Written by Maninder Kalkat
Belsey pioneered the use of colonic interposition for oesphageal atresia and following this delivered an outstanding lecture in 1972 on “Congenital Anomalies of the Oesophagus”.
The earliest description of oesophageal atresia with tracheoesophageal fistula was made in 1697 by Gibson in London. Oesophageal atresia was invariably fatal. Early diagnosis and surgical correction within the first few days of birth must be performed. In 1941, C Haight at the University of Michigan performed the first successful one-stage closure with primary anastomosis.
In the Proceedings of the Royal Society of Medicine, Belsey described 3 cases of congenital oesophageal anomalies. He emphasized clear history taking as a fundamental step in establishing the diagnosis. “Listen to the patient – the customer is always right”. The diagnosis should always be suspected if there is frothy mucus around the nose and mouth, cyanosis during feeding and regurgitation and abdominal distention on screaming.”
The most common form of oesophageal atresia consists of the absence of the upper third of the thoracic oesophagus, the cervical oesophagus ending blindly and the lower part of the oesophagus communicating with the trachea. This is then followed by atresia without a fistula, usually a long-gap atresia. In conditions with long gap atresia where primary anastomosis is impossible, the use of an interposition graft can be useful. In such a situation, there are essentially two alternatives – elongation with delayed primary anastomosis or colon interposition. The first option fell into disfavor because of the high incidence of postoperative
complications and severe gastroesophageal (GE) reflux in the late follow-up; thus colon interposition is preferred.
Kelling and Vulliet first proposed the use of isoperistaltic transplants of left colon in 1911. Following this, several modifications were introduced using the right, left and transverse colon as an interposition graft. In 1955 a clinical trial was initiated to study synchronous resection and reconstruction with isoperistaltic segments of left colon and splenic flexure supported by the left colic artery as an alternative to right colon interposition. The trial was initially confined to reconstruction and bypass for benign obstructive lesions but later the technique was extended to the management of malignant lesions with a more promising long term prognosis where the late functional results become increasingly important.
In 1965, oesophageal reconstruction with left colon transplant had been carried out in 105 patients of which 31 were in infants or children under the age of 10 years. Ten of the infants had congenital oesophageal atresia where no primary anastomosis was possible because of the length of the gap between the two oesophageal segments. Shortly after birth, the first operation for a temporary oesophagostomy and gastrostomy was performed with closure of the tracheoesophageal fistula. Subsequently at the age of 15 months to 2 years the reconstruction of the entire intrathoracic oesophagus was performed with long segment colon transplant. There was one death in the congenital group and this was due to small bowel obstruction.
Based on these successful results and the perseverance of Belsey in disseminating his knowledge and experience, the left colon has been successfully used as a conduit in long gap stenosis in the management of benign and malignant conditions of the oesophagus.