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Journal of Medical Cases

Case Report

Volume 6, Number 5, May 2015, pages 188-193

Tubular Adenomatous Polyp in a Colon Interposition: A Case Report and Review of Literature

Colon interposition surgery has been utilized post esophagectomy with success [1]. The colon has a number of characteristics that make it an excellent option for esophageal replacement. Advantages include long length, acid resistance, and typically excellent blood supply [1]. Adenoma and adenocarcinoma can appear as a late complication in colonic tissue grafts used to substitute the esophagus [2]. Early detection and treatment can decrease morbidity and mortality [3]. At our institution, we present a case of an adenomatous polyp found in a patient with colonic interposition 6 years after surgery for Barrett’s esophagus with high grade dysplasia.

A 59-year-old white male with a history of Barrett’s esophagus diagnosed 24 years ago, underwent esophagectomy with colonic transposition (6 years ago) for high grade dysplasia. He came into our clinic complaining of a “stricture like sensation” in his throat, difficulty eating, and weight loss. His symptoms started a few months back and were getting progressively worse. There were no alleviating or aggravating factors. The patient also complained of fatigue, anorexia, a sense of early satiety, and diarrhea.

His past medical history includes diverticulitis, hypoglycemia, and Barrett’s esophagus. His surgical history includes esophagectomy with colonic transposition using the sigmoid colon, a previous tonsillectomy, and a colonoscopy in 2010. The patient smokes half a pack of cigarettes a day, and consumes 12 bottles of beer every week. He consumes one pot of regular coffee every day. He denies any illicit drug use. There is no family history of Barrett’s esophagus or colon cancer.

An esophagogastroduodenoscopy (EGD) procedure was performed using an Olympus video gastroscope. This showed a 0.8 cm polyp (Fig. 1) arising from the mid portion of the interposed colon. The polyp was completely removed with multiple bites of a jumbo biopsy forceps.

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Figure 1. Olympus video gastroscope shows a 0.8 cm polyp in the mid portion of the interposed colon.

The pathology report of the polyp revealed a tubular adenoma (Fig. 2, Fig. 3). The gastroesophageal junction biopsy showed benign colonic mucosal segments, squamocolumnar anastomosis with intense chronic inflammation and reactive epithelial change. No Barrett’s metaplasia was seen.

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Figure 2. Hematoxylin and eosin (H&E) of tubular adenomatous polyp at × 40 magnification. Right lower piece of colonic mucosa shows a polyp containing tubular structures. The tubules are composed of columnar cells with hyperchromatic and basally located nuclei.

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Figure 3. Hematoxylin and eosin (H&E) of tubular adenomatous polyp at × 100 magnification which shows tubules that are composed of columnar cells with hyperchromatic and basally located nuclei.

The use of long segments of the colon, either for replacement or bypass of all or part of the thoracic esophagus, was introduced independently by Kelling and Vulliet in 1911 [4]. Since then, the colon has emerged as a well-functioning and durable esophageal substitute when the stomach cannot be used [4-6].

To date, gastric pull-up is the most frequent reconstruction after esophagectomy. Yildirim et al demonstrated that the overall satisfaction was superior in patients undergoing colonic interposition [7]. However, other studies done by Hashesh et al suggested that gastric pull-up was more preferable and easier to perform [8]. Colonic interposition had increased morbidity, compared with gastric transposition. However the overall mortality and survival were similar to those for gastric transposition [9].

Esophagectomy with colon interposition has been used in benign and malignant diseases of the esophagus such as strictures [10] and cancer [11]. This procedure may cause surgical complications such as anastomotic leakage and sepsis due to colon necrosis [5], delayed fibrosis [12], esophagocolonic anastomotic stricture [13], dysphagia [14], Claude Bernard-Horner syndrome [15], and aorto-colonic fistula [16].

Advantages include long length, acid resistance, typically excellent blood supply, and the potential for a wide gastric resection margin in patients with cancers of the gastroesophageal junction [17]. Peters et al showed that replacement of the esophagus with the colon can be successful in over 80% of patients screened by angiographic criteria [18]. The left colon is the most common segment used in colon interposition due to its good blood supply [19]. Absolute contraindications to colon interposition are the presence of intrinsic colon disease such as inflammatory bowel disease, malignancy, or inadequate arterial blood supply from peripheral vascular disease [20].

Screening or surveillance for colorectal cancer is a crucial preventative measure. In addition to a screening colonoscopy, clinicians should perform a screening upper endoscopy in patients with a history of colon interposition as pathology may arise from the colonic segment. The patient in our case should have had a screening EGD in addition to screening colonoscopy in 2010. This case serves as a reminder of the importance of colon interposition screening. Furthermore, in the review of literature (Table 1) [14, 21-38], 15 out of 22 patients have developed adenocarcinoma in the grafted interposed colon. This could have been prevented if the patients had regular EGD screening or surveillance follow-up. Our patient was fortunate enough to be diagnosed with tubular adenoma prior to the development of advanced cancer. According to the European Society of Gastrointestinal Endoscopy (ESGE) guidelines, our patient is considered a “low risk group” based on the histology and the size of the polyp removed from the interposed colon [39]. The current recommendation for surveillance and screening after polypectomy is between 5 and 10 years [40]. It is also suggested that patients who have polyps in the interposed colon should undergo colonoscopy to rule out synchronous lesions [21]. Since there are no guidelines available for screening and surveillance of the grafted colon interposition, we recommended that our patient should have a repeat EGD and colonoscopy surveillance in 3 years.

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Table 1. Review of Literature of Tumors Arising from the Grafted Colon Interposition

Esophagectomy with colon interposition is a successful treatment for the diseased esophagus. The emphasis of our case is to continue screening and surveillance for colon cancer where ever colonic tissue is found. Since there are no current guidelines for the management of screening or surveillance of colon interposition, we suggest that clinicians who encounter these patients must always screen the interposed colonic graft at the same time that the patient has a colon cancer screening.

Disclosure

The authors have no funding or conflicts of interest to disclose.

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