Graft redundancy

This is a recognised late complication of this technique and occurs in 5% of patients. This can also trigger worsening gastrocolic reflux, hastening the deterioration of the graft. The aetiology varies between patients. In some, the surgeon used a longer piece of colon than necessary due to fear of anastomosis tension; in other cases growth of the colon intrathoracically was greater than the growth of the thorax; lastly, there may be intrapleural herniation of graft, forming hiatus hernia and exposure of the graft to constant negative pressure. Treatment is complex due to the variety of surgical procedures and techniques carried out in this patient group. In some, the choice of past procedures and previous complications greatly limits treatment options. First-line treatment is always symptomatic and directed at alleviating presenting complaints with medication and lifestyle measures (see section on GI conditions above) or, if not manageable through medication, tube feeding has been necessary in those for whom surgery is not an option. Surgery is performed when other methods fail and methods in the literature include refashioning the colonic interposition, segmental resection, anastamotic revision, replacement with a supercharged jejunal tube, or a gastric tube or gastric pull-up. (178,179)

Very rare emergency complications of graft redundancy

1. Colonic interposition volvulus. This is intermittent twisting of the conduit causing intermittent ischaemia, secondary to redundancy. This is a medical emergency and needs admission, preferably to a tertiary centre with knowledge of this adult with repaired long-gap OA, though may still be managed conservatively with decompression, parenteral nutrition and antibiotics. This can happen on a number of occasions in the same patient. Surgery may be needed at a later date. (185,186)
2. Cardiac compression. There is a single case report of a dilated colonic conduit causing cardiac compression in adulthood. This presented as 24-hour history of inability to swallow, shortness of breath, and a left-sided non-reducible supraclavicular mass, accompanied by hypotension, tachycardia and tachypnoea. The authors attribute this to a progressive cycle of increased retention of liquid and particulate matter and low-grade ischemia ultimately leading to massive conduit dilatation and secondary cardiac compression. This was alleviated by emergency removal of the conduit to immediate effect. (187)