Management of complete crico-pharyngo-esophageal strictures caused by corrosive injuries remains a significant surgical challenge due to the complex anatomy, scar formation and restriction of mobility and the need for a robust and functional reconstruction. Corrosive ingestion results in extensive damage leading to severe fibrosis, strictures, and loss of normal swallowing function. This paper highlights the use of colonic interposition as a definitive reconstructive strategy in two patients with high esophageal strictures involving the cricopharynx due to corrosive ingestion. The procedure employs a vascularized segment of the colon, mobilized through a subcutaneous route and anastomosed proximally to the pharynx and distally to the pyloro-duodenal junction.

The choice of the left colic artery as the primary vascular supply ensures adequate blood flow to the conduit, which is critical for graft viability. Usually middle and right colic arteries are used.

This technique, supported by successful outcomes in the presented cases, demonstrates its efficacy as a viable solution for severe corrosive esophageal injuries. The discussion emphasizes the importance of preoperative nutritional optimization, meticulous surgical technique, and intensive postoperative care in achieving favorable outcomes.

This approach aligns with global best practices for esophageal reconstruction and offers insights into managing such complex cases effectively.

The authors performed colonic interposition technique on 2 patients who presented with high oesophageal stricture involving the cricopharynx, post corrosive ingestion. For the first 2 months, patients were managed conservatively with feeding jejunostomy. Following which a definitive procedure was done.  In the procedure the colonic conduit which was supplied by the ascending branch of left colic artery; was anastomosed proximally to the pharynx and distally to the pyloro-duodenal junction.

Definitive Surgical Procedure:

Colonic Interposition:

The procedure includes creating a conduit from the colon and anastomosing it to the pharynx and stomach.

Selection of the Colonic Conduit:

A segment of the colon was chosen based on vascular supply, predominantly utilizing the ascending branch of the left colic artery.

The middle and right colic arteries were ligated to ensure sufficient blood flow from the left colic artery and splenic flexure collaterals and to give length to bridge the gap.

Mobilization of the Colonic Conduit:

The selected segment of the colon was mobilized and brought up through a subcutaneous tunnel to the neck.

Proximal Anastomosis:

The proximal end of the colonic conduit was anastomosed to the posterior pharynxin a dependent position, allowing reconstruction of the upper digestive tract.

Distal Anastomosis

The distal end of the colonic conduit was anastomosed to the pyloro-duodenal junction, ensuring continuity with the stomach and lower digestive tract.

Ensuring Vascular Supply:

Intraoperative confirmation of blood flow through the left colic artery was performed to verify graft viability by applying bull dog clamps to the middle and right colic arteries for 4-5 minutes.

Caeco-sigmoid anastomosis was done to complete the tract

CASE 1

A 19-year-old female, weighing 21 kg, presented to our emergency department with progressive dysphagia and significant weight loss after an intentional ingestion of an alkaline solution (Drainex®). On arrival, she was hemodynamically stable but exhibited complete inability to swallow. Upper gastrointestinal endoscopy (UGIE) revealed extensive fibrosis and a complete stricture at the pharyngo-esophageal junction. Given her severe malnutrition and inability to maintain oral intake, a feeding jejunostomy (FJ) was performed for nutritional rehabilitation. One month following the FJ, the patient presented with acute onset difficulty in breathing, inability to phonate, and bilateral wheeze. Indirect laryngoscopy (IDL) showed extensive glottic fibrosis, leaving a residual 2 mm airway space between the false vocal cords. An emergency tracheostomy was undertaken to secure the airway.

After three months of nutritional buildup and stabilization, definitive surgical reconstruction was pursued. Given the non-salvageable native esophagus, a colonic interposition (coloplasty) was successfully performed to restore gastrointestinal continuity.

Further Management Plan -

• Decannulation of tracheostomy: Once airway patency is confirmed.
• Speech therapy: To address voice restoration post-glottic injury.
• Regular colonic dilatation: To prevent postoperative strictures at the anastomosis site.
• Psychosocial counseling: Given the psychological impact associated with corrosive ingestion and prolonged hospitalization

A 24-year-old male presented with a history of alkaline (Harpic®) ingestion 25 days prior to admission. He was hemodynamically stable, complaining primarily of inability to swallow and significant weight loss. Initial upper gastrointestinal endoscopy (UGIE) revealed extensive fibrosis of the oropharynx and multiple ulcerations of the tongue.

A feeding jejunostomy (FJ) was performed to provide enteral nutrition and allow for nutritional build-up. After three months, coloplasty (colonic interposition for esophageal replacement) was performed. However, in the postoperative period, a steadily increasing drain output was observed. A contrast-enhanced CT scan suggested an anastomotic leak.

The patient was taken for surgical re-exploration, where intraoperative findings confirmed the leak. Re-anastomosis was successfully performed.

Postoperatively, the patient required an extended one-month ICU stay for monitoring and recovery. Subsequently, he was shifted to the ward and is currently undergoing regular colonic dilatation sessions during outpatient follow-up to prevent anastomotic stricture formation.

Surgical Procedure: Colonic Interposition

• Conduit Selection:

A segment of the colon was selected, utilizing the ascending branch of the left colic artery to ensure robust blood supply.

The middle colic and right colic arteries were ligated to optimize perfusion to the conduit.

• Mobilization:

The chosen colonic segment was mobilized through a subcutaneous tunnel extending up to the neck, carefully preserving vascular pedicle integrity.

• Proximal Anastomosis:

The proximal end of the colon was anastomosed directly to the pharynx, reconstructing the upper alimentary continuity.

• Distal Anastomosis:

The distal end was anastomosed to the pyloro-duodenal junction to establish a functional lower connection for food transit.

• Additional Bowel Reconstruction:

A caeco-sigmoid anastomosis was performed to maintain colonic continuity in the abdomen after conduit harvesting.

Corrosive injuries in crico-pharyngo-esophageal region necessitate complex reconstructive procedures.

Challenges:

Ingested corrosive substances - acidic or alkaline - extensive damage through coagulative or liquefactive necrosis leading to complete pharyngo-esophageal strictures with significant necrosis and fibrosis.

Management of such strictures is challenging due to:

• Severe nutritional compromise.
• Risk of airway compromise
• Need for a reliable and vascularized conduit

Colonic Interposition as a Viable Option

• Robust
• Vascularized conduit
• Sufficient luminal diameter
• The left colic artery and its collaterals offer reliable blood supply even after the ligation of middle and right colic arteries.

Other Techniques:

• Gastric pull-up - is simpler, it may not reach the pharynx without significant tension
• Free jejunal transfer - technically demanding and less feasible in resource-constrained settings

Caustic ingestion remains a significant cause of morbidity, particularly in regions where household cleaning agents are readily accessible. Alkali ingestion, as seen in both our cases, typically results in liquefactive necrosis, allowing deep tissue penetration with progressive fibrosis and stricture formation. The esophagus and upper aerodigestive tract are especially vulnerable due to prolonged contact time and lack of protective barriers.1

Both patients in this series demonstrated the classic sequelae of severe caustic injury: progressive dysphagia, severe weight loss, and critical upper gastrointestinal strictures. Early nutritional support via feeding jejunostomy was pivotal in stabilizing these patients before definitive reconstructive procedures could be safely undertaken. Nutritional optimization not only prevents catabolic deterioration but also improves postoperative healing outcomes.2

Despite similar initial management strategies, the clinical courses diverged based on the severity and distribution of injuries:

The 19-year-old female developed critical glottic fibrosis, resulting in airway compromise necessitating emergency tracheostomy. Airway involvement after caustic ingestion is rare but well-recognized and mandates prompt intervention to avoid fatal respiratory obstruction.3

In contrast, the 24-year-old male's course was complicated postoperatively by an anastomotic leak following colonic interposition. Anastomotic leak remains one of the most serious complications after esophageal or colonic substitution surgery, requiring early identification and immediate surgical re-exploration to prevent widespread sepsis.4

Colonic interposition remains a well-established option for esophageal reconstruction in patients with extensive injury, offering a reliable vascular supply, good functional outcomes, and acceptable long-term durability. In both cases, the left colic artery ascending branch was preserved to maintain conduit vascularity, while middle and right colic arteries were ligated, and the conduit was tunneled subcutaneously to the neck with proximal pharyngo-colonic and distal colo-duodenal anastomoses.

Long-term rehabilitation remains crucial in such patients. Both patients continue to require regular colonic dilatations to prevent anastomotic stricture, and in the female patient, airway decannulation and speech therapy are planned as part of her recovery trajectory. Additionally, psychosocial support forms an integral component of the post-injury rehabilitation, addressing the significant psychological burden associated with caustic ingestion, particularly in cases of intentional ingestion.

In summary, these cases highlight the wide spectrum of complications that may follow caustic ingestion, the importance of a staged multidisciplinary approach, and the need for long-term structured follow-up to achieve the best functional and quality-of-life outcomes.

Colonic interposition using the left colic artery as the primary vascular supply is a reliable and effective surgical option for managing complete crico-pharyngo-esophageal strictures caused by corrosive injuries. The success of the procedure depends on thorough preoperative planning, nutritional optimization, and careful postoperative management with long term psychosocial counselling.

1. Gonzalez E, Caniano DA. Caustic ingestion. In: UpToDate, Wyllie R (Ed), UpToDate, Waltham, MA.
2. Contini S, Swarray-Deen A, Scarpignato C. Caustic ingestion: A plea for an endoscopy-based classification. World J Gastroenterol. 2017 Jul 7;23(25):4561–4564. doi:10.3748/wjg.v23.i25.4561
3. Tariq MA, Iftikhar H, Manzoor K. Tracheostomy. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.
4. Kahrilas PJ, Blackwell J. Esophageal Replacement. StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.