperistaltic ileocolic segment in this period. Age at presentation varied from 1 month to 14 years with an average of 4.6 years. The indications for ileocolic replacements were corrosive strictures in 5, failed esophageal atresia repair in one and gastric volvulus related esophageal stricture in another. The average follow-up duration was 37 months. One child with corrosive stricture lost to follow-up and died 2 years later in another center. Other 6 children were free of dysphagia till the last follow-up.
CONCLUSIONS: Although the ileocolic segment is not commonly used for esophageal substitution, it can be useful in special situations where the substitution needs to reach the high cervical esophagus and also where the stomach is scarred and not suitable for gastric pull-up.

INTRODUCTION

Esophageal replacement is needed in cases of extensively scarred or inadequate esophagus. The corrosive strictures and esophageal atresia are main indications for esophageal replacement in children.[123] The stomach, small intestine, and various parts of the colon are used for esophageal substitution. There is no ideal substitute for esophagus. Here, we describe our experience with the use of ileocolic segment for the substitution of scarred esophagus in 7 children and its follow-up. While gastric pull up remains the preferred operation for esophageal atresia, the ileocolic technique finds a special place where the replacement must reach the neck at a higher level than the thoracic inlet and also when the stomach is scarred.

MATERIALS AND METHODS

We review 7 children with esophageal injuries, who underwent esophageal replacement using ileocolic segment in Christian Medical College, Vellore, India between 2006 and 2014. Children were identified by an electronic search of Pediatric Surgery database and operation records. A review of the preoperative hospital out-patient records, radiological investigations, operation records and postoperative follow-up records were done. Follow-up of patients was done with clinical examination and barium swallow imaging.

RESULTS

A total of 31 children underwent esophageal replacement between the year 2006 and 2014. The conduits used were stomach in 22, ileocolic segment in 7, and transverse and left colon in 2 patients.

There were 4 girls and 3 boys, who underwent esophageal replacement using isoperistaltic ileocolic segment in this period. Age at presentation varied from 1 month to 14 years with an average of 4.6 years. The indications for ileocolic replacements were corrosive strictures involving the cervical and thoracic esophagus in 5, failed esophageal atresia repair with multiple previous surgeries in one and gastric volvulus related esophageal stricture in another. The average follow-up duration was 37 months.

The child with esophageal atresia with tracheoesophageal fistula underwent primary repair in another center and came with anastomotic stricture. An attempt was made to repair the stricture, but failed, and child developed leak which did not close even after applying omental patch based on gastroepiploic vessels and thus precluding a gastric pull-up. She underwent ileocolic transposition by bypassing strictured esophagus leaving intact gastroesophageal junction. She developed an anastomotic leak at cervical esophagocolic anastomosis which was managed conservatively. She was tolerating normal feeds at last follow-up.

The youngest child of the series was a 1-month-old girl who presented with abdominal distension and vomiting and found to have mesentrico-axial gastric volvulus with gangrenous proximal stomach. She underwent partial gastrectomy and feeding jejunostomy. Later, she developed dysphagia secondary to distal esophageal stricture and small capacity stomach. She underwent resection of distal esophagus and part of stomach and replacement by ileocolic segment. Her intact appendix was used as feeding enterostomy. She developed abdominal wound dehiscence, which was repaired. She is tolerating normal feeds. Her appendicostomy closed 2 years later electively.

Of the 5 children with corrosive esophageal stricture who underwent ileocolic replacement, one child developed stricture of the esophagus proximal to the esophagoileal anastomosis secondary to corrosive injury. The stricture was not easily dilatable, and he was tolerating only a liquid diet. This child was lost to follow-up, and later inquiry revealed that he had died 2 years after ileocolic replacement during an attempted dilatation in another center.

The esophagectomy was performed in 3 out of 5 children with corrosive strictures; while complete resection of scarred stomach with esophagus done in one. One child had partial gastrectomy in another center before coming to our institute.

The early postoperative complication seen in children with corrosive strictures were proximal esophago-ileal anastomotic leak in one, a distal colo-gastric anastomotic leak in one, abdominal wound infection in one and adhesive intestinal obstruction in one patient.

All four surviving children in corrosive stricture category are free of dysphagia, and there was no stasis in barium studies at the time of the last follow-up [Figure 1]. One child has a visible bulge of underlying ileum appearing in lower cervical region while taking meals without dysphagia.

Figure 1

The barium contrast studies of a child with esophageal stricture: Preoperative image on the left showing strictured esophagus and postoperative follow-up image (after 2 years) on the right showing ileocolic segment as a replacement with free flow of contrast. Although the small bowel is redundant in length, it is far less bulky than gastric or colonic replacement. In addition, active peristalsis and quick passage of contrast were noted in all cases

Operative technique

Esophagoscopy is done to assess the distance of stricture from the incisors and to know the status of the esophageal mucosa.

With the child in supine position and head turned to left side, the neck, chest, and abdomen are prepared and draped as a single sterile field. Abdomen entered via a midline vertical incision, and the right colon is fully mobilized to the level of the hepatic flexure including the caecum and the appendix. The ileocolic segment based on the ileocolic artery is then isolated by detaching ileum approximately 10-15 cm away from the ileocecal junction and 4-5 cm of right colon [Figure 2]. The graft included the right ascending colon, cecum, and ileocecal valve and approximately 10-15 cm of the ileum. Bowel continuity is restored by anastomosing the ileum to the remaining right colon in an end to end fashion. A cervical incision put on the lower neck crease on the right side. The platysma is cut, strap muscles separated and the carotid sheath reached. The space between the carotid artery laterally and the trachea anteromedially then entered and the esophagus isolated. The esophagus was pulled out from the mediastinum as much as possible and taped. The esophagus is divided and mucosa of cut end inspected. Retrosternal space is created using fingers and blunt dissection. The manubrium sterni was nibbled to create smooth passage. The ileocolic graft with vascular pedicle is brought up in front of the stomach or through retrogastric route and placed in the retrosternal space in an isoperistaltic fashion. The ileal end can be anastomosed to the native esophagus in an end to end or end to side fashion. The detached and strictured native esophagus can be left in situ attached to the stomach. The cologastric anastomosis is done, and appendix can be brought out as feeding port (feeding appendicostomy) [Figure 3]. Alternatively a feeding jejunostomy can be done. Abdomen is closed.

Figure 2

Ileocolic segment anatomy in reference to the operative procedure. The constant ileocolic artery and the wide avascular area in the terminal ileal mesentery allow adequate lengthening of the ileum to reach the high cervical level. Multiple level arterial arcades in the ileum allow for minor adjustments in length if the graft is just a little short after pulling it up into the neck by judicious division of the arcade vessels. The ileocecal valve helps in preventing gastroesophageal reflux while the appendix may be used as a feeding port (Inset showing intraoperative image)

Figure 3

Line diagram showing ileocolic segment replacement of esophagus after anastomosis

DISCUSSION

Preservation of native esophagus for swallowing is the best situation in cases of congenital or acquired esophageal disease. However, in certain circumstances such as nondilatable scarred esophagus, long gap esophageal atresia, and esophageal malignancies, esophageal substitution becomes inevitable.

Various techniques have been used in cases of scarred or inadequate esophagus. Tubularized or pulled-up stomach, small intestine, and colon are the conduits used to substitute esophagus.[2345] While the use of colon for esophageal substitution in a child with corrosive stricture was first described by Lundblad in 1921, the use of isoperistaltic ileocolic segment was first utilized in isolated esophageal atresia by Javid in 1953.[67] The isoperistaltic ileocolic segment has certain advantages as esophageal substitute: (1) A good peristaltic small bowel avoids a large volume reservoir in chest, liable to massive aspiration in higher level esophageal anastomosis as in cases of gastric or colonic conduits, (2) ileocolic vessel is constant,[89] (3) constant wide mesenteric gap between ileal and colic branch of ileocolic vessel allows mobilization of ileum for the desired length [Figure 2], (4) appendicostomy allows feeding, if neck anastomosis in trouble, (5) the nipple valve at ileocolic junction acts as anti-reflux mechanism,[10] (6) retrosternal ileocolic replacement allows to leave behind esophagus in situ, (7) the stomach is not interfered with, (8) cecum may act a gastric replacement if stomach is scarred or small. Raffensperger et al. in 1996 have reported 48 children with esophageal replacement using ileocolic segment with good outcome.[5] Other authors such as Touloukian and Tellides (8 children), Han (12 children) and recently Lima et al. (11 children) have reported good outcomes in their series with ileocolic esophageal replacement.[21011]

While the gastric pull-up operation was our preferred technique for most esophageal replacements, it is ideally suited for esophageal atresia as popularized by Spitz et al.[12] In esophageal atresia, the upper esophageal pouch is a large supple structure reaching even below the thoracic inlet after mobilization. Thus, the mobilized stomach in the gastric pull-up operation reached the mobilized cervical esophagus easily. The gastric reservoir lies in the mediastinum, but it does not pose a great danger as regards massive aspiration, even though it is a large baggy and aperistaltic pouch. In corrosive esophageal stricture, however, the cervical esophagus is often not the supple structure as in esophageal atresia and the esophageal replacement has not only to reach a higher level in the neck but a large baggy reservoir in the neck poses a danger of sudden massive aspiration. In addition, the corrosive stricture may also involve the stomach precluding its use as an esophageal substitution. Thus, we have reserved gastric pull up in corrosive stricture to only those children who have stenosis of the mediastinal esophagus alone. We have opted to use the ileocolic replacement when either the cervical esophagus and or the stomach were involved. The danger of leaving behind a questionable segment of cervical esophagus above the anastomosis is illustrated by the late mortality in one child.

CONCLUSIONS

Isoperistaltic retrosternal substitution of esophagus using ileocolic segment is a useful way of bypassing a complex and scarred esophagus and is relatively easy to perform. This technique is particularly valuable in cases of esophageal stricture where the stomach is also scarred, and/or the substitute has to reach the high cervical esophagus. The peristalsis of this segment is excellent and complications are fewer.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.