caustic esophageal injury in infants is a devastating insult to the gastrointestinal tract and will often require major reconstructive surgery to replace the damaged esophagus . esophageal replacement with colonic
interposition has been utilized since dale and sherman performed the first retrosternal colonic interposition in 1955 . up to 80% of patients with colonic interposition
endoscopic dilation is relatively safe and effective for the initial treatment of anastomotic strictures , but surgical management is indicated in refractory cases . when surgery is required , graft revision utilizing both a thoracotomy and laparotomy is common .
we report a case of cologastric stricture treated with resection and reconstruction of the anastomosis solely through an abdominal approach , which can offer less morbidity and mortality .
a 31-year - old male developed a caustic esophageal injury after ingestion of an alkaline solution when he was 2 years old .
he required emergent esophagectomy , proximal gastrectomy and reconstruction with a colonic interposition graft from the cervical esophagus to the stomach .
the patient also had a pyloric stricture , for which a gastrojejunostomy was performed . over the next three decades , he required frequent hospital admissions for abdominal pain and dysphagia , and had multiple endoscopic dilations performed for a severe cologastric anastomotic stricture ( fig .
the patient had severe malnourishment , with a body mass index of 14 kg / m .
he had a jejunostomy feeding tube for nutritional support , which had been removed due to abdominal pain a few months prior to presentation . 

endoscopic evaluation revealed the severe cologastric stricture , severe inflammation just proximal to the cologastric anastomosis , and significant ulcerative disease at his gastrojejunal anastomosis .
the patient underwent resection of the cologastric anastomosis and the gastrojejunal anastomosis with ulcerated stomach , neo - cologastric anastomosis and neo - gastrojejunal anastomosis via a transabdominal approach without a thoracotomy .
intraoperative endoscopy was utilized during the case to ensure that the cologastric anastomotic stricture was entirely resected . 

figure 2:preoperative cologastric and pyloric strictures ( a ) and post - operative changes including new cologastric , gastrojejunal , duodenojejunal anastomoses ( b ) .
preoperative cologastric and pyloric strictures ( a ) and post - operative changes including new cologastric , gastrojejunal , duodenojejunal anastomoses ( b ) .
the patient tolerated the procedure well and was transferred to the intensive care unit . on post - operative day 2 , he was transferred to the floor .
his post - operative course was remarkable for development of an intra - abdominal fluid collection , which required percutaneous drainage , but was otherwise uncomplicated .
severe esophageal damage may require resection with creation of a neo - esophagus . because these operations occur in children , complications in regards to the colonic interposition graft
classically , a transthoracic approach has been used to resect the entire colonic graft . in this situation
, a repeat colon graft may be needed , which carries high morbidity and mortality .
in particular , the majority of the proximal colon graft , which was functional , was able to be spared .
given our patient 's preoperative nutritional status , he would be at a predisposed risk for wound healing complications . via transabdominal approach ,
to the best of our knowledge , this is the first written report of using a completely transabdominal approach for revision of the colonic graft .
our patient had previously been refused surgery by multiple surgeons . if this relatively less complex surgical management was used , perhaps he would have had definitive treatment much earlier .
our patient did well with our transabdominal approach given the chronicity of his symptoms . in light of his clinical dilemma of continued non - operative versus operative intervention , his symptoms were relieved immediately .
this surgical approach should be considered in patients with history of colonic interposition requiring reoperation for complications of the colonic graft .
 a 31-year - old gentleman who had undergone an emergent esophagectomy and reconstruction with a colon interposition graft , presented with a long - standing cologastric stricture . 
 he had undergone multiple attempts at endoscopic dilation over multiple decades with little symptomatic relief . 
 he underwent a resection and reconstruction of the anastomosis entirely through an abdominal approach . 
 he did well from surgery and experienced complete symptomatic relief immediately . 
 complications of colon interposition grafts can occasionally be treated using an abdominal incision only . 