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

Esophageal atresia (EA) is a rare congenital abnormality occurring in 1 in 2,500 to 4,500 live births․¹ It involves a discontinuity or gap in the esophagus, often with a tracheoesophageal fistula (TEF) connecting the esophagus to the trachea․² It is associated with other congenital anomalies in 50–70% of cases, including VACTER association (vertebral, anorectal, cardiac, tracheoesophageal, renal, and limb anomalies), CHARGE syndrome (coloboma, heart defects, atresia choanae, growth retardation, genital abnormalities, and ear abnormalities), and trisomies․^3–5 Without surgical treatment, EA is fatal, as the infant cannot swallow saliva or feed orally․⁶

Colon interposition uses a segment of the patient's colon to bridge long gaps between the esophageal remnants․ It is indicated for long-gap EA (>3 vertebral body lengths) or after failed primary repair․ In high-income countries, gastric pull-up or jejunal interposition are preferred over colon for esophageal replacement․⁷ However, in low-resource settings, colon interposition is favored due to technical simplicity․ Advantages include surgical accessibility, adequate length, motility to promote conduit emptying, and acid/bile resistance․ Potential complications include anastomotic leak,⁸ stricture,⁹ gastrointestinal reflux,¹⁰ and future malignancy risk․¹¹ Despite higher complication rates compared to other conduits, colon interposition offers a survival benefit in underserved regions․¹²

The case described in the provided video transcript involves a 6-year-old boy from Honduras with Down syndrome (trisomy 21) and congenital EA. At birth, the proximal esophagus ended blindly in the upper chest, while only a short nubbin extended up from the stomach, leaving a long gap between the two esophageal segments. To prevent aspiration of oral secretions and allow feeding, the patient had previously undergone two palliative procedures: the creation of a cervical esophagostomy (spit fistula) and the placement of a gastrostomy tube. With these interventions in place, the patient was able to grow and achieve normal height and weight for his age over the subsequent 6 years leading up to the definitive esophageal reconstruction. Preoperative evaluation, including a contrast study, ECG, and echocardiography, confirmed the complete EA without any native esophageal connection to the stomach and ruled out structural heart defects that could increase surgical risk.

The colon interposition procedure begins with a midline abdominal incision to gain access to the abdominal cavity. The steps are as follows: adhesions from the previous gastrostomy are carefully lysed, and the stomach is mobilized from the liver. The colon is then mobilized, including the splenic flexure. The attachments around the ligament of Treitz are released to facilitate further colon mobilization.

A crucial step in the procedure is determining the appropriate blood supply and length of the colon segment to be used for the interposition. The middle colic and left colic vascular supplies are compared, ultimately choosing to use the left colic artery as the main vascular supply. Once the vascular supply is secured, the chosen segment of the colon is divided using a stapling device, and the mesentery is divided while preserving the marginal artery. The marginal artery is located in the mesentery towards the large intestine as part of the vascular arcade that links the superior and inferior mesenteric arteries. It creates an effective anastomosis between the  arteries of the colon. The colon is then transposed posteriorly to the stomach, creating a tunnel through the mediastinum and neck to facilitate the passage of the colonic graft.

At the cervical level, the esophagostomy is mobilized, and the proximal esophagus is anastomosed to the colonic graft in an end-to-side fashion. The distal end of the colonic graft is then anastomosed to the stomach in a side-to-side manner, creating a neo-esophagus.

To ensure proper feeding and prevent aspiration, a new gastrostomy tube is placed in the left upper quadrant. The continuity of the remaining colon is reconstructed through a right-to-distal left colo-colonic anastomosis, and the mesentery is closed. Following the abdominal closure, the cervical incision is closed, with careful attention to secure the drains and reapproximate the muscles and skin.

The provided video offers a comprehensive demonstration of the colon interposition procedure, highlighting the critical operative steps and technical nuances involved in performing a successful esophageal replacement, particularly in resource-limited settings, where advanced treatment options such as gastric pull-up or jejunal interposition may be limited. Colon interposition remains a viable solution for restoring swallowing function in patients with EA or other esophageal disorders requiring esophageal replacement.

By providing a detailed visual representation of the surgical process, this video serves as a valuable educational resource for surgeons and healthcare professionals involved in the care of patients with EA or related conditions. It underscores the importance of meticulous surgical technique, vascular preservation, and careful planning to ensure successful outcomes. Moreover, the video emphasizes the crucial role of multidisciplinary care in managing these complex cases. The involvement of specialists in pediatric surgery, anesthesiology, and intensive care is essential for optimizing patient outcomes and addressing potential complications.

The parents of the patient referred to in this video have given their informed consent for surgery to be filmed and were aware that information and images will be published online.