Dual causes for post coloplasty dysphagia: An interesting case report

Interposition coloplasty is the procedure of choice for long term mangement of intractable oesophageal corrosive strictures. Parodoxically, patients may present with dysphagia after surgery for the very symptom for which they had curative surgery in the first place. The causes of dysphagia are many including anastomotic stricture at the oesophago-colic anastomosis.

Eighteen year old male patient presented with dysphagia to liquids and to solids immediately after intake with increasing intensity for two months. He had history of corrosive acid ingestion four years back. As patient developed complete stricture at 19 cm, oesophagocoloplasty was done three years back. Patient was asymptomatic for a year and then he insidiously developed dysphagia which had increased in intensity over the past two months. Clinical examination revealed midline laparotomy scar with a feeding jejunostomy in situ. Laboratory findings were within normal limits.

Barium swallow done showed dilated distal oesophagus (oesophagocele) and extrinsic compression of the interposed colon (Figure 1). Oesophagoscopy showed dilated native oesophagus with complete stricture at 19 cm. Oesophago-colic anastomosis was narrowed and could not be negotiated. Patient was planned for cervical exploration along the previous left cervical incision. Intraoperatively, oesophago-colic anastomosis had anastomotic narrowing and native esophagus below the anastamosis was dilated causing extrinsic compression on the interposed colon with complete stricture at end of native oesophagus (Figure 2). Oesophago-colic anastamosis was dismantled and oesophagocoele was transected. The distal end of the native oesophagus above the stricture was closed with 2-0 vicryl. End to end oesophago-colic anastamosis done with 2 o vicryl (Figure 3). Post-operative barium showed clear flow of contrast across the oesophagocolic anastomosis (Figure 4).

The dysphagia in this patient was due to two causes: a) anastomotic stricture b) extrinsisc compression of the oesophagocele on the interposed colon especially when eating (Figure 5). Patient made prompt recovery and is on follow-up (Figure 6).

Interposition coloplasty is done for intractable corrosive strictures of the oesophagus where a segment of colon is used to bypass the diseased and strictured oesophagus to the stomach. The interposed colon can be either the left or right colon and can be routed through the retrosternum, presternum or orthoptically through the mediastinum. Generally, a retrosternal route is usually perred. Interposition coloplasty may be associated with various complications. Re-surgery after colon interposition may be warranted in 15–30% of cases [1],[2]. Dysphagia is a complication which may occur either early or late after surgery. Early dysphagia may be primarily due to mechanical causes like kinking or angulation of the axis of the interposed colonic graft. Colonic redundancy is the most common late complication causing dysphagia after surgery [3]. It may also be associated with obstruction at the sternal inlet causing compression of the transposed colon. The incidence of colonic redundancy is underestimated by the patient and may vary between 8–21% of operated cases [4],[5],[6],[7].

However, the dysphagia in this case was due to primary anastomotic stricture leading to native oesophageal dilation causing extrinsic colonic compression. The above problems can be circumvented to some extent but are not totally preventable. Allowing adequate time for corrosive stricture formation to occur is variable which may take usually six months to one year after corrosive intake. Delay in surgery is believed to cause decrease of the already smouldering fibrosis in the native oesophagus and reduce the probability of anastomotic stricture in the first place.

To our knowledge, this is the first such reported case of such a unique complication after interposition coloplasty.

This case is presented to emphasize that coloplasty should be attempted six months to a year after corrosive ingestion and that the distal native oesophagus should ideally be transected above the site of complete corrosive stricture. Also, the oesophaagocoloplasty anastomosis should be wide and just above the corrosive stricture so that a dilation of the native oesophagus does not occur and cause complications.