(Chest. 2003;124:2027-2028.)
© 2003
American College of Chest Physicians
Delivery Following Colon Interposition*
Peter Jakobi, MD;
Ido Solt, MD;
Jehuda Adoniram Bar-Maor, MD and
Lael-Anson Best, MBBS, FCCP
* From the Departments of Obstetrics and Gynecology (Drs. Jakobi and Solt), Pediatric Surgery (Dr. Bar-Maor), and Thoracic Surgery (Dr. Best), Rambam Medical Center and Rappaport Faculty of Medicine, Technion-Israel Institute of Technology, Haifa, Israel.
Correspondence to: Peter Jakobi, MD, Department of Obstetrics and Gynecology, Rambam Medical Center, Haifa 31096, Israel; e-mail: h_gruber{at}rambam.health.gov.il
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Abstract
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Background: Colon interposition carries a significant complication rate due to attenuated arterial blood supply, because the interposed colon segment depends on a single vascular pedicle.
Cases: We report for the first time five vaginal deliveries in two women following the operation, illustrating the dilemmas encountered in choosing the delivery method in these patients.
Conclusion: We suggest that vaginal delivery following colon interposition is feasible. If cesarean section has to be performed, extra care must be exercised not to damage the vascular pedicle, particularly when there is a need for mobilizing or palpating the posterior aspect of the uterus.
Key Words: cesarean section • colon interposition • delivery • esophageal replacement • pregnancy
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Introduction
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Colon interposition is the surgical procedure in which the right or left colon is used as an esophageal substitute.1
In young people, one of the common indications for this operation is caustic stricture following accidental or suicidal lye injury.1
2
3
The operation carries a significant complication rate due to attenuated arterial blood supply, because the interposed colon segment depends on a single vascular pedicle.1
2
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5
We report five vaginal deliveries in two women following the operation, illustrating the dilemmas encountered in choosing the delivery method in these patients.
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Case Reports
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The patient, a 26-year-old primigravida, underwent total esophageal replacement with left colon interposition because of a suicidal lye injury at the age of 20 years. Ten months and 12 months following the primary operation, balloon dilatations of the proximal anastomosis were performed due to strictures. The pregnancy follow-up was uneventful, and she had only mild "esophageal" reflux without the need for pharmacologic treatment. Near term, her thoracic surgeon suggested an elective cesarean section for the prevention of possible damage of the blood supply to the transposed colon during vaginal delivery or at an emergency cesarean section. Following a discussion of the case with the obstetricians, a trial of labor was advised, with cesarean section left for obstetric indications. At 41 weeks of gestation, spontaneous labor developed and a vacuum extraction was performed because of severe variable decelerations at the end of the second stage of labor. A healthy female infant was delivered, weighing 2,500 g, with Apgar scores of 9 and 10 at 1 min and 5 min, respectively. The mother’s postnatal course was uneventful.
In a subsequent telephone survey of the patients with colon interposition operated on by one of the authors (J.A.B.),2
3
another woman who became pregnant following the operation was detected. This woman has had four uncomplicated pregnancies; all infants were born by uncomplicated vaginal deliveries at term, with birth weights of 3,000 to 3,500 g.
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Discussion
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Colon interposition as an esophageal substitute was first reported in the early years of the 20th century. Since then, various surgical techniques were reported, aimed at decreasing complications.1
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7
However, the operation carries a significant complication rate, mainly due to attenuated arterial blood supply, as the interposed colon segment by any technique depends on a single vascular pedicle, the ascending branch of the left colic artery or the right branch of the midcolic artery. Furthermore, obstetricians may have difficulties because of adhesions to the uterus due to previous peritonitis, even during primary cesarean section. Most patients who undergo colon interposition due to lye injury already have adhesions at the time of the operation due to the primary insult and the associated peritonitis and possible previous laparotomy. This may cause distortion of the transposed anatomy and the possibility for damage, if mobilization of the uterus has to be performed or if the repair of the hysterotomy incision is done not in situ but after lifting the uterus through the abdominal incision, a common practice of many obstetricians. This may explain the anxiety of the surgeon who performed the colon interposition, when the mode of delivery came into question. He was disturbed by the possibility that the vascular pedicle might be damaged during delivery or at an emergency cesarean section and suggested an elective cesarean section, allowing for dealing with possible complications under direct vision. The obstetricians, however, were reluctant to perform an elective cesarean section as mobilization of the uterus might be needed during the operation or might be done inadvertently, with possible damage to the vascular pedicle due to adhesions, and increasing the probability for future repeated cesarean section(s). In addition, there are reported difficulties in patients with colon interposition who need surgery for future acquired diseases.1
In a MEDLINE search of the literature using the key words colon interposition, esophageal replacement, delivery, and pregnancy, we could find no suggestions on the preferred delivery method, or reports on women who had vaginal deliveries following colon interposition. We did find, however, one case report of a chronically malnourished woman treated by colonic interposition because of congenital tracheoesophageal fistula/esophageal atresia.8
Yet, her colonic interposition was subsequently bypassed by a percutaneous gastrostomy due to stenosis of the distal anastomosis and nonfunctioning of the transplant. The woman delivered twice by cesarean section because of maternal or fetal indications: the first time at 33 weeks of gestation when she became dyspneic at rest, and the second time at 31 weeks because of breech presentation in labor.8
In our patient, vaginal delivery was elected as the preferred method of delivery, cesarean section being left for maternal or fetal indications. During delivery, the surgeon was on-call for a possible cesarean section, while the obstetricians were advised not to mobilize the uterus during an eventual cesarean section.
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Conclusion
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To the best of our knowledge, our cases are the first reported in the literature with vaginal delivery following colon interposition. We suggest that vaginal delivery in these patients is feasible and cesarean section is best left for accepted obstetric indications. However, during an eventual cesarean section, extra care must be paid not to damage the vascular pedicle supplying the interposed colon segment, with particular care when there is a need for mobilizing or palpating the posterior aspect of the uterus. It is suggested that, in this situation, the repair of the hysterotomy incision should be done in situ rather than lifting the uterus through the abdominal incision.
Received for publication January 6, 2003.
Accepted for publication May 9, 2003.
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References
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- Ashcraft, KW (2000) Colon interposition. Ashcraft, KW eds. Pediatric surgery 3rd ed. ,325-347 WB Saunders. Philadelphia, PA:
- Bar-Maor, JA, Nissan, S Improved vascularization of transplanted colon for esophageal replacement. Surg Gynecol Obstet 1970;131,755-756[Medline]
- Sweed, Y, Bar-Maor, JA Esophageal replacement by the right colon in children. Harefuah 1989;117,138-141[Medline]
- Loinaz, C, Altorki, NK Pitfalls and complications of colon interposition. Chest Surg Clin N Am 1997;7,533-549[Medline]
- Cheng, B, Chen, K, Gao, S, et al Colon interposition. Recent Results Cancer Res 2000;155,151-160[Medline]
- Furst, H, Hartl, WH, Lohe, F, et al Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon. Ann Surg 2000;231,173-178[CrossRef][ISI][Medline]
- Fujita, H, Yamana, H, Sueyoshi, S, et al Impact on outcome of additional microvascular anastomosis-supercharge-on colon interposition for esophageal replacement: a comparative and multivariate analysis. World J Surg 1997;21,998-1003[Medline]
- O’Connell, MP, Wilson, OF, Masson, EA, et al Pregnancy outcome in a patient with chronic malnutrition: case report. Hum Reprod 2000;15,2443-2445[Abstract/Free Full Text]
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Abstract
Introduction
