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326 Corrosive Ingestion and Oesophageal Replacement
Figure 51.5: Fixing the round ligament to the sternum. to the sternum (Figure 51.5) avoids the colon being stretched over the
Figure 51.6: Colonic graft based on the left colic vessels and
sigmoid vessels (double blood supply).
Figure 51.7: End-to-side oesophagocolic anastomosis. clavicular tissue. A wide bore nasogastric tube is introduced into the
Colon Substitution
The isoperistaltic left colon segment based on the left colic vessels is a
very suitable substitute for the oesophagus in children. A sufficient length
is available to replace the whole oesophagus and even the lower pharynx
if needed. The blood supply from the left colic vessels is robust and rarely
prone to anatomic variations. The close relation between the marginal
vessels and the border of the viscus results in a straight conduit with little
redundancy. The left colon seems to transmit food more easily than the
right colon, and has proved to be relatively acid resistant. 22–24
The transhiatal oesophagectomy with posterior mediastinal
isoperistaltic left colon has been the most direct and shortest route for
the oesophageal substitute between the neck and abdomen. It permits the
removal of the scarred oesophagus, which has a definite increased risk
of malignant changes, cyst formation, and empyema if left in place. 22–24
The retrosternal route is still an ideal route for many surgeons.
Retrosternal colon by-pass avoids any thoracic dissection and preserves
the vagus nerves. It takes less operative time and avoids injuries to such
intrathoracic structures as trachea and major vessels. The postoperative
period is less stormy than the transhiatal route, and few patients require
postoperative ventilations. Many modifications have been performed to
make a straight route out of the anterior mediastinal/retrosternal route.
Dividing the strap muscles in the neck and fixing the falciform ligament
liver when the child is in an erect position. 22–24
An equal number of each technique were performed at Ain Shams
University in Cairo. We prefer using the transverse colon, based on
a double blood supply from the left colic vessels (Figure 51.6) with
comparable results for retrosternal and transhiatal techniques. Usually,
we add an antireflux procedure while performing the cologastric
anastomosis by wrapping the lower colon by stomach in the transhiatal
approach and creating an angle between the lower colon and the anterior
gastric wall. The length of tucking of the colon to the anterior gastric wall
to create an antireflux mechanism should be 4–5 cm.
Leakage from the cervical oesophagocolic anastomosis has been
reported to be 12–71% and is usually followed by varying degrees
of stricture after the cessation of leakage. Performing an end-to-side
anastomosis between the unequal diameters of the oesophagus and
colon has decreased the incidence of leakage from the neck anastomosis
(Figure 51.7). The use of a double blood supply to the colonic graft and
the use of a vascularised omental flap to wrap the anastomosis have also
reduced the leakage rate. 22–24
Long-term follow-up for patients with colonic replacement of the
oesophagus have shown excellent results. Late complications, such as
strictures of the cervical end, may lead to varying degrees of dysphagia.
Strictures may be dilated; however, the majority will need revision of
the anastomosis. Redundancy of the interposed colonic graft in the chest
may lead to stasis and dysphagia due to kinking of the graft (Figure
51.8). Proper measurement of the graft length and avoiding opening the
pleura may decrease the incidence of redundancy of the colonic graft. 22–24
Gastric Substitution
In gastric substitution, a cervico-abdominal approach is used. The
neck incision may be right- or left-sided. The abdominal incision may
be upper umbilical midline or transverse. The gastrostomy is care-
fully taken down and closed in two layers. The vessels on the greater
curvature of the stomach are preserved for the gastric transposition
or if a carefully constructed gastric tube is used. Where possible, a
posterior mediastinal route is preferred to a retrosternal route. The
fundal end of the stomach is anastamosed to the oesophageal stump
in the neck, securing the neck anastamosis with sutures to the retro
thoracic stomach to avoid acute gastric distention. Gastrohiatal sutures
are applied to prevent herniation of abdominal contents. A pyloroplasty
is performed and the pylorus is kept below the diaphragm (Figures 51.9