Salvage Esophageal Reconstruction with Colonic Conduit: A Single Center 25-Year Experience.

Objective: Colonic interposition restores alimentary continuity after esophagectomy when a gastric conduit is unavailable, but its use has been limited by concerns about morbidity and functional outcomes. Hence, we aimed to assess our 25-year institutional experience, including perioperative outcomes, a subset with patient-reported outcomes, and a contemporary cohort treated with middle-colic microvascular "supercharging" to augment perfusion.

Methods: From 1/2000 to 6/2024, 99 patients underwent substernal colonic interposition. Endpoints included perioperative outcomes, post-operative symptoms, assessed by Cleveland Clinic Esophageal Questionnaire (CEQ), and overall survival estimated by Kaplan-Meier method.

Results: Median age was 61 [47, 73] years. Forty-eight (48%) patients had esophageal cancer. An inferior mesenteric artery-based transverse colon segment was used in 83 (84%). Sixteen (16%) underwent supercharge. Thirty-day mortality was 5%. One patient with supercharge (6.3%, 68% CI 2.3%-16%), and 36 without (43%, CI 38%-49%), developed a cervical anastomotic leak (P = 0.004). Among 18 patients with CEQ, most symptoms were experienced never or rarely; weekly postprandial diarrhea and bloating were the most common symptoms, reported by 10 (56%) and 9 (50%) patients, respectively. Median CEQ T scores for each symptom domain ranged from 42-56 following colon interposition vs 40-47 following gastric conduit. Overall survival with and without esophageal cancer was 25% vs 66% at 10 years (P<.0001).

Conclusions: Colonic interposition historically carried substantial short-term morbidity due to sequelae of frequent anastomotic leak. Present day, this can be mitigated with microvascular supercharge and a standardized multidisciplinary approach, warranting routine use. Contradicting conventional wisdom, long-term functional outcomes are similar to patients with a gastric conduit.