Using right colon interposition in patients with caustic ingestion, an introduction of a new surgical technique for post-gastrectomy reconstruction: a case series

Abstract

Background

Corrosive substance ingestion is rare but can cause severe injury, especially to the upper gastrointestinal tract, and can be a potentially fatal event. Various surgical procedures have been advocated for gastroesophageal reconstruction, but especially those using the right colon, when the ileocecal valve is preserved for gastric reconstruction, are briefly exposed in literature and have not been studied in humans by controlled studies. Using the right colon is believed to be beneficial because of the anti-reflux mechanism of the ileocecal valve. This study aims to report our experience in the use of right colon interposition for gastric reconstruction in the management of caustic injury, and to assess its influence on patient outcomes.

Case presentation

We describe five cases, all of which included corrosive substances ingested by patients referred to a local tertiary center institution undergoing right colon interposition for esophageal and gastric reconstruction. We evaluated five Iranian patients undergoing ileocolic segment interposition for gastric reconstruction. Of these, two were male patients (patient 1 was 51 years old, patient 2 was 32 years old), and three were female patients (patient 3 was 49 years old, patient 4 was 32 year old, patient 5 was 59 year old), with an age from 32 to 59 years (mean: 57 ± 10.95). The operating surgeon’s first to fifth procedures proceeded uneventfully, with only one case of cervical leakage as a complication with spontaneous closure; relative mean operative time of 5.95 ± 1.17 hours, hospital stays of 25 ± 15.29 days for all five patients. No excess morbidity rate was observed.

Conclusion

In this case series, a novel technique for post-gastrectomy reconstruction using right colon interposition along with an ileocecal reservoir with identical advantages in improving eating capacity, and avoiding biliary reflux thanks to the presence of the ileocecal valve, is introduced.

Background

Various gastric reconstruction procedures after total gastrectomy have evolved over the century [1] to compensate, and prevent complaint of, diarrhea, post-prandial upper abdominal pain, dumping syndrome, and refractory anemia, conjointly called post-gastrectomy syndrome [2]. More than 50 reconstruction sorts have been reported in the literature for restoring gastrointestinal tract continuity of refs. [3,4,5,6]. Unfortunately, to date, due to a lack of clinical evidence and inhomogeneous reported series, no gold-standard technique has been established, and many questions about the usefulness of either creating a reservoir or restoring duodenal passage after total gastrectomy are still debated [6]. To achieve adequate postoperative outcomes, decrease complication rates, maintain satisfactory nutritional status and the patient’s ability to gain and maintain weight, and improve quality of life, surgeons should choose an appropriate reconstruction method with the aims of conservation of the anatomical structure and preserving as much of the physiological function as possible.

Several modifications to the colon interposition approach have been described, using the left, right, or transverse colon as an isoperistaltic interposition graft for gastroesophageal reconstruction [7]. Some aspects of anatomical, functional, and single patient features, as well as surgeon’s experience, must be taken into consideration before deciding which colonic segment to use is the best [8]. Left colon interposition carries complications arising postoperation, occurring at any time [9]. For instance, the absence of the ileocecal valve leads to symptomatic reflux of bile into the colic graft [9]. An additional dysfunctional complaint of the transposed left colic segment is regurgitation, which is a result of the lower esophageal sphincter destruction [10, 11]. Furthermore, the left colonic flexure wide mobilization technique, and inadequate collateral flow through arterial anastomoses, may increase the risk of injury to the branch of the left colic artery supplying the graft and lead it to ischemic graft failure and necrosis [12, 13]. Therefore, successful use of the colon as a substitute requires a colon graft with adequate arterial inflow, sufficient distribution of blood throughout the graft, and unobstructed venous drainage [12]. The aim of the present study is to describe the experience of the novel technique implying preferentially the right colon among caustic injury patients for post-gastroesophagectomy reconstruction, and especially post-gastrectomy reconstruction. This study was conducted to evaluate their outcomes to provide evidence supporting utilizing this technique in other institutions and worldwide.

Case presentation

Patient selection

This retrospective case series included data of patients with caustic burn who underwent gastroesophagectomy, and in whom the right colon interposition was used for esophageal and gastric replacement at local tertiary referral centers, from September 2020 to March 2022. Patients’ information was anonymized prior to analysis and the confidentiality was assured by the researcher.

Demographic data including the patients’ age, sex, past psychiatric problems, past medical history, history of previous surgeries, preoperative nutrition status, preoperative total parenteral nutrition (TPN) receiving, intraoperative blood loss, intensive-care-unit (ICU) stay, and postoperative complications were recorded from the patients’ medical files.

Repair surgical technique

Once in the operating room, the patient is positioned supine and put under general anesthesia along with endotracheal intubation. After preoperative sterile prep and drape, the procedure is carried out in the following phases.

Phase I: resection and vascular pattern identification

This initial step of the operation is performed with the surgeon standing at the left side of the patient. The surgical technique of choice is to enter the abdominal cavity through a previous midline laparotomy incision of total gastrectomy. Initially, extensive adhesions are properly released, and the long isoperistaltic right colon graft, supplied by the right colic artery, right branch of the middle colic artery, and ileal branch of the ileocolic artery, is chosen from the territory and mobilized followed by the Cattell’s maneuver.

After colonic graft selection, an inspection of the right colic and middle colic artery pulsations is done to assure the viability of the segment. The ileocolic artery is then dissected and temporarily occluded. Caution should be applied to protect other vessels in the vascular pedicle from any possible injuries following pressure, tearing, or twisting.

Phase II: replacement technique

The proximal anastomosis in the neck exploration requires mobilization of the trimmed retracted segment of the esophagus. Therefore, the mediastinum is retrosternally opened, and a tunnel is made by a blunt dissection, with adjacent division of the endothoracic fascia to the sternum, while maintaining great caution to avoid penetration of the pleura.

Phase III: graft transplantation

The extracted right colon graft is washed with diluted povidine iodine solution, and passed anteriorly in mediastinal position, in an isoperistaltic manner. To enable passage through the chest, the right colon along with the terminal ileum is stitched with a silk suture and pulled through the cervical incision until the colon is retrosternally placed in the tunnel. Redundant parts are then resected. The pyriform sinus (esophago-colonic anastomosis) is anastomosed to the terminal ileum side-to-end at an appropriate site using hand-sewn polydioxanone suture (PDS) 4-0 with interrupted stitches, and the colon is fixated to the neck muscles. The cervical incision is closed after a Penrose drain is placed.

Using a linear cutting stapler 80 mm, the distal part of the evaluated colon is removed. The gastrointestinal (GI) tract continuity is then completed by performing a jejunocolic and ileocolic anastomosis. The previous jejunostomy remains in its place while a Jackson-Pratt (JP) drain and corrugated drain are also inserted. The mesenteric defect is closed in the usual manner, and the omentum, if available, is placed over the anastomosis. The abdominal wall is subsequently closed layer by layer. Finally, bilateral chest tube number 028 is inserted and the patient is transferred to the intensive care unit (ICU) for further care.

Figure 1 represents the patient who had undergone exclusive gastrectomy, and was candidate for gastric reconstruction. GI continuity was re-established between the extracted right colon/ileum and trimmed retracted segment of the esophagus (esophago-colonic anastomosis).

Fig. 1

Gastric reconstruction using right colon including ileocecal valve by an esophago-colic anastomosis via a single-layer permanent suture. Gastrointestinal continuity was established by jejunocolic and ileocolic anastomosis. Previous jejunostomy remained in place

Postoperative course

Discharge criteria

A successful discharge program depends on the appropriate meeting of discharge criteria. To do this, each patient (P) needs to achieve the enhanced recovery protocols, especially emphasizing patient toleration of liquid diet after surgery and healthy leakage-free anastomosis. In terms of early discharge, pain management, early mobility, and judicious intravenous fluid and electrolyte management should be considered as contributing to a healthy patient and anastomosis.

We evaluated five Iranian patients (P₁, P₂, P₃, P₄, and P₅) undergoing ileocolic segment interposition for gastric reconstruction. The mean (± standard deviation) age of patients who underwent right colon interposition was 57 ± 10.95 (range: 32–59) years. Our sample was predominantly composed of female patients (60%, P_3, P₄, P₅). No significant chronic medical conditions were observed in these patients. All cases presented psychiatric medical backgrounds, but only one patient had a history of subsequent suicide attempts in the follow-up (P₂). Of importance, all cases suffered from major depressive disorder. Only two patients suffered from bipolar and slightly psychotic symptoms (P₂, P₅).

In this study, four patients had undergone surgical treatment of gastroesophagectomy (Fig. 2), and only one patient underwent gastrectomy exclusively (P₃) (Fig. 1). All patients obtained nutritional support by feeding jejunostomy for 5.25 ± 3.59 months and underwent the operation after the corrosive ingestion episode within a period of 11.2 ± 11.90 months. Preoperative serum albumin level was 3.10 ± 0.82. Additional preoperative data are summarized in Table 1.

Fig. 2

Gastroesophageal reconstruction using right colon including ileocecal valve. Small bowel at 10 cm (cm) was cut. The graft was pulled up retrosternally. Esophago-hypopharynx anastomosis was performed, and jejunostomy remained in place

Table 1 Demographic, preoperative, intraoperative, and postoperative clinical information of five patients undergoing right colon interposition after total gastroesophagectomy

Intraoperatively, surgical access was by previous midline laparotomy as well as left cervicotomy. Only two patients underwent partial upper sternotomy to provide additional access for cervical esophageal exploration (P₂, P₅). The mean time in the operating room was 5.95 ± 1.17 hours. Estimated blood loss averaged 1570 ± 1242 ml.

Postoperatively, all patients were admitted to the ICU under the care of an intensivist for an average of 5.80 ± 3.11 days. The mean duration of hospital admission was 25 ± 15.29 days. One patient had a surgical-related complication of cervical leakage, which was resolved spontaneously (P₁). Among the five patients, only one had pulmonary complications, with no need for prolonged or recurrent mechanical respiratory support (P₂).

No excess morbidity rate was observed for colon interposition. Enteral feeding initiated within the first 9.00 ± 1.83 days and advanced to the liquid diet over the next 13 ± 4.24 days. All five patients were discharged from the hospital. In this study, mean follow-up time was 18 months, and no significant complications occurred during the course.

Discussion

The colon has been introduced as a gastroesophageal replacement since 1911 [7]. In this study, in four patients requiring reconstruction after gastroesophagectomy, the choice was ileocolic graft, right colon, and to graft a segment from the terminal ileum to the ascending colon. The graft was interposed isoperistaltically as a gastroesophageal substitute, which uses the ileocolic and middle colic vessels as a pedicle [14]. As a result of using ileocecal valve, reflux esophagitis seldom occurs after reconstruction using a right colon graft. Other advantages of this traditional method are a reservoir-like capacity of the cecum due to the large caliber of the cecum, and close similar match in the diameters of the esophagus and the ileum, which leads to easier anastomosis [15]. In this study, only one of the patients (P₁) who underwent right colon interposition as a gastroesophageal reconstruction presented with postoperative cervical leakage left for spontaneous closure. There were no intraoperative complications, and no significant problems were encountered during the procedure.

The first proposed idea of using the ileocolic segment as a substitute for esophageal reconstruction with the purpose of taking advantage of the anti-reflux mechanism of the ileocecal valve was brought about by Lee in 1950 [16]; however, it did not gain popularity. This inspired the authors to come up with a modified technique, preferentially using the right colon for reconstruction after total gastrectomy with the preservation of the ileocecal valve, aimed to prevent pharyngeal bile reflux and storage of ingested contents within a cecal reservoir to increase eating capacity, maintain body weight, preserve quality of life, and avoid dumping syndrome [17, 18]. Therefore, the above-mentioned technique used in (P₃) succeeded in achieving the ideal goals of reconstruction with satisfactory results.

Additionally, early onset roux syndrome, which is responsible for vomiting, can occur when Roux-en-Y loop is used [19]. This is a gastric emptying disorder attributed to postoperative gastroparesis and stasis in the Roux-en-Y limb [20], which subsequently delays adequate feeding and prolongs hospital stay. In this study, no patient complained of roux syndrome or any other postprandial symptoms during the follow-up period. We believe that these favorable surgical outcomes appear to be safe to be accepted as a new surgical procedure.

The appropriate graft for anastomosis must be sufficiently elongated, mobile and well vascularized with adequate arterial inflow, sufficient distribution of blood throughout the graft, and unobstructed venous drainage to reach the distal part of remnant esophagus [1, 12]. The ileocolic artery, arising independently from the superior mesenteric artery that supplies the large intestine, is a constant vessel supplying the terminal ileum, cecum, and the ascending colon, which gives off the important appendicular branches [21]. Importantly, there is an extremely effective anastomotic arcade, the marginal artery, more often seen on the right side, linking these successive arteries around the margin of the bowel [21]. Along these points, experimentally the congruence and size of the cervical esophagus and the terminal ileum facilitate the construction of anastomosis at cervical level [22, 23]. Consequently, these results support the hypothesis for the preference of using right colon interposition.

To our knowledge, this is the first case series that carries out and describes an innovative technique of using the ileocolic segment and right colon for gastric reconstruction substitute. However, there were several limitations in this research. First, the sample size was relatively small, and was not calculated on the basis of any hypothesis. A larger sample size is required to perform statistical adjustments for multiplicity, which has not been accomplished in the current study. In addition, short follow-up period was a limitation. Further inevitable limitations of this technique are in patients who underwent previous sternotomy or colectomy of any region, and those requiring a long adhesiolysis due to a former surgical procedure. Despite the above limitations, the results of this series suggest that the described modifications represent an alternative to established procedures for creating a colon interposition graft. Although this method may be particularly helpful, the conclusions of this study cannot be directly applied; thus, a prospective randomized trial needs to be performed to confirm these observations.

Conclusion

The paper provides a detailed description of a surgical technique employed on five caustic-ingested patients, and the ileocecal segment interposition. With regard to construction of a reservoir, prevention of biliary reflux, as a result of ileocecal valve restoration of a more physiological gastroduodenal circuit and adequate arterial perfusion, provides significant advantages for the patient. Concluding from this experience, it can be considered as a choice in methods of post-gastrectomy reconstruction.