A patient is to undergo transhiatal esophageal resection for failed previous reflux procedures. Reconstruction with a long colon interposition based on the left colic artery is planned. The operative detail which best prevents gastrocolic reflux is 

A. anterior cologastric anastomosis. 
B. antiperistaltic position. 
C. isoperistaltic position. 
D. posterior cologastric anastomosis. 
E. ten centimeter intra-abdominal colon segment. 

Answer E

Colon may be favored as the conduit of choice when the esophagus is resected for benign conditions and it is used when the stomach is inadequate or absent. When the anastomosis is in the neck, the left colon based on the left colic artery is the best choice of conduit.

All colon interpositions should be oriented in the isoperistaltic position. The colon graft has delayed emptying. Contractive waves between meals probably help empty food saliva and mucous secretions from the graft. After mobilization of the left colon, the conduit is placed through the lesser sac in a retrogastric position. The posterior mediastinal route is favored for transposition as it is the shortest route and best avoids tension and rotation.

A lower posterior cologastric anastomosis protects the vascular pedicle against tension and angulation. One should plan on at least a 10 cm intra-abdominal colon segment (infradiaphragmatic high pressure region) to create a barrier to reflux.