Colon Interposition to Replace an Absent Esophagus is the Procedure of Choice in Low-Income Countries

CHAPTER 1

Today we're performing a colon interposition to replace an absent esophagus on a 6-year-old boy. Our patient is a 6-year-old Honduran boy who has Down syndrome, or trisomy 21, who was born with the esophagus ending up in the upper chest and the lower esophagus, only a nubbin from the stomach. So there's a long gap between the distal and proximal esophagus. So what they did here in Honduras was they created a cervical esophagostomy, known as spit fistula, to prevent him from aspirating his own saliva and secretions. And also performing a gastrostomy so that he can be fed. And through the feeding gastrostomy, he was able to grow like a normal 6-year-old boy of height and weight. And when we saw him, he looked healthy, and he had a workup, which included a contrast study of the stomach, which showed that the esophagus never grew on the lower end. And also he had an EKG, which was read as normal, and we couldn't hear any heart murmurs. So we ordered an echocardiogram to make sure that he doesn't have any structural defects in his heart that would make it a high risk for surgery. And he had none. He had a normal echocardiogram. So today we proceeded and did the colon interposition. The objective of the operation is to create a conduit between the upper and lower esophagus using the colon. We have to go in the belly first. We mobilize the gastrostomy fistula and release all the adhesions from the stomach and the liver. And then we proceeded and mobilized the colon from right to left. And by mobilizing the colon from right to left, we could identify which blood supply will eventually be the main blood supply to the colon interposition. And we picked the middle colic and the right colic artery as the main blood supply to that colon. We then measured the length of the interposition by getting an umbilical tape from the neck to the belly and measured about 8 cm. And so we went ahead and placed the umbilical tape on top of the colon that we selected for the interposition, and that was our guide for our division of the colon. So we divided the colon using that measurement, using a GIA stapling device that would minimize bleeding and also prevent leakage so the area of operation would remain clean. So when we divided the colon with GIA, we proceeded and mobilized the colon but preserving the marginal artery and also preserving the middle colic and the right colic artery and vein to supply our interposition. And using the Harmonic scalpel, we didn't have to litigate any blood vessels in the process. We just divided the vessels with the Harmonic scalpel. And preventing any transmission of the energy to the marginal artery, we clamped the blood vessels with a hemostat that's towards the marginal artery, and then divided the vessel towards the proximal artery and vein, and then preventing any transmission of the energy to the vessel that we're preserving. We then created a tunnel between the inner part of the sternum and the pleura in the mediastinum, and we dissected bluntly with our finger, and then eventually with a hemostat with a gauze in the end of it so we can go to the neck. We then proceeded and opened the neck and went around the spit fistula, or the cervical esophagostomy. Once we mobilized the esophagus, we then proceeded and opened the space in the manubrium sterni and connected the tunnel to the neck. And then created this tunnel wide enough to accommodate the colon and its blood supply. So, we then proceeded and bring the umbilical tape through this tunnel and then sutured the colon to the umbilical tape so that we can bring the colon up to the neck. And it was done nicely because we prevented the colon from twisting. Because we created a marker of the umbilical tape by suturing to the colon and knowing where the mesenteric side and the anti-mesenteric side. And then we brought the colon from the abdomen to the neck. After that we anastomosed the proximal esophagus to the colon. Of course, the lumen between the esophagus and the colon is quite a variation because the colon is bigger than the esophagus. But if you're an expert surgeon, you can anastomose no matter what size and you can allow it to heal. And if that area becomes strictured in the future, you can always dilate it or inject steroids and dilate it. So there's no problem with that at all. And after the neck anastomosis was completed, we went ahead and anastomosed the colon to the stomach at the lesser curvature area and using 3-0 Vicryl, two layers, 3-0 Vicryl. And following that, reinserted gastrostomy tube, created a new site for the gastrostomy. Because before, it was in the midline. Now it's in the left upper quadrant. And using a number 16 French Foley catheter. And secured that gastrostomy tube site with several sutures inside and then outside. Following that, the neck was closed first, putting a drain close to the suture line, closed the muscles that are exposed, closed the subcutaneous tissue, excised any skin that's partially necrotic from the Harmonic scalpel, and then close in the normal fashion with Vicryl and then nylon. The fascia was first closed with 0 Vicryl, followed by the subcutaneous tissue with 4-0 Vicryl, and then nylon for the skin. And that was the conclusion of the operation. The blood loss for the operation that I can surmise is less than 50 cc, or even less than that. It's amazing because this is generally a bloody procedure because of adhesions from the neck area, as well as adhesions the abdomen. And then, if you were to lose a tie or something, he would bleed, but in this case, because we used the harmonic scalpel, we hardly had any blood loss, it's minimal for this particular child.

CHAPTER 2

So you make the incision around the gastrostomy? We're going to take it out. We're going to go - we're not going to preserve it because the gastrostomy tube is a midline. So, we don't know where it is. Okay. So we're going to take it down. Okay. Make sure you push it hard. And then you push the - lay it hard, like that. Make sure you don't move around, okay? Push hard. That's good. Perfect. This way. That's right. That's correct. That's good. Just push hard. Just to see - now she's got it. The way she does the Harmonic is wonderful. That's the way to do it, okay? The other Babcock? Good. You want to put it on the stomach. Let's go in the fascia. Push it. Good. Push it against the, yeah the - it's scar tissue, so it's a little bit more difficult. There, you're doing good. Do you want him to sterilize the protector? It's okay, it'll be okay. There. It's okay. Now we have the adhesion to the liver. So we went through the fascia. We went through the fascia? Yeah, we're going through it now. Okay, with the...? And then the peritoneum we just opened up. We're now in the peritoneal cavity. Take down adhesions with finger dissection. We're currently removing the gastrostomy fistula and the adhesions. Normally this is a bloody procedure without the Harmonic scalpel. If you use sharp dissection, it can be bloody. Yeah, that's fine, you can cut that. We're not in the main thing anyway, yet. We're still taking down adhesions, and he's trying to avoid injury to the colon that's stuck to the adhesion. So that's what we're trying to do now. I think that's fat. It's preperitoneal fat. I think it's fat, it's not colon. It's all right, it's better to be careful then be sorry. Yeah, it's good. See it's fat. It's like a - no, it's like an epigastric hernia. Epigastric hernia, basically. See? It's epigastric hernia. Okay, go down. I was right. Good. See, we got it. Now it's clean. See, it's all fat. See, then you can go through there. It's a good lesson. See, there's the colon, see? And there's the stomach, right here. Now you can see the stomach adhered to the liver from the gastrostomy But, we can take care of that later or now. It's okay, we can look - you can divide this. We're going through omentum. See the stomach. Yeah, we're you going to mobilize the colon. That's our next step. As much colon as we can. And then - ooh, this a nice blood supply. Better than the last one. Yep. Okay, hold this is like this. Hold that. Beautiful. Okay. You can divide here. If you notice, we're using the Harmonic to divide the blood vessels; otherwise, we would have clamped and tied, and that takes a little bit longer, But here we can just divide it with the Harmonic scalpel, and you won't see any bleeding if you do it. You're going to - oh, there's the gallbladder. Oh, it's a big one. A dilated one. Okay, so - go ahead and mobilize this. Duodenum, there's duodenum, duodenum. There's duodenum, now we're just going to mobilize this a little bit of the transverse. Okay. There's duodenum, still. Second portion. Good, let's go that way. So you can remove the omentum from here.

CHAPTER 3

So now we are doing an omentectomy. The colon that we're going to be transpositioning. and these are our blood vessels, you can see that - yeah. Okay. Good. This is not as critical yet. We're just mobilizing the colon up to the splenic flexure, so we can see the blood supply to the colon.

CHAPTER 4

So we can't bring, as soon as we get that divided, you can see where we are. Here. The splenic flexure. Yes. Yes. There's the spleen, right here. I got the spleen on my finger. We're going after the splenic flexure. And there's adhesions to the spleen. Do you want me to hold it for you? Yeah. I got it, almost there. Bleeding is there - there is the bleeding, right there.

CHAPTER 5

So what's our blood supply that I choose? Which one is the best one? These two guys here would be a good blood supply. Go ahead. Take some of that down. Ligament of Treitz.

CHAPTER 6

Good, okay. So if we can preserve - there's the middle colic - middle. We have this one here. There's pancreas, the pancreas. So... Okay, mobilize more here. Left colic, yeah. And middle colic. So if we can use the left colic as the main blood supply, we have to preserve all this. And then this one would go up there. So this is the surgical cervical esophagostomy. This is going to be - there we go. And we need to get enough length of the colon. We need this much length. Okay, cut. Just cut it? Cut it. Okay, now... So, if we use this vessel as a main blood supply and that, this will stay here, and this will be the one that goes up there. Okay, so we'll try to preserve as - you're going to cut these vessels really, way far away, so - so that marginal artery will be well supplied by these two vessels. So we're going to use these two vessels as - these two guys are going to be our main blood supply. Okay.

CHAPTER 7

So we can divide this and then put the staple. I'm going to mark this as a marker. Okay, so do you normally do that when you mark where the distal end or the proximal end is? Yeah, whatever. Okay. Okay, staple. Is there a certain angle that you need to put the staples. No, just make sure that they are aligned. And that the bowel is flat. And there, it goes through the notch, that... They're making the esophagus section now from the colon. Okay, then we push it. Okay. Perfect. Okay. Okay. Good. See, by going back you close the staples. Okay, see? All right, so now we can - okay, it's all right. A little bleeder. It's not coming from the staple line, it's coming from the mesentery. Don't stop. Okay, let go. It's fine. So we have to decide which had the better blood supply. It looks like - they're all nice. I think that's beautiful. They're all okay, they're long. So it's okay, we can use these two guys here, so we can divide it here. Get a hemostat. Now what I do is I clamp this proximal one, and you divide it with the Harmonic on there. Okay, minimum. Next time, let it... Perfect. Okay. Mm hmm, yeah. So we're maintaining the... Marginal artery, right here, see? So we have enough length already, look. Just one more, and we'll... Those are our two ones that we... Yeah, those are the ones we've chosen. That's good enough. Perfect.

CHAPTER 8

Yeah, we have to go posterior to stomach, but we have to mobilize the stomach first. Okay. Is that the little liver, that he's holding - aww! His gallbladder is distended. You go ahead and go through. Harmonic. Good. Okay, it's all right. Stomach? No, it's not stomach, it's scar tissue. Okay. That's it. Yeah, you're fine. Yeah. Okay, yep. Adhesive coming off. See? Yeah. Yeah, yeah, I got it. Go right through there. We're going to repair that. You have to remove the scar tissue anyway. If that's the right place, we could use the anastomosis. Here, see. Liver, that's part of liver. No, it's okay. Yeah, vesicula is there. There. See if you can go behind the stomach for the colon. We can use - yeah, we can use that for maybe anastomosis. Where's the pylorus? We're going to - it's too close. We have to repair it. Yeah, too close, pyloris is right there. Okay. See, so repair, okay? Then we do a gastrostomy here. Gastrostomy here, and then colon here. Yeah, correct, colon there. Yeah. Okay. So... Do you want to repair it now? Yeah, we can repair it now. Okay. We're going to excise this, excise that with a...

CHAPTER 9

Good. Mm hmm. Yeah, we don't need that anymore. We're fine. We can go that way. Okay. No, just the whole layer is fine. Yeah, just run it, then you're going to do interrupted. Hemostat. Connell stitch? Nah. It's a waste of time. Okay. Nah, we don't do that. Okay. No, not in, out - just inter - in the sutures. Oh, yeah, no, we don't need that. Just go here. Is there a specific tissue or a time that you do interlock? No, never. Just go running, and then she can put - you can put your muscular, Lambert, running also if you want to. The stomach has a good blood supply and it doesn't make any difference what you do. Okay. We did it transversely, so close to the pylorus that we're almost like doing a... I don't want to do it the length of the stomach to make the stomach really deformed. Okay. After we close this with another layer, then we'll... What part of the colon is that, Dr. Alvear? It's transverse and left colon. Transverse and left? Yeah. Oh, you're going to Lembert it? Yeah, I'm going to do a running Lembert. Push it down. Cut. I need another 3-0, 3-0 Vicryl. It's coming. What we're doing is closing where the gastrostomy tube was. And after that, we're going to move this colon that we have isolated behind the stomach. So then we're going to start tunneling into the neck. Tuck it. There, you got it. You cut this. Hemostat or cut? Cut, cut. Okay.

CHAPTER 10

All right, go under, behind the stomach. Right here. Find that space. Right? Go find that space. Yeah, right there. Mm hmm. Okay. So we're now behind this - the colon is now behind the stomach. And there's the blood supply to it. Very nice, this one is sitting very nicely, better than... Let's see if we have to do anything to the liver. Nope, it looks fine by itself. So we'll start making the tunnel.

CHAPTER 11

You're going to go in front of the sternum. Okay. And I'm going to go into the neck. Allis? We're now mobilizing the fistula in the neck. Cervical esophagostomy. So we can bring the colon to the neck area. Good. Small one, here. Yeah. See here, right here. I have your gauze, you're... Kelly.

CHAPTER 12

You already made a track through there, or not yet? Not yet, we're going to poke right through it. And so you point it directly up onto the sternum, so you don't hurt the... Yeah. Si, go ahead. Yeah. Right here, you want. Okay, there. Harmonic. You can divide it. There, it's open. Yeah, I agree. Yeah, you got it. Yeah? Yeah. You got it. Yeah, I know. But then I'm like in her... In here? It feels good.

CHAPTER 13

What are you doing now? We're going to move the colon to the neck now. We sutured the - cut, cut. The medical tape? With the umbilical tape, and we are identifying where the mesenteric side, and where's the anti-mesenteric side. So we don't twist, we don't twist the colon when we... You want it to come up straight. We don't want it to twist, yeah. Here we go. Now we're pulling the colon now. Here. And we make sure that it's not twisted. So I'm feeding it. Go ahead. I'm going to try. She's feeding it. Into the tunnel. Go ahead. It's okay. There it comes. There it is. It looks nice, the color's nice. So this is the - see, this is the - see how nice color of the colon? The colon, it looks very nice. The colon is viable. No tension. Nope. We're good. Nice. So mesenteric side, anti-mestenteric. It's right there. Correct. Okay. So now we anastomose to the stomach. Okay.

CHAPTER 14

Go ahead, go ahead. Go ahead. Hemostat? Hemostat? So now we're doing an esophago-to-colonic anastomosis using interrupted sutures. Figure out the planes and keep the anatomy how it's supposed to be, so the posterior end of the esophagus will be sewn to the posterior part of the colon. So whenever you're anastomosing like something narrow versus something larger like this esophagus and the- Oh, like there's a diameter discrepancy? If there's a discrepancy, yeah. So she was saying take smaller bites on the narrow end. The narrower side. And then larger bites on that side. Thank you. And you do that for any kind of an anastomosis because - you'll do that venous to arterial, you know, any kind of vascular anastomosis or any kind of colon or... Okay, thank you. And when you say larger bites, like the distance you travel with your throw? Yeah. Okay. Not thickness, large? Well, sometimes it can be thicker, thicker bites. Okay. Full-thickness bites? Mm hmm. Both sides? Yeah, full-thickness on both sides. So she was saying that because the diameter was so narrow for the esophagus, in the future, he might need dilation. Endoscopic dilation, uh huh. Via the endoscope. Uh huh. But the good thing is, the colon is beautiful and pink. Is [alive]. Yes.

CHAPTER 15

Okay. Okay. So we're going to put a G tube in there, so she's just marking off where to put the G tube, and then, now she knows where to put her anastomosis where it won't be too close. This was an attachment to the liver that we had to dissect down. Okay. And yeah, here is where the gastrostomy was. And it was repaired? Yeah. Okay. Just watch the IV pull. Be careful Dom. [Suction]. Where are you now? We're anastomosing the colon to the stomach. Oh, the stomach? Yes, sir. It's a nice color. Mm hmm. Sorry. So you'd call this an end-to-side anastomosis. So interrupted's more - much more safe, right? In this country? Okay. So we have one more anastomosis to do, which is the colon to colon. And then the fat? And then close up the mesentery. Mm hmm. Suction.

CHAPTER 16

So now what? So we checked the anastomosis, and it's a good diameter, so we're not worried about that. So she's going to do the gastrostomy first. Hemostat.

CHAPTER 17

They're closing the tissue that connects the colon pieces, essentially. Is it like a sac or something? Um, kind of like - how would you describe mesentery? Like the drape that connects... Umm, here, I'll show you a picture.

CHAPTER 18

So she's checking to see where the stomach will be adjacent to the abdominal wall. So she's going to do a purse-string sutures times two. We're doing that now. Oh, okay. So, the gastrostomy tube now. Yeah, check the balloon already? The balloon? Yeah.

CHAPTER 19

So she's closing up the peritoneum now. What are you closing now? The anterior fascia. Uh huh. Okay, thank you. The count is correct, now? Yes, it's complete and correct.

CHAPTER 20

Peekaboo! Oh right, because he's rotated, right? Yeah. Okay. Hello. Are we doing neck? Yep. Closing the neck? Yep. And as you cut sharply, make sure you don't go beyond 2 mm so it doesn't bleed. Okay - right on the perimeter, okay. Okay. Yep, that's it. It won't bleed too much because it's... Cauterized. It's been, Harmonic... Uh huh. Sometimes you straighten out the neck and you straighten out the head, the wound will... Get smaller? Get - yeah. Uh huh. But it's okay, she'll get it together. So do you also turn the neck contralateral to where your repair is, not only for visualization, but when you turn the neck back, then you just automatically have a little bit more length? Yeah. Less tension, even... Less tension. Uh huh, okay. What size nylon do you like? 3-0 nylon to close the skin? 3-0. 3-0. Okay Doctor, they said they have one. Tighten it. It's okay.

CHAPTER 21

[No dialogue.]

CHAPTER 22

What will happen here is the child would, they'll probably observe the child in the ICU for a day or two. And I don't think he is on a ventilator because he's breathing on his own. They'll probably get him extubated and breathing on his own. Most centers, they have these kids on a ventilator for a while, for two or three days. But we don't do that here. If they're awake and extubate - they extubate them. They just watch them in the ICU for precaution. They're going to have to get a chest x-ray to make sure that he doesn't have a pneumothorax, or you can listen to it. And then in a week, you get a barium swallow to make sure there's no leak in the anastomosis. And if the anastomosis is healed, you can start feeding him by mouth. Liquids first and then maybe - or solids later. And the gastrostomy tube will be used for feeding while he's not eating fully for his nutrition. And then you can remove the gastrostomy tube in about a month or two.