pediatric thoracic surgery || esophageal replacement

Introduction

It is well established that there is no better conduit than the native esophagus1 but there are some conditions in which the native esophagus cannot be preserved and needs to be replaced. The main indications for esophageal replacement in the pediatric population are long-gap esophageal atresia (LGEA) and severe esophageal strictures. There are several options for replacement depending on the organ (i.e., stom-ach, colon, jejunum) and the route used (i.e., subcutaneous, retrosternal, transhiatal).

In most patients with esophageal atresia (EA) it is possible to preserve the native esophagus and perform a primary anas-tomosis.2 But the group of patients with EA without a distal tracheoesophageal fistula (8% pure EA and 2% EA with prox-imal tracheoesophageal fistula) shares the common features of a small stomach and small distal esophageal stump, which may preclude a primary anastomosis. The initial surgery of these patients is done during the first days of life. At this stage a laparotomy and gastrostomy are performed. Through an upper abdominal incision the stomach is accessed and the lower esophageal pouch is assessed under fluoroscopy intro-ducing metal dilators. The gastrostomy should be placed dis-tally and away from the greater curve to facilitate surgery at a later stage; it can be difficult in these patients due to a small stomach. The presence of a proximal tracheoesophageal fistula should be recognized before or at the beginning of the surgery with a contrast study of the upper esophagus and endoscopic

examination. If a proximal fistula is demonstrated it should be divided, generally through a neck incision. Cervical esopha-gostomies are avoided whenever possible and reserved as a salvage option in a patient with catastrophic complications. The patients are kept on intermittent or continuous oroesopha-geal sump suction and bolus feeds through the gastrostomy.

All patients with LGEA are assessed for possible primary anastomosis. In those with a very meager lower esophagus, that is about one-third of the patients, a primary replacement is considered sometime in the first 3 months, depending on prematurity. This waiting period is important to allow the stomach to grow. But esophageal replacement surgery should not be delayed unnecessarily as delay may harm the patients’ ability to develop a normal swallowing mechanism.

Esophageal strictures are a less common indication for esoph-ageal replacement. They can be congenital, caustic, or peptic in origin. Most of them can be treated conservatively with repetitive dilatations, medical therapy, and antireflux surgery when indi-cated. When the medical treatment fails, more radical procedures can be done with preservation of the native esophagus (i.e., resec-tion of the stricture and anastomosis). There are a small number of patients who will need an esophageal replacement.

Esophageal replacement has occasionally been used in other rare conditions in children such as large benign tumors,3 scleroderma,4 epidermolysis bullosa,5–8 diffuse candidiasis,9,10 herpes virus infections,10 etc.

24Esophageal ReplacementJuan Carlos Pattillo and Alex W. Auldist

The ideal esophageal replacement

• Allows normal swallowing• Does not become redundant and tortuous• Does not cause respiratory embarrassment• Technically simple to perform • Low morbidity and possible in small children/infants• Minimal GER in the conduit and low risk of future malignancy

Indications for esophageal substitution in esophageal atresia

• Long-gap esophageal atresia (LGEA) (Fig. 24.1)• Extreme prematurity unsuitable for delayed primary

anastomosis• EA + TEF long gap (rare)• Failed anastomosis leading to esophagostomy• Major after EA repair leak with anastomotic disruption• Nonfunctioning aperistaltic esophagus due to overzealous

attempts to preserve native esophagus• Failed previous esophageal substitutes

D.H. Parikh et al. (eds.), Pediatric Thoracic Surgery, 321DOI: 10.1007/b136543_24, © Springer-Verlag London Limited 2009

322 J.C. Pattillo and A.W. Auldist

Historic Perspective

The history of esophageal replacement is closely related to the management of esophageal carcinoma in adults. The first attempt for esophageal reconstruction was done by Bircher11 in 1894 using a skin tube. Since then, many methods for esopha-geal replacement have been developed. Esophageal replace-ment in children was not employed until the second half of the twentieth century when it was introduced for the treatment of various types of EA, particularly EA without a fistula, but also in patients with EA and distal fistula in whom it was not possible to achieve an end-to-end esophageal anastomosis.12 Before that, patients in whom esophageal continuity could not be restored were treated with cervical esophagostomy (“spit fistula”) and gastrostomy. Later on, connection was accom-plished by a rubber tube passing from the cervical esopha-gostomy to the gastrostomy stoma.13 The next step was the formation of a skin tube down the anterior chest wall, which was unsatisfactory for a variety of reasons including esthetics and development of malignancy.14

The history of esophageal replacements in children needs to be examined in the context of the organ used, the route whereby the conduit is placed, and the timing of the procedure.

Stomach: Gastric Tube

In 1905 Beck and Carrel15 developed gastric tubes from the greater curve of the stomach in dogs and human cadavers and

placed them subcutaneously in front of the sternum. In 1944 Swenson and Magruder16 reported experimental work using a gastric tube in dogs. Heimlich and Winfield17 published the experimental use of gastric tubes in dogs and suggested that it may have clinical use in 1955. He performed his first gastric tube in 1957 after visiting Gavriliu in Rumania who had been using this technique since 1951 and by this year reported a series of 52 patients.18 He acknowledged that Gavriliu was the pioneer of the gastric tube.19 Lately, Heimlich described his experience over 15 years with 53 cases ranging in age from 14 to 70 years.20 The technique described by Heimlich, and sub-sequently by Burrington and Stephens21 in Toronto, involves the formation of a reverse gastric tube from the greater curve of the stomach, splenectomy, and use of the substernal route. In Sydney, Cohen22 brought the tube through the left hemitho-rax and avoided splenectomy, and Middleton23 described the isoperistaltic tube. Ein et al.24,25 in Toronto and Anderson and Randolph26,27 in Washington, DC are more recent advocates of this procedure.

Stomach: Gastric Pull-Up

The first publication on gastric pull-ups was done by Kummel28 in 1922. He reported two patients who died after an attempted gastric pull-up utilizing the mediastinal route. Sweet29 popu-larized the direct anastomosis of the stomach to the proximalesophagus in the chest for esophageal cancer. The first attempts of substitution of the stomach for the absent esophagus in

Fig. 24.1. Long-gap esophageal atresia

24. Esophageal Replacement 323

cases of atresia were done by Rienhoff,30 although he placed the stomach subcutaneously anterior to the sternum. Potts31 replicated the operation shortly after its description, but the poor cosmetic result made him reoperate on the patient plac-ing the esophagus inside the chest. Swenson32 and Sweet33 successfully used this method in children, but after the good results obtained with gastric tubes and colonic replacements, the gastric pull-up was virtually abandoned because of the believed high postoperative morbidity and mortality rates combined with poor functional results and impaired postoper-ative growth. Later, in 1980, Atwell and Harrison34 published a series of six children treated with gastric pull-up as described by Lewis,35 of whom five had esophageal atresia and one had caustic strictures. Two patients died and one had severe early complications, but in the long term the surviving patients did well. Contemporary advocates, headed by the group at Great Ormond Street in London,36–40 continue to support the gastric pull-up based mainly on its simplicity.

Jejunum

Wullstein41 developed an experimental model of jejunal replacement in 1904 after the high incidence of fistulae and strictures observed in skin tubes. Roux42 was the first to attempt an esophageal replacement with jejunum in a child. In 1906, he created an antethoracic Roux-en-Y limb in a 12-year-old boy with caustic stricture of the esophagus. However, the procedure was not completed until 1911 when the cervical esophagojejunostomy was done. The patient was followed-up for long time43 and finally died at the age of 53 of causes not related to the surgery. Meanwhile, Herzen44 in 1907, in Mos-cow, performed the first complete replacement of the esopha-gus with jejunum in a 20-year-old woman with stricture after acid ingestion. In 1946, Reinhoff45 placed the jejunum inside the chest in an attempt to gain further length for lesions of the upper third of the esophagus. Large series of jejunal replace-ment for acid injuries came later from Russia by Yudin46 and Petrov.47 Jezioro,48 from Poland, published a detailed series of total esophageal replacement with jejunum in children in 1958. He performed staged jejunum interposition in 14 chil-dren. Two patients died but the rest had excellent functional results up to 5 years later.

In 1982, Ring49 published his experience in 32 cases of jejunal interposition with no operative mortality and good long-term results (Table 24.3). Recent advocates of jejunal replacement include Saeki50 from Tokio, Cusik51 from Leeds, Bax52,53 from Utretch in The Netherlands, and Cauchi54 from Birmingham, UK. While jejunum interposition is a popular esophageal replacement method in adult, it has not been as popular in children.

Colon

Historically, colon replacement has been the preferred esoph-ageal replacement technique in children.

Kelling55 reported the first case of colonic bypass of the esophagus in 1911. He could not use the jejunum as planned to bypass an esophageal cancer and had to use transverse colon. The patient died of advanced esophageal cancer before the completion of the cervical anastomosis. Lundblad56 performed the first colonic reconstruction of the esophagus in a 3-year-old child with a caustic stricture in 1921; the patient lived and swal-lowed normally until he died in a car accident 37 years later. In 1948, Sandblom57 was the first to use the colon for replacement in esophageal atresia. In the 1950s, colon replacement became more popular with the availability of antibiotics and better anesthetics. Javid58 in 1953 performed a retrosternal ileocolic replacement in an 18-month-old baby with pure esophageal atresia. Sherman and Waterston59 continued to communicate further progress in colonic replacement in 1957. Waterston and coworkers59,60 and Belsey61 used isoperistaltic transverse colon based on the left colic artery in the left chest.

Later, in 1982, Freeman and Cass62 described the use of the colon through the native esophageal bed.

Management Options

There is no agreement on the best esophageal replacement technique. But there are some characteristics that make some techniques superior to others. Overall, the long-term quality of life, the ability to eat normally and the fulfillment of the nutritional requirements of the children are the most impor-tant goals.63 Creation of a conduit of normal caliber in the mediastinum is important to avoid respiratory and cardiac impairment secondary to a “space-occupying lesion.”64 The technique chosen should minimize gastric acid reflux, and the esophageal substitute will hopefully have the ability to tolerate gastric acidity if this happens. Finally, the operation should be easy to replicate, with low morbidity and mortality and feasible in small children.65

Almost all segments of the gastrointestinal tract have been used to replace the esophagus, including the stomach, small bowel, and colon.

The stomach has been used to form a tube with preservation of the native esophagus elongating the lesser curve, as described by Scärli66 (Fig. 24.2a). From the greater curve, gastric tubes can be formed with their base in the proximal stomach to form a reverse gastric tube as described by Gavriliu18 and popular-ized by Heimlich17,19,67 (Fig. 24.2b), or with their base distally in the stomach (isoperistaltic tube) (Fig. 24.2c).68 The stomach can be mobilized and completely pulled up to the neck, through the posterior mediastinum or through the retrosternal space, without the need of a thoracotomy36–39 (Fig. 24.3).

The jejunum is the less popular alternative for esophageal replacement in pediatric surgery because it is technically demand-ing. It is difficult to achieve enough length for a safe anastomosis without jeopardizing the precarious blood supply of a pediculated jejunal loop52,53 (Fig. 24.4), and it is even more challenging and less reproducible to perform a free jejunal graft with microvascu-lar anastomoses, particularly in small children.51


The colon is still a popular alternative for esophageal substi-tution, but serious long-term complications have been reported including bleeding, perforation, and cancer (see later). The right or left colon is used based on their main blood supply: ileocolic and middle colic or left colic artery. The right colon is placed retrosternally while the left colon can be placed in the left pleural cavity or the posterior mediastinum (Fig. 24.5). Subcutaneous colonic bypass was used in the past, but now has been abandoned due to the lack of functionality and esthetics.

Other replacement techniques used in the past, like syn-thetic prosthesis or subcutaneous skin tubes, have been aban-doned due to severe complications.14

Gastric Tube

The primary reverse gastric tube is the preferred method of esophageal replacement at The Royal Children’s Hospital in Melbourne.69

Operative details: The reverse gastric tube is formed from the greater gastric curve (Fig. 24.6). The abdomen is explored via a transverse upper abdominal incision. The previous gastrostomy is taken down. The distal esophageal stump is excised if present. The spleen is preserved and the short gastric vessels divided. The gastric tube is formed with preservation of the left gastroepiploic arcade. A vertical inci-sion is made 2–3 cm proximal to the pylorus, and the tube is completed incising the stomach parallel to the greater curve until adequate length is achieved. The stomach is sutured over a large bore tube in two layers of continuous absorb-able material forming the tube. Alternatively, the stomach can be cut with GIA stapler70,71 (Fig. 24.7). While the blood supply through the gastroepiploic vessels is quite marginal it is likely that the tube is mainly perfused through intramural

Fig. 24.2. Formation of different types of gastric tubes. (a) Gastric tube formed from the lesser curve with preservation of the lower esophagus. (b) Reverse gastric tube formed from the greater curve. (c) Isoperistaltic gastric tube formed from the greater curve

Fig. 24.3. Esophageal replace-ment with gastric pull-up. (a) The esophageal stump is removed; the upper portion of the fundus is identified, and pyloromyotomy is performed. (b) The stomach is pulled up and then (c) anastomosed to the cervical esophagus


Fig. 24.4. Jejunal transposition. (a) A suitable loop of jejunum is identified. (b) The vascular arcade is preserved and extravascular length is gained by excising a segment of bowel. (c) The chosen segment is passed up in front of the stomach and anastomosed in the chest. Jejunal continuity is reestablished

Fig. 24.5. Colon replacement. (a) A suitable loop of transverse colon is identified. The middle colic is divided after confirming the viability of the colon based on the left colic. (b) The colon is passed behind the stomach and anastomoses performed

Fig. 24.6. Gastric tube. The figure shows the placement of a reverse gastric tube in the greater curve


vessels; it is important to preserve a wide base for the tube near the angle of Hiss. The hiatus is gently dilated. The new esophagus is introduced into the chest via the hiatus and the abdominal wound is closed after formation of a new gastros-tomy (Fig. 24.8).

The position of the patient is changed to approach the upper pouch through a right extrapleural thoracotomy. The upper esophagus is mobilized and anastomosed to the gastric tube with interrupted absorbable material (Fig. 24.9).

Pyloroplasty is not routinely indicated.The patients go to neonatal intensive care for their postop-

erative management, though mechanical ventilation is not rou-tinely used. Continuous gastrostomy feeding is commenced as soon as tolerated. A contrast study is performed 1 week after the operation and oral feed is started.

Results and Discussion on Gastric Pull-Ups (Table 24.1)

Gastric tubes were done in two stages in the past72–74; the for-mation and positioning of the gastric tube in the neck was done initially and the cervical esophagogastric anastomosis was completed at a later stage. Nowadays, cervical esophago-stomies are avoided and the gastric tube is completed in one

procedure. The restrosternal position has been abandoned and the tubes are placed in the native esophageal bed.

The reverse gastric tube is easy to reproduce and is reli-able. The perfusion through the gastroepiploic vessels can be quite marginal but the presence of a submucosal plexus in the stomach keeps a reliable blood supply to the tube even after extensive mobilization. For this reason tube necrosis is uncommon.

The incidence of strictures is comparable with other tech-niques and they seldom need to be revised.

The formation of the tube demands a long suture line and therefore an increased risk of leakage. The incidence of leak-age is higher at the site of a cervical anastomosis24 compared with intrathoracic anastomosis.71 Leakages from a gastric tube hardly ever need operative management.

Redundancy and dumping syndrome are uncommon.68

Perforations of the tube, fistulization, and hemorrhage have been described74,78 but these are rare complications in chil-dren.

With the gastric tube based on the greater curve one can achieve enough length to perform the gastroesophageal anas-tomosis without tension, even more when the gastric tube is

Fig. 24.7. Gastric tube. The distal esophageal stump is removed and the tube is formed

Fig. 24.8. Gastric tube. The tube is passed up through the hiatus


positioned in the native esophageal bed. The small gastric capacity after the formation of the tube is compensated rap-idly as the patients grow and start to feed. For those reasons it does not seem to be a major benefit in preserving the distal esophagus.

A serious problem of the gastric tubes is the exposure of the normal esophageal mucosa to acid. Two factors contribute to this: (a) gastroesophageal reflux determined by the absence of

a competent and functional lower esophageal sphincter and the lack of effective esophageal clearance and (b) the vicinity of the gastric mucosa to the esophagus. A series of long-term follow-up with pH studies of gastric tubes have confirmed the presence of both elements.68 Long-term complications of the exposure of the native esophagus to the gastric acid include esophagitis and gastric metaplasia.79,80 Gastric metaplasia was confirmed microscopically in 8 of 18 patients and reported as Barret’s esophagus by Lindahl in 1992,80 but the definition of Barrett’s esophagus has evolved since its initial descrip-tion in 1957.81 Nowadays, the accepted definition includes the “displacement of the squamocolumnar junction proximal to the gastroesophageal junction with the presence of intestinal metaplasia”82 and acknowledges for the malignant potential of these findings. Therefore, these patients do not fulfill crite-ria for Barrett’s esophagus under the present definition. There have been no reports of intestinal metaplasia, dysplasia, or can-cer in pediatric patients with gastric tubes. In adults, reports of carcinoma of the reconstructed stomach tube are rare; most of them are documented in the Japanese literature, and usually, correspond to metachronous double cancers after esophageal malignancies though there are reports after replacement for benign strictures.83–85 Patients with a gastric tube frequently complain of gastroesophageal reflux symptoms,86 but their quality of life does not differ significantly from other recon-struction techniques.63 Symptoms and social problems usually improve when the patients reach their 20s.63,87 In the meantime these symptoms and the gastric acidity can be controlled very effectively with proton pump blockers.

Gastric Pull-Up

Operative details: The gastric pull-up is based on the capacity of the stomach to tolerate extensive mobilization – thanks to a rich submucosal plexus.

To start the mobilization the abdomen is opened through an upper abdominal incision. The previous gastrostomy is taken down. The great curve is mobilized after division of the vessels of the gastrocolic omentum and the short gastric ves-sels. This should be done at safe distance from the stomach to preserve the gastroepiploic vessels. The lesser omentum is

Table 24.1. Results of gastric tubes series published after 1980.

Type n Leaks % Strictures % Tube failure Deaths

Lindahl et al.72 1983 Reverse gastric tube 14 3 21 1 7 2 0Goon et al.73 1985 Isoperistaltic/reverse gastric tube 46 35 76 27 59 0 1Ein et al.74 1987 Isoperistaltic/reverse gastric tube 36 24 66 15 41 1 3Scärli66 1992 Isoperistaltic tube (lesser curve) 5 1 20 2 40 0 0Pendersen et al.70 1996 Reverse gastric tube 3 0 0 1 33 0 1Ein75 1998 Isoperistaltic/reverse gastric tube 11 9 82 8 73 0 1Fernandez et al.76 1998 Isoperistaltic tube (lesser curve) 4 2 50 1 25 0 0Schettini and Pinus77 1998 Isoperistaltic/reverse gastric tube 19 12 63 8 42 1 0McCollun et al.71 2003 Reverse gastric tube 7 0 0 3 43 0 0Rao et al.64 2003 Isoperistaltic tube 4 0 0 0 0 0 0Borgnon et al.68 2004 Isoperistaltic tube 21 2 10 2 10 0 0

Fig. 24.9. Gastric tube. The anastomosis is completed in the chest


opened, the right gastric artery is identified and preserved, and the left gastric artery is divided. The distal esophageal stump is now freed. The body and fundus of the stomach are now completely mobilized, and the distal esophagus can be excised and oversewn. To achieve further length the second portion of the duodenum is mobilized. Pyloroplasty can be done at this stage, though this is still controvertial.88 The highest part of the fundus is identified and stay sutures are placed.

The advocates of this technique usually perform a cervical esophagostomy at the first operation, which is now mobilized, taking care not to damage the recurrent laryngeal nerve. The virtual space between the trachea and the prevertebral fascia is opened by blunt dissection. The same is done from the abdo-men through the bed of the esophagus, developing the plane behind the heart and anterior to the prevertebral fascia. In a case with extensive adhesions (i.e., caustic injury) or previous surgery, a thoracotomy may be needed to complete the resec-tion of the esophagus and the tunnel is created under direct vision. Alternativelly, the retrosternal space can be used for the pull-up.

A large hemostat is placed from the neck and the stay sutures are pulled. Particular care must be taken not to twist the stomach during this maneuver.

The gastroesophageal anastomosis is completed in the neck. A large nasogastric tube is left in the stomach through the anastomosis and the cervical wound is closed.

The pylorus is fixed bellow the hiatus. A feeding jejunos-tomy can be created before the abdominal wound is closed.

Most of these patients require postoperative mechanical ven-tilation. A contrast study is performed 1 week after the operation and oral feed is commenced.

The gastric pull-up can be assisted with the laparoscope.89

Results and Discussion on Gastric Pull-Ups

The main advantage of the gastric pull-up lies in its simplic-ity. Gastric pull-ups have been used after the failure of other replacement techniques, and, even with previous gastric tubes or antireflux operations, it is possible to mobilize the stomach safely.38 Gastric pull-ups involve only one anastomosis and hence a theoretical reduced risk of leakage.90

One of the major problems with the gastric pull-up is the large amount of space occupied by the stomach in the chest and the risk of compression of intrathoracic organs. The mortality rate in contemporary series is about 5% usually

secondary to respiratory failure. The average postoperative mechanical ventilation was 4 days in one series.38 Despite this, the long-term respiratory function remains acceptable in most of the patients.90

The incidence of leakage and stricture is about 20% and is comparable to other replacement techniques (Table 24.2).

Because of the mobilization, essential to complete the pull-up, the stomach is vagotomised and therefore gastric emptying relies on gravity. Gastric emptying is quite variable but there is no good correlation between symptoms and functional stud-ies.90 Patients frequently complain of heartburn, regurgitation, vomiting, and breathlesness.93 Dumping is not infrequent with almost every series reporting some cases. Some advocates of the procedure perform a pyloromyoromy or pyloroplasty rou-tinely though this is controversial.88 In general, patients who have the procedure done primarily are less symptomatic than patients who had previous procedures, including attempted primary esophageal anastomosis.90,93

Volvulus of the stomach is a well-described and serious complication of the operation.94

Jejunal Transposition

Operative details: A pedicled jejunum transposition is per-formed dividing a loop of bowel distal to the angle of Treitz with preservation of its vascular pedicle. The length of the pedicle is achieved by sacrificing variable length of the distal jejunum. The curvature of the isolated jejunal loop is reason-ably straight if the mesentery is divided keeping the first vas-cular arcade intact. As mentioned earlier, it can be difficult to achieve enough length due to the inferior attachments of these vessels. Secondly, the loss of distal jejunum may cre-ate short bowel syndrome. The recent practice is to prepare the jejunum while performing the initial gastrotomy ligating the vessel at the base of the jejunal loop in continuity. This procedure develops improved vascular anastomosis from dis-tal jejunal mesentery and hypertrophy of the vascular arcade, thus improving the blood supply of the isolated jejunal loop when required for interposition. Initial results with this tech-nique are encouraging allowing the replacement of the entire length of the thoracic esophagus without any anastomotic leak or graft necrosis. The isolated loop of jejunum with its pedi-cle is then pulled up through the mesentery of the transverse colon, posterior to the stomach and through the esophageal

Table 24.2. Results of gastric pull-up series published after 1980.

n Leak % Stricture % Reoperations Death

Atwell34 1980 6 1 17 1 17 Reoperations 2 in 1 patient for small bowel obstruction 2Valente40 1987 10 2 20 2 20 1 Revision to colonic replacement 3 (late)Marujo91 1991 21 4 19 3 14 1 Gastric necrosis 1Hirschl3 2002 41 15 37 20 49 0 0Spitz38 2004 173 21 12 34 20 1 For leak, 3 for strictures 9Tannuri92 2007 34 6 18 4 12 1 Graft necrosis, 1 anastomotic dehiscence, 3 volvulus of

stomach, 2 leaks2


hiatus into the mediastinum. During this process the pedicle should not be allowed to be twisted. The jejunum is then anas-tomosed to the stomach and introduced in the chest through the hiatus where the thoracic anastomosis with the proximal esophagus is completed. A primary jejunojejunal anastomosis is done at the site where the graft was taken. If the jejunum is straightened then the redundancy is minimal in long term and can be an ideal substitute. Experience suggests that it retains the peristaltic activity and has no jejunogastric reflux causing ulceration. However, the technical aspect of the pedicle jeju-nal graft is demanding and does not produce the same results in all centers. It requires dedicated surgeons to produce con-sistently good results, unlike other techniques of esophageal substitution, which can reproduce results of other surgeons.

A free jejunal graft involves a microsurgical anastomosis between the vascular pedicle of the graft and suitable vessels in the chest. The procedure is then completed as with a pedi-cled graft. This technique has high rate of failure and carries significant postoperative morbidity and mortality.51,54

Discussion on jejunal interpositon: Jejunum interposi-tions have some theoretical advantages compared with colon interpositions and gastric pull-ups. The jejunum has a similar diameter to the esophagus, and thus there is no compression of mediastinal structures by a space-occupying lesion. The jejunal grafts preserve the peristaltic activity, which contrib-ute to the clearance of the organ and help in prevention of acid injury.51,54 As with colon interposition, this technique involves three intestinal anastomoses. Leakage and stricture are not uncommon complications (Table 24.3). The precarious blood supply of the jejunum is responsible for some of the seri-ous early complications seen with this technique, including complete necrosis, perforation of the graft, and mediastini-tis.49–51,54 For that reason leakage in free jejuna grafts should be approached earlier and aggressively.54 The potential advan-tages of free jejunum grafts are eclipsed by the discouraging complications and long-term results. The pedicled jejunal interposition is less demanding technically and results seem to be better.53

Colonic Transposition

Colonic transposition still is the most popular esophageal replacement technique in children despite the severe compli-cations it can have. The viability of the colon is based on the collateral circulation provided by Riolan’s arcade.

Operative details: To perform the transposition the abdo-men is accessed through an upper abdominal incision. The

colon is completely mobilized after division of all the peri-toneal attachments from the distal ileum. The mesocolon is lifted and the arterial system is identified assisted by transil-lumination.

If the right colon95 is to be used, the middle colic vessels are preserved. The right colic artery is identified and occluded with a vascular clamp. The appendix is removed and the distal ileum is prepared for division. After 15 min of occlusion the colon is inspected and the pulsation of the marginal arcade is reassessed. If the colon remains pink and the pulsation through the vessels is satisfactory the right colic artery is divided near its origin. The graft is completed after division of the terminal ileum and transverse colon distal to the middle colic artery. The ileum is anastomosed to the transverse colon to reestablish intestinal continuity. The graft is passed behind the stomach and in front of the left lobe of the liver.

A cervical incision is then performed, the esophageal space accessed, and the retrosternal space opened with blunt dissec-tion. The anterior attachments of the diaphragm are divided from below and the tunnel is completed. The graft is advanced through the retrosternal space taking special care not to twist it. The colon is anastomosed to the anterior wall of the stom-ach, and the cervical anastomosis between the ileum or colon and the esophagus is completed.

The transverse colon and the left colon can be used based on the left colic vessels. The complete procedure can be done through a left thoracotomy as described by Waterston,60 through separate thoracic and abdominal incisions,96 or through a thoracoabdominal incision.8 The colon is mobi-lized and the vascular arcades are identified. Viability is confirmed; the selected loop is divided, and a colocolonic anastomosis is performed. The graft is advanced behind the pancreas and the stomach. The left colon can be placed in the left chest through the diaphragm at the costodiaphragmatic angle or in the mediastinum through the hiatus.62 After the cervical esophagostomy is freed the coloesophageal anasto-mosis is completed.

Pyloroplasty or pyloromyotomy can be performed to improve gastric emptying.

Results and Discussion on Colonic Transposition

Serious complications of colonic grafts are related to its delicate vascular supply. Arterial obstruction can cause early necrosis of the graft. Venous thrombosis is responsible for low-grade obstruc-tion, necrosis, and late perforations.

Table 24.3. Results of jejunal grafts – series published after 1980.

n Leaks % Strictures % Lost grafts Deaths

Ring et al.49 1982 16 4 25 2 13 0Saeki et al.50 1988 19 3 16 2 11 1 2Cusick et al.51 1993 6 1 17 2 33 1 2Bax et al.52,53 2007 24 5 21 10 42 0 0Cauchi et al.54 2007 8 4 50 4 50 3 1


Leakage is a common complication, usually at the esopha-geal anastomosis site.

Strictures are frequent too and most of the time can be treated with dilatations.

Colon grafts are aperistaltic and they empty by gravity.97–100 Redundancy of the transposed colon is a well-described long-term complication and occasionally needs surgical correc-tion.101–103 Several corrective techniques are available as they have to fit specific anatomic situations.104–106

Complications due to exposure of the colonic mucosa to gastric acid include ulceration, bleeding, and perforation. Perforation of the colon frequently can lead to empyema; in rare occasions, the thoracic aorta can be involved in the formation of a fistula107; these patients present severe hematemesis. There are reports of malignancy arising in colonic interpositions after esophageal replacements for benign conditions.108–110

Complications

The fact that various surgical procedures are accepted as esophageal replacements means that none of them is the ideal. All around the world, the advocates of each procedure make an effort to show the superiority of theirs over the others. However, there are complications that are common to all of them.

Anastomotic leakage is a frequent problem after any esophageal replacement. Leakage usually happens at the esoph-ageal anastomosis site. A good blood supply to the anasto-mosis is essential to the healing process, and the stomach has an intrinsic superiority compared with colon or jejunum. The presence of fibrous tissue and scarring after a cervical esophagostomy can determine poor blood supply and hence the increased rate of leakage observed in cervical anasto-mosis. Leakage, in general, can be treated conservatively, the only exception being a leakage with suspicion of graft necrosis. Leakage of an intrathoracic anastomosis is usually more serious than leakage through a cervical wound, and occasionally they can progress to more serious conditions such as mediastinitis.

Strictures at the anastomosis site are rather common too. They can be aggravated in the presence of gastroesophageal reflux. Most of the patients with strictures are treated success-fully with dilatations and prevention of the acid reflux (phar-macological or surgical). There is morbidity associated with dilatation, primarily due to perforation of the esophagus. A small number of patients require revision of the anastomosis or a new replacement when the symptoms are severe.

Patients with esophageal atresia have some specific prob-lems related more to their condition rather than to the replace-ment. They may have growth retardation and they are usually under the 50th percentile for weight.63,93 Swallowing difficul-ties and feeding aversion are common, especially if the repair has been delayed and no sham feeding has been given. Again, this is not observed in patients who have undergone replace-ment for caustic injuries.74

Prognosis/Long-Term Outcome

In general, the prognosis of esophageal replacements in the long term is good.

There does not seem to be a major difference in the long-term quality of life of patients with EA and primary anas-tomosis and those with EA who required an esophageal replacement.

There are reports of malignancy in colonic replacements and we still do not know how the other replacements are going to do.

We still have to learn about the long-term complications and behavior of the different types of esophageal replacements.

Conclusion

Esophageal replacements have satisfactory results. None of them is the ideal replacement as they have advantages and disadvantages. Primary repairs are better than secondary attempts. Long-term follow-up is necessary.

References

1. Myers N. Oesophageal atresia: the epitome of modern surgery. Ann R Coll Surg Engl 1974;54:277–87.

2. Puri P, Khurana S. Delayed primary esophageal anastomosis for pure esophageal atresia. Semin Pediatr Surg 1998;7(2):126–9.

3. Hirschl RB, Yardeni D, Oldham K, et al. Gastric transposition for esophageal replacement in children: experience with 41 consecu-tive cases with special emphasis on esophageal atresia. Ann Surg 2002;236(4):531–9; discussion 9–41.

4. Mansour KA. 1988: Surgery for scleroderma of the esopha-gus: a 12-year experience. Updated in 1995. Ann Thorac Surg 1995;60(1):227.

5. Demirogullari B, Sonmez K, Turkyilmaz Z, et al. Colon inter-position for esophageal stenosis in a patient with epidermolysis bullosa. J Pediatr Surg 2001;36(12):1861–3.

6. Touloukian RJ, Schonholz SM, Gryboski JD, Oh TH, McGuire J. Perioperative considerations in esophageal replacement for epi-dermolysis bullosa: report of two cases successfully treated by colon interposition. Am J Gastroenterol 1988;83(8):857–61.

7. Harmel RP Jr. Esophageal replacement in two siblings with epi-dermolysis bullosa. J Pediatr Surg 1986;21(2):175–6.

8. Canty TG Sr, LoSasso BE. One-stage esophagectomy and in situ colon interposition for esophageal replacement in children. J Pediatr Surg 1997;32(2):334–6; discussion 7.

9. Diaz M, Leal N, Olivares P, Larrauri J, Tovar JA. Infectious stric-tures requiring esophageal replacement in children. J Pediatr Gastroenterol Nutr 2001;32(5):611–13.

10. Avila LF, Luis AL, Encinas JL, et al. [Esophageal replacement. 12 years experience]. Cir Pediatr 2006;19(4):217–22.

11. Bircher E. Ein Beitrag zur plastischen Bildung eines neuen Oesophagus. Zentralbl Chir 1907;34:1479–1482.

12. Myers NA. The history of esophageal surgery: pediatric aspects. Pediatr Surg Int 1997;12(2–3):101–7.

13. Waterston D. The long term clinical state after resection with colon replacement in children. In: Surgery of the Esophagus, The Coventry Conference, London: Butterworths, 1972, p. 35–9.


14. Nakayama K, Yazawa C, Sakakibara N, Suzuki H, Yano M. A report on three cases with carcinoma developing after antetho-racic reconstructive surgery of the esophagus (by skin graft). Sur-gery 1971;69(5):800–4.

15. Beck C, Carrell A. Demonstration of specimens illustrating a method of formation of a pre-thoracic esophagus. Illinois Med J 1905;7:463.

16. Swenson O, Magruder T. Experimental esophagostomy. Surgery 1944;15:954–63.

17. Heimlich HJ, Winfield JM. The use of a gastric tube to replace or by-pass the esophagus. Surgery 1955;37(4):549–59.

18. Gavriliu D. Etat actual du procede de reconstruction de I’oesophage par tube gastrique. Am Chir 1965;19:219.

19. Heimlich HJ. The use of a gastric tube to replace the esophagus as performed by Dr. Dan Gavriliu of Bucharest, Rumania; a pre-liminary report following a visit to Bucharest, Rumania. Surgery 1957;42(4):693–5.

20. Heimlich HJ. Esophagoplasty with reversed gastric tube. Review of fifty-three cases. Am J Surg 1972;123(1):80–92.

21. Burrington JD, Stephens CA. Esophageal replacement with a gas-tric tube in infants and children. J Pediatr Surg 1968;3(2):24–52.

22. Cohen D. Esophageal reconstruction using a gastric tube. Aust Paediatr J 1970;6:22–4.

23. Middleton A. Esophageal replacement with a gastric tube. In: Proceedings of the Paediatric Surgical Congress, The Royal Children’s Hospital, Melbourne, 1970, p. 430–5.

24. Ein SH, Shandling B, Simpson JS, Stephens CA. A further look at the gastric tube as an esophageal replacement in infants and children. J Pediatr Surg 1973;8(6):859–68.

25. Ein SH, Shandling B, Simpson JS, Stephens CA, Vizas D. Four-teen years of gastric tubes. J Pediatr Surg 1978;13(6D):638–42.

26. Anderson KD, Randolph JG. The gastric tube for esopha-geal replacement in children. J Thorac Cardiovasc Surg 1973;66(3):333–42.

27. Anderson KD, Randolph JG. Gastric tube interpostion: a satis-factory alternative to the colon for esophageal replacement in children. Ann Thorac Surg 1978;25(6):521–5.

28. Kummel H. Ueber intrathorakale Oesophagus Plastik. Beitr Klin Chir 1922;126:264.

29. Sweet R. Carcinoma of the mid-thoracic esophagus, its treatment by radical resection and high intra-thoracic esophago-gastric anastomosis. Am Surg 1946;124:653.

30. Rienhoff W. Antethoracal transplantation of the stomach in the treatment of congenital atresia of the thoracic esophagus: a pre-liminary report. Bull John Hopkins Hosp 1948;82:496–9.

31. Potts WJ. Congenital atresia of the esophagus; antethoracic placement of the stomach followed by intrathoracic transplanta-tion. J Thorac Surg 1950;20(5):681–8.

32. Swenson O. End-to-end anstomosis of the esophagus for esopha-geal atresia. Ann Surg 1947;22:324–34.

33. Sweet R. A new method of restoring continuity of the alimen-tary canal in cases of congenital atresia of the esophagus with trachea-esophageal fistula not treated by immediate primary anastomosis. Ann Surg 1948;127:757–68.

34. Atwell JD, Harrison GS. Observations on the role of esophago-gastrostomy in infancy and childhood with particular reference to the long-term results and operative mortality. J Pediatr Surg 1980;15(3):303–9.

35. Lewis I. The surgical treatment of carcinoma of the oesophagus. Br J Surg 1946;34:18–31.

36. Spitz L. Gastric transposition via the mediastinal route for infants with long-gap esophageal atresia. J Pediatr Surg 1984;19(2):149–54.

37. Spitz L. Gastric transposition for esophageal substitution in chil-dren. J Pediatr Surg 1992;27(2):252–7; discussion 7–9.

38. Spitz L, Kiely E, Pierro A. Gastric transposition in children – a 21-year experience. J Pediatr Surg 2004;39(3):276–81; discus-sion 81.

39. Spitz L, Kiely E, Sparnon T. Gastric transposition for esophageal replacement in children. Ann Surg 1987;206(1):69–73.

40. Valente A, Brereton RJ, Mackersie A. Esophageal replacement with whole stomach in infants and children. J Pediatr Surg 1987;22(10):913–17.

41. Wullstein L. Ueber antethorakale Oesophago-jajunostomie und Operationen nach gleichem Prinzip. Deutsch Med Wochenschr 1904;31:734–6.

42. Roux C. L’esophago-jejuno-gastrome: Nouvelle operation pour retrecessement infranchissable de l’esophage. Semin Med 1907;27:34–40.

43. Pirot-Roux L. Epicrise de la premiére operatain de l’oesophagplastie prethoracique faite par le Dr. Cesar Roux en 1906. Rev Med Suisse Romande 1950;90:19.

44. Herzen P. Eine Modifkation der Roux’schen Oesophagojejuno-gastrostomie. Zentralbl Chir 1908;35:219–22.

45. Reinhoff W. Intrathoracic esophagojejunostomy for lesions of the upper third of the esophagus. South Med J 1946;39:928–40.

46. Yudin S. The surgical construction of eighty cases of artificial esophagus. Surg Gynecol Obstet 1944;78:561–83.

47. Petrov B. Retrosternal artificial esophagus from jejunum and colon. Surgery 1959;45:890–8.

48. Jezioro Z. Experiences with the retrosternal esophageal replace-ment employing jejunum or ileum. Surgery 1958;44:275–86.

49. Ring WS, Varco RL, L’Heureux PR, Foker JE. Esophageal replacement with jejunum in children: an 18 to 33 year follow-up. J Thorac Cardiovasc Surg 1982;83(6):918–27.

50. Saeki M, Tsuchida Y, Ogata T, Nakano M, Akiyama H. Long-term results of jejunal replacement of the esophagus. J Pediatr Surg 1988;23(5):483–9.

51. Cusick EL, Batchelor AA, Spicer RD. Development of a tech-nique for jejunal interposition in long-gap esophageal atresia. J Pediatr Surg 1993;28(8):990–4.

52. Bax N. Early one-stage orthotopic jejunal pedicle-graft interposition in long-gap esophageal atresia. Pediatr Surg Int 1994;9:483–5.

53. Bax NM, van der Zee DC. Jejunal pedicle grafts for reconstruction of the esophagus in children. J Pediatr Surg 2007;42(2):363–9.

54. Cauchi JA, Buick RG, Gornall P, Simms MH, Parikh DH. Oesophageal substitution with free and pedicled jejunum: short- and long-term outcomes. Pediatr Surg Int 2007;23(1):11–19.

55. Kelling G. Oesophagoplastik mit Hilfe des quercolon. Zentralbl Chir 1911;38:1209.

56. Lundblad O. Uber antethorakale Osophagoplastik. Acta Chir Scand 1921;53:535–41.

57. Sandblom P. Treatment of congenital atresia of the esophagus from a technical point of view. Acta Chir Scand 1948;97:25–34.

58. Javid H. Esophageal reconstruction using colon and terminal ileum. Surgery 1954;36(1):132–5.

59. Sherman CD Jr, Waterston D. Oesophageal reconstruc-tion in children using intrathoracic colon. Arch Dis Child 1957;32(161):11–16.

60. Waterston D. Replacement of oesophagus with transverse colon. Thoraxchir Vask Chir 1963;11:73–4.


61. Belsey R. Reconstruction of the esophagus with left colon. J Thorac Cardiovasc Surg 1965;49:33–55.

62. Freeman NV, Cass DT. Colon interposition: a modification of the Waterston technique using the normal esophageal route. J Pediatr Surg 1982;17(1):17–21.

63. Koivusalo A, Pakarinen MP, Turunen P, Saarikoski H, Lindahl H, Rintala RJ. Health-related quality of life in adult patients with esophageal atresia – a questionnaire study. J Pediatr Surg 2005;40(2):307–12.

64. Rao KL, Menon P, Samujh R, Chowdhary SK, Mahajan JK. Fun-dal tube esophagoplasty for esophageal reconstruction in atresia. J Pediatr Surg 2003;38(12):1723–5.

65. Belsey R. Reconstruction of the oesophagus. Ann R Coll Surg Engl 1983;65(6):360–4.

66. Schärli AF. Esophageal reconstruction in very long atresias by elon-gation of the lesser curvature. Pediatr Surg Int 1992;7(2):101–5.

67. Heimlich HJ. Reversed gastric tube (RGT) esophagoplasty for failure of colon, jejunum and prosthetic interpositions. Ann Surg 1975;182(2):154–60.

68. Borgnon J, Tounian P, Auber F, et al. Esophageal replacement in children by an isoperistaltic gastric tube: a 12-year experience. Pediatr Surg Int 2004;20(11–12):829–33.

69. Beasley S. Oesophageal atresia without fistula. In: Oesophageal Atresia, Beasley SW, Myers NA, Auldist AW (eds), London, England: Chapman and Hall, 1991, pp. 137–59.

70. Pedersen JC, Klein RL, Andrews DA. Gastric tube as the pri-mary procedure for pure esophageal atresia. J Pediatr Surg 1996;31(9):1233–5.

71. McCollum MO, Rangel SJ, Blair GK, Moss RL, Smith BM, Skars-gard ED. Primary reversed gastric tube reconstruction in long gap esophageal atresia. J Pediatr Surg 2003;38(6):957–62.

72. Lindahl H, Louhimo I, Virkola K. Colon interposition or gas-tric tube? Follow-up study of colon-esophagus and gastric tube-esophagus patients. J Pediatr Surg 1983;18(1):58–63.

73. Goon HK, Cohen DH, Middleton AW. Gastric tube oesophago-plasty – a long-term assessment. Z Kinderchir 1985;40(1):21–5.

74. Ein SH, Shandling B, Stephens CA. Twenty-one year experi-ence with the pediatric gastric tube. J Pediatr Surg 1987;22(1):77–81.

75. Ein SH. Gastric tubes in children with caustic esophageal injury: a 32-year review. J Pediatr Surg 1998;33(9):1363–5.

76. Fernandez MS, Gutierrez C, Ibanez V, et al. Long-gap esoph-ageal atresia: reconstruction preserving all portions of the esophagus by Scharli’s technique. Pediatr Surg Int 1998;14(1–2):17–20.

77. Schettini ST, Pinus J. Gastric-tube esophagoplasty in children. Pediatr Surg Int 1998;14(1–2):144–50.

78. Salo JA, Heikkila L, Nemlander A, Lindahl H, Louhimo I, Mattila S. Barrett’s oesophagus and perforation of gastric tube ulceration into the pericardium: a late complication after reconstruction of oesophageal atresia. Ann Chir Gynaecol 1995;84(1):92–4.

79. Shamberger RC, Eraklis AJ, Kozakewich HP, Hendren WH. Fate of the distal esophageal remnant following esophageal replace-ment. J Pediatr Surg 1988;23(12):1210–14.

80. Lindahl H, Rintala R, Sariola H, Louhimo I. Cervical Barrett’s esophagus: a common complication of gastric tube reconstruc-tion. J Pediatr Surg 1990;25(4):446–8.

81. Barrett NR. The lower esophagus lined by columnar epithelium. Surgery 1957;41(6):881–94.

82. Sharma P, McQuaid K, Dent J, et al. A critical review of the diagnosis and management of Barrett’s esophagus: the AGA Chicago Workshop. Gastroenterology 2004;127(1):310–30.

83. Kobayashi T, Kimura T, Yoshida M, et al. Carcinoma of the reconstructed stomach tube following esophageal resection for a benign stricture: report of a case and review of the literature. Surg Today 1995;25(3):257–60.

84. Shigemitsu K, Naomoto Y, Shirakawa Y, Haisa M, Gunduz M, Tanaka N. Five cases of early gastric cancer in the reconstructed gastric tube after radical resection for esophageal cancer. Jpn J Clin Oncol 2002;32(10):425–9.

85. Pasalega M, Burdescu C, Mesina C, Mirea C, Tenea T, Vasile I. [Unusual late complication after esophagoplasty type Gavriliu II for esophageal stenosis from chemical burns – cancer of the esophagoplasty tube]. Chirurgia (Bucur) 2005;100(2):175–9.

86. Ure BM, Slany E, Eypasch EP, Weiler K, Troidl H, Holsch-neider AM. Quality of life more than 20 years after repair of esophageal atresia. J Pediatr Surg 1998;33(3):511–15.

87. Anderson KD, Noblett H, Belsey R, Randolph JG. Long-term follow-up of children with colon and gastric tube interposition for esophageal atresia. Surgery 1992;111(2):131–6.

88. Cheung HC, Siu KF, Wong J. Is pyloroplasty necessary in esophageal replacement by stomach? A prospective, random-ized controlled trial. Surgery 1987;102(1):19–24.

89. Ure BM, Jesch NK, Sumpelmann R, Nustede R. Laparoscopi-cally assisted gastric pull-up for long gap esophageal atresia. J Pediatr Surg 2003;38(11):1661–2.

90. Davenport M, Hosie GP, Tasker RC, Gordon I, Kiely EM, Spitz L. Long-term effects of gastric transposition in children: a physiological study. J Pediatr Surg 1996;31(4):588–93.

91. Marujo WC, Tannuri U, Maksoud JG. Total gastric transposi-tion: an alternative to esophageal replacement in children. J Pediatr Surg 1991;26(6):676–81.

92. Tannuri U, Maksoud-Filho JG, Tannuri AC, Andrade W, Mak-soud JG. Which is better for esophageal substitution in chil-dren, esophagocoloplasty or gastric transposition? A 27-year experience of a single center. J Pediatr Surg 2007;42(3):500–4.

93. Ludman L, Spitz L. Quality of life after gastric transposition for oesophageal atresia. J Pediatr Surg 2003;38(1):53–7; dis-cussion 7.

94. Chan KL, Saing H. Iatrogenic gastric volvulus during transpo-sition for esophageal atresia: diagnosis and treatment. J Pediatr Surg 1996;31(2):229–32.

95. Gundogdu HZ, Tanyel FC, Buyukpamukcu N, Hicsonmez A. Colonic replacement for the treatment of caustic esophageal strictures in children. J Pediatr Surg 1992;27(6):771–4.

96. Dickson J. Esophageal substitution with colon – the Waterston operation. Pediatr Surg Int 1996;11:224–6.

97. Isolauri J, Koskinen MO, Markkula H. Radionuclide transit in patients with colon interposition. J Thorac Cardiovasc Surg 1987;94(4):521–5.

98. Isolauri J, Reinikainen P, Markkula H. Functional evaluation of interposed colon in esophagus. Manometric and 24-hour pH observations. Acta Chir Scand 1987;153(1):21–4.

99. Louhimo I, Pasila M, Visakorpi JK. Late gastrointestinal compli-cations in patients with colonic replacement of the esophagus. J Pediatr Surg 1969;4(6):663–73.

100. Rodgers BM, Talbert JL, Moazam F, Felman AH. Functional and metabolic evaluation of colon replacement of the esopha-gus in children. J Pediatr Surg 1978;13(1):35–9.


101. DeMeester TR, Johansson KE, Franze I, et al. Indications, sur-gical technique, and long-term functional results of colon inter-position or bypass. Ann Surg 1988;208(4):460–74.

102. Jeyasingham K, Lerut T, Belsey RH. Revisional surgery after colon interposition for benign oesophageal disease. Dis Esoph-agus 1999;12(1):7–9.

103. Urschel JD. Late dysphagia after presternal colon interposition. Dysphagia 1996;11(1):75–7.

104. Mosca F, Stracqualursi A, Lipari G, Persi A, Consoli A, Latteri S. [Surgical treatment of redundant colon after retrosternal esophagocolonoplasty for caustic esophageal stenosis]. Chir Ital 2001;53(1):89–93.

105. Schein M, Conlan AA, Hatchuel MD. Surgical management of the redundant transposed colon. Am J Surg 1990;160(5):529–30.

106. Shokrollahi K, Barham P, Blazeby JM, Alderson D. Surgical revision of dysfunctional colonic interposition after esophago-plasty. Ann Thorac Surg 2002;74(5):1708–11.

107. Debras B, Kanane O, Enon B, Robert M. Aorto-colonic fistula as a late complication of colon interposition for oesophageal atresia. Eur J Pediatr Surg 1996;6(5):310–11.

108. Altorjay A, Kiss J, Voros A, Szanto I, Bohak A. Malignant tumor developed in colon-esophagus. Hepatogastroenterology 1995;42(6):797–9.

109. Houghton AD, Jourdan M, McColl I. Dukes A carcinoma after colonic interposition for oesophageal stricture. Gut 1989;30(6):880–1.

110. Martin MA, Ferras A. [Colon cancer: a rare complication in a colonic esophageal segment after coloesophagoplasty]. Cir Esp 2005;77(1):46–7.

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