30 AJR:189, July 2007

AJR 2007; 189:3034

0361803X/07/189130
American Roentgen Ray Society
Li et al.
Nonanastomotic Strictures
After Colonic Interposition
Gas t roi nt es t i nal I magi ng Cl i ni cal Obs er vat i ons
Nonanastomotic Strictures
After Colonic Interposition
Diane X. Li
1
Marc S. Levine
Stephen E. Rubesin
Igor Laufer
Li DX, Levine MS, Rubesin SE, Laufer I
Keywords: colonic interposition, esophageal atresia,
esophageal cancer, esophageal replacement surgery,
gastrointestinal radiology, ischemia, swallowing disorders
DOI:10.2214/AJR.06.1217
Received September 13, 2006; accepted after revision
December 6, 2006.
M. S. Levine and S. E. Rubesin are consultants for E-Z-EM.
1
All authors: Department of Radiology, Hospital of the
University of Pennsylvania, 3400 Spruce St., Philadelphia,
PA 19104. Address correspondence to M. S. Levine
(marc.levine@uphs.upenn.edu).
OBJECTIVE. The purpose of this study was to describe the clinical and radiographic find-
ings in a series of patients with nonanastomotic strictures after colonic interposition.
CONCLUSION. Nonanastomotic strictures usually appear on upper gastrointestinal tract ra-
diography as relatively long segments of smooth, tapered narrowing involving the interposed colon,
most likely resulting from chronic ischemia. Unlike strictures at the esophagocolic or cologastric
anastomosis, these long nonanastomotic strictures generally have a poor response to endoscopic di-
latation procedures and are more likely to necessitate surgical revision of the colonic interposition.
olonic interposition is a form of
esophageal replacement surgery
performed for severe caustic stric-
tures and other debilitating dis-
eases affecting the esophagus, such as acha-
lasia and esophageal atresia [15]. This
procedure may also be performed on patients
with malignant esophageal tumors in whom an
esophagogastrectomy is not feasible because
of previous gastric surgery. Although colonic
interposition can have excellent long-term re-
sults [2, 6], it is a major surgical procedure as-
sociated with a substantial morbidity and mor-
tality related to a variety of complications,
including anastomotic leaks, wound infec-
tions, aspiration pneumonia, and ischemic ne-
crosis of the interposed colon [710]. Anasto-
motic strictures are the most common late
complication of colonic interposition, with a
reported prevalence ranging from 17% to 59%
[3, 4, 7, 1113]. These strictures are sometimes
thought to occur as the sequela of healed anas-
tomotic leaks with subsequent scarring [11].
Anastomotic strictures may cause severe dys-
phagia, but they often respond to one or more
endoscopic dilatation procedures without need
for additional surgery [11, 13, 14].
Although anastomotic strictures are a well-
recognized complication of colonic interposi-
tion, we have encountered a number of patients
who developed nonanastomotic strictures of
the interposed colon. To our knowledge, this
finding has been described only anecdotally
in the radiology literature [11, 15]. We there-
fore report a series of patients with nonanas-
tomotic strictures after colonic interposition
and present the clinical and radiographic find-
ings in these patients.
Materials and Methods
A computerized search of the radiology depart-
ments database at our university hospital revealed
16 patients with colonic interposition who under-
went upper gastrointestinal tract radiography dur-
ing an 8-year period from January 1998 to Decem-
ber 2005. A subsequent review of the radiology
reports showed that eight (50%) of these 16 patients
developed nonanastomotic strictures in the inter-
posed colon. Medical records were available for
seven of the eight patients. These seven patients
constituted our study group. The mean age of the
seven patients was 47 years (range, 2379 years).
Six patients were men and one was a woman.
The seven patients in our study group underwent
a total of 14 upper gastrointestinal radiographic ex-
aminations during the study period; four patients
had multiple studies (mean, 2.8 studies; range, 24
studies). When multiple studies were performed,
the first study in which a nonanastomotic stricture
was detected was designated as the index study.
Three of the four patients with multiple radio-
graphic studies had one or more follow-up exami-
nations, and one patient had undergone a previous
examination before the index study. The mean du-
ration from surgery to the time of the index study
was 8.5 years (range, 7 days28 years). Four of the
14 radiographic examinations were performed with
a 250% weight/volume (w/v) barium suspension
(E-Z-HD, E-Z-EM), two with a 100% w/v barium
suspension (Solopaque, Lafayette Pharmaceutical),
and eight with a water-soluble contrast agent (dia-
trizoate meglumine and diatrizoate sodium [Gas-
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Nonanastomotic Strictures After Colonic Interposition
AJR:189, July 2007 31
troview, Mallinckrodt]) followed by barium if there
was no evidence of a leak.
All the studies were performed with digital flu-
oroscopy equipment (Diagnost 76, Philips Medical
Systems; or Sireskop SD, Siemens Medical Solu-
tions) using a combination of spot images, rapid se-
quence imaging, and video and DVD recordings.
Swallowing function was evaluated initially with
the patient in the upright frontal and lateral posi-
tions; for subsequent evaluations of the interposed
colon, proximal and distal anastomoses, and stom-
ach, the patient underwent imaging in the upright
and in various recumbent positions.
The images from the index examinations were re-
viewed retrospectively by consensus of two authors,
both of whom are experienced gastrointestinal radi-
ologists, to determine the morphologic features of
these nonanastomotic strictures, including their
length and width (accounting for magnification),
contour (smooth vs irregular), and proximal and dis-
tal margins (tapered vs abrupt). The strictures were
also assessed for the presence of obstructive features,
including proximal dilatation and delayed emptying.
The anastomoses and interposed colon were evalu-
ated for the presence of anastomotic leaks or fistulas,
ulceration, spasm, thickened or effaced haustral
folds, and other abnormalities. Finally, the studies
and study reports were evaluated for the presence of
gastrocolic reflux, aspiration, or other types of swal-
lowing dysfunction.
Medical, endoscopic, surgical, and pathologic
records were reviewed to determine the indications
for colonic interposition; type of colonic interposi-
tion performed (including the portion of colon used
for the conduit, the orientation of the interposed co-
lon, and whether the interposed colon was clamped
at surgery); nature and duration of symptoms after
colonic interposition; subsequent treatment (in-
cluding endoscopic dilatation procedures or addi-
tional surgery); histopathologic findings (if a por-
tion of the interposed colon was resected); and
patient course. The mean duration of clinical fol-
low-up from the time of the index examination was
1.2 years (range, 12 days5.2 years). When two or
more radiographic examinations were performed,
serial examinations were reviewed to determine the
course of the strictures over time.
Our institutional review board approved all as-
pects of this retrospective study and did not re-
quire informed consent from the patients included
in our study.
Results
Indications and Technique for Colonic
Interposition
The indications for colonic interposition
included esophageal carcinoma in four pa-
tients, caustic injuries to the esophagus in
two, and congenital esophageal stenosis sec-
ondary to VATER (vertebral defects, imperfo-
rate anus, tracheoesophageal fistula, and ra-
dial and renal dysplasia) syndrome in one.
Three of the four patients with esophageal
carcinoma had recurrent tumor after an
esophagogastrectomy and one had a new
esophageal tumor. Both patients with caustic
injuries had undergone previous surgery
(failed colonic interposition in one and cervi-
cal esophagostomy in the other) for treatment
of intractable lye strictures.
The left colon was used as the neoesoph-
ageal conduit in three patients and the right
colon in three. We were unable to determine
which portion of the colon was used as the
conduit in the remaining patient. The inter-
posed colon had an isoperistaltic orientation
in three patients, an antiperistaltic orientation
in two, and an unknown orientation in two.
The interposed colon was not clamped at sur-
gery in any of the seven patients.
Clinical Findings
Four (57%) of the seven patients with co-
lonic interposition had dysphagia as the major
presenting symptom at the time of the index
radiographic studies. Two patients had dys-
phagia for solids only, and two had dysphagia
for solids and liquids. The mean duration of
dysphagia was 6.6 years (range, 3 days14
years). The remaining three patients (43%)
with colonic interposition had clinical signs
and symptoms (fever, leukocytosis, and in-
creased wound drainage) of anastomotic
leaks at the time of the index radiographic
studies, which were performed much earlier
in the postoperative course; the mean duration
from colonic interposition to the index studies
was only 3 months (range, 7 days8 months)
for this group versus 16.7 years (range, 2
months28 years) for the group with dysph-
agia. Subsequently, all three patients in the
group with clinically suspected leaks also de-
veloped dysphagia.
Two patients (29%) had clinical signs of as-
piration, and one (14%) had a wound infection.
Radiographic Findings
Index examinationThe mean length of
the nonanastomotic strictures in the seven pa-
tients with colonic interpositions was 8 cm
(range, 3.514 cm), and the mean width was
0.9 cm (range, 0.31.8 cm). These strictures
therefore were relatively long segments of
narrowing involving the interposed colon
(Figs. 13). The strictures had a smooth con-
tour in six patients and an irregular contour in
one. The proximal margins of the strictures
were tapered in all seven patients, and the distal
margins were tapered in six and abrupt in one.
Haustral folds in the interposed colon were ef-
faced in six patients and were thickened in one.
The strictures caused partial obstruction in two
patients, with proximal dilatation and delayed
emptying of contrast material into the stomach
in both. One of the patients with delayed emp-
tying had a food impaction above the proximal
end of the stricture.
Two patients also had small sealed-off leaks
from the esophagocolic anastomosis into the
adjacent mediastinum. Three patients had tra-
cheobronchial aspiration, and one had divertic-
ulosis of the interposed colon. No patients had
evidence of gastrocolic reflux at fluoroscopy.
Serial examinationsIn two of the four
patients with nonanastomotic strictures in the
interposed colon who had multiple studies,
we observed progressive shortening and nar-
rowing of the strictures, which decreased in
both length and width on follow-up examina-
tions. One of these patients also had a sealed-
off leak from the esophagocolic anastomosis
that subsequently progressed to a colocutane-
ous fistula on later examinations. In contrast,
the third patient with multiple studies had a
stricture that increased in length and width on
follow-up examinations. The final patient
with multiple studies had an earlier radio-
graphic examination showing no evidence of
a nonanastomotic stricture in the interposed
colon 3 months before the index study re-
vealed a stricture (Fig. 1B).
Treatment
Six (86%) of the seven patients with co-
lonic interpositions underwent a total of 27
endoscopic dilatation procedures (mean num-
ber of dilatations, 5; range, 111). Four pa-
tients (57%) ultimately required surgical revi-
sion of the colonic interposition (with
resection of a portion of the interposed colon
in three) because of intractable dysphagia.
Pathologic examination of the resected speci-
mens revealed extensive submucosal fibrosis
in two patients and erosion of the mucosa
with hemosiderin-laden macrophages in one.
When surgery was repeated, the mean dura-
tion from the time of the original colonic in-
terposition to the time of the first surgical re-
vision was 5.7 years (range, 4 days15 years).
Discussion
Anastomotic strictures are a well-known
complication of colonic interposition second-
ary to postsurgical scarring at the esophago-
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Li et al.
32 AJR:189, July 2007
colic or cologastric anastomosis [3, 4, 7,
1113]. These strictures usually appear as rel-
atively short segments of narrowing that are
confined to the region of the affected anasto-
mosis [11, 12]. In contrast, the radiology lit-
erature contains only anecdotal descriptions
of nonanastomotic strictures developing after
colonic interposition [11, 15]. Such strictures
have manifested on barium studies as seg-
mental or diffuse colonic narrowing and are
postulated to be caused by ischemia of the
surgically mobilized colon [11, 15]. In our
study, however, seven (44%) of the 16 pa-
tients with colonic interpositions who under-
went postoperative upper gastrointestinal
tract radiographic examinations had nonanas-
tomotic strictures of the interposed colon.
These nonanastomotic strictures after co-
lonic interposition had characteristic findings
on upper gastrointestinal radiographic stud-
ies: The nonanastomotic strictures appeared
as relatively long segments of narrowing in-
volving the interposed colon (Figs. 13). The
strictures almost always had smooth con-
tours, tapered margins, and effaced haustral
folds. The location, length, and appearance of
nonanastomotic strictures after colonic inter-
position therefore enable differentiation from
anastomotic strictures on upper gastrointesti-
nal radiography in almost all cases.
All seven patients with nonanastomotic
strictures after colonic interposition presented
with dysphagia at the time of the index exami-
nation (n = 4) or developed dysphagia after the
index examination (n = 3). When dysphagia
was present at the index examination, it usually
occurred months to years after colonic interpo-
sition, and the strictures responded poorly to
treatment, frequently necessitating multiple
endoscopic dilatation procedures or even sur-
gical revision of the interposed colon. In con-
trast, anastomotic strictures that develop after
colonic interposition are often amenable to en-
doscopic dilatation without the need for multi-
ple dilatation procedures or repeat surgery [11,
13, 14]. The development of nonanastomotic
strictures in the interposed colon therefore has
important implications for the long-term man-
agement of these patients.
Although the cause of nonanastomotic
strictures after colonic interposition is uncer-
tain, the frequent effacement or obliteration
of haustral folds and the relatively long length
of the narrowed colonic segment in our pa-
tients are characteristic of ischemic strictures
involving the colon elsewhere [16]. In two
cases, pathologic examination of the resected
portion of the interposed colon revealed ex-
tensive submucosal fibrosis. Although none
of the patients in our series had radiographic
A B
Fig. 155-year-old man with nonanastomotic stricture after colonic interposition for esophageal carcinoma.
A, Frontal spot image from single-contrast upper gastrointestinal tract examination shows long segment of narrowing (white arrows) involving proximal two thirds of
interposed colon. Note relatively smooth contour and tapered margins (long black arrows) of stricture. Esophagocolic anastomosis (short black arrow) is located proximally
in upper chest just above aortic arch.
B, Frontal spot image from upper gastrointestinal tract examination with water-soluble contrast material 3 months before A shows relatively normal distention of proximal
portion of interposed colon with effacement of haustral folds. Nodular indentations (white arrows) along left lateral wall of colon could be secondary to bowel wall edema
or weak colonic contractions. Note esophagocolic anastomosis (black arrow) in upper chest below medial end of left clavicle.
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Nonanastomotic Strictures After Colonic Interposition
AJR:189, July 2007 33
findings of acute colonic ischemia, other au-
thors have described edema, spasm, ulcer-
ation, and thumbprinting as radiographic
signs of acute ischemia in the interposed co-
lon and actual perforation as a sign of is-
chemic necrosis of the interposed colon [11,
12]. The surgical literature also contains sev-
eral reports of patients who developed dys-
phagia as a result of long nonanastomotic
strictures after colonic interposition [1719].
One patient had an acute hypotensive episode
after surgery [17]; in another patient, a post-
operative angiogram showed abnormal vas-
cularization of the interposed colon [18]. We
therefore believe these nonanastomotic stric-
tures most likely develop as a result of chronic
ischemia from inadequate perfusion of the
surgically mobilized colon.
Nonanastomotic strictures after colonic in-
terposition could also result from postopera-
tive leaks with associated scarring and fibrosis,
but most leaks involve the esophagocolic or
cologastric anastomosis, so developing stric-
tures are usually located at or near these anas-
tomoses [2, 7, 11, 13]. Although two of our pa-
Fig. 227-year-old man with nonanastomotic stricture
after colonic interposition for chronic lye stricture.
Double-contrast upper gastrointestinal tract examination
shows moderately long stricture (white arrows) in lower
one third of interposed colon. Note smooth contour and
tapered margins (black arrows) of stricture.
Fig. 325-year-old man
with nonanastomotic
stricture after colonic
interposition for VATER
(vertebral defects,
imperforate anus,
tracheoesophageal
fistula, and radial and
renal dysplasia)
syndrome with
congenital esophageal
stenosis. Single-contrast
upper gastrointestinal
tract examination shows
3.5-cm-long stricture
(white arrows) in
midportion of interposed
colon. This tight stricture
is causing partial
obstruction with
proximal colonic
dilatation. Note smooth
contour and tapered
margins of stricture. Also
note proximal
esophagocolic
anastomosis (black
arrow) and Harrington
rod in thoracic spine.
tients did have small sealed-off anastomotic
leaks, we doubt that these leaks were an impor-
tant contributing factor because of the long
length of the strictures in our patients and be-
cause of the location of these stricturesthat
is, at a discrete distance from the proximal and
distal anastomoses. Reflux of acid from the
stomach via the cologastric anastomosis could
also account for the development of nonanas-
tomotic strictures in the interposed colon, but
such reflux was not observed at fluoroscopy in
any of our patients. Furthermore, one would
expect reflux-induced strictures in the inter-
posed colon to be located distally at or near the
cologastric anastomosis, whereas all of the
strictures in our patients were located well
above the distal anastomosis.
Our investigation has the inherent limita-
tions of a retrospective study. Selection bias
may also have increased the prevalence of
nonanastomotic strictures in our series be-
cause many patients were referred to our in-
stitution as a result of preexisting complica-
tions from failed colonic interpositions. The
limited duration of follow-up for several pa-
tients also limits our ability to draw firm con-
clusions in all cases.
In summary, nonanastomotic strictures
after colonic interposition have characteris-
tic features on radiographic examinations of
the upper gastrointestinal tract, appearing as
relatively long segments of smooth, tapered
narrowing involving the interposed colon
that are separate from the proximal esoph-
agocolic and distal cologastric anasto-
moses. These strictures most likely develop
as a result of chronic ischemia of the surgi-
cally mobilized colon. Unlike strictures at
the esophagocolic or cologastric anastomo-
sis, nonanastomotic strictures after colonic
interposition have a poor response to endo-
scopic dilatation procedures and are more
likely to necessitate surgical revision of the
colonic interposition.
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