Jejunal pedicle grafts for reconstruction of the esophagus in children

Objective

Reconstruction of the esophagus in children remains a challenge. Although jejunal grafts retain peristaltic activity, large series with long-term follow up are rare. We like to present our experience in a series of 24 children.

Methods

In the period 1988 through 2005, 24 children received an orthotopic jejunal pedicle graft reconstruction of the esophagus. Nineteen had esophageal atresia (18 had no distal fistula; all but 1 had a jejunal graft as a primary procedure), 3 had an extensive caustic stricture, and 2 had a peptic stricture. All strictures had been dilated many times, and peptic strictures had been treated with antireflux surgery as well. Median age at reconstruction was 76 days in the esophageal atresia group. The technique involves a right-sided thoracotomy with preparation of the esophageal ends or resection of the diseased esophagus. At laparotomy, a small pediculated jejunal graft is prepared and placed transhiatally in an orthotopic position in the right chest.

Results

All patients survived, and none of the grafts were lost. There were 5 intrathoracic leaks, 4 in the esophageal atresia group and 1 in peptic stricture group, requiring reoperation in 1. In the esophageal atresia group, there was 1 early distal stenosis requiring reoperation. In patients in which the distal esophagus was preserved (esophageal atresia and caustic stricture group), there were always signs of distal functional subobstruction, responding to dilatation in all but 1 patient. Gastroesophageal reflux was not a problem except for 1 patient with esophageal atresia, in whom the distal esophagus was resected because of ongoing distal obstruction with dilatation of the graft. Most patients eat and grow well, and respiratory problems were rare.

Conclusion

Orthotopic jejunal pedicle graft reconstruction of the esophagus in children is a demanding operation with considerably morbidity but good long-term results.     

Laparoscopically assisted esophagectomy and colon interposition for esophageal replacement in children: preliminary results of a novel technique

Background

Colonic interposition is one of the surgical options in children when esophageal replacement is necessary, especially when the stomach is not suitable as a conduit. Conventional open surgery and blind mediastinal dissections present reasonable morbidity, which can be reduced by videosurgery. The authors present novel techniques and the preliminary results of the first series of laparoscopically assisted esophagectomies and colonic interpositions (LECIN) in children.

Methods

Five children aged 19 months to 4 years underwent LECIN. Indications were complicated esophageal atresia and severe caustic esophagitis. The patients were operated on laparoscopically using 3 ports, including the gastrostomy site. Transhiatal esophagectomy was carried out, followed by pyloroplasty and mobilization of the transverse colon maintaining a double blood supply from the left pedicle. The stomach at the gastrostomy site was freed and closed in 3 cases. The colon was exteriorized through this 2- to 3-cm site or through the umbilicus, and the conduit was fashioned extracorporeally, including the colocolic and gastrocolic anastomosis. The colon was pulled up along the retromediastinal tunnel for the coloesophageal anastomosis through a cervical incision.

Results

Operative times ranged from 3 to 4.3 hours; there were no conversions and no complications related to laparoscopy. There were no cardiorespiratory problems, and 4 were extubated immediately after operation. Feedings could be started by day 3 to 4. Postoperative complications included atelectasis (1), pneumonia (1), and cervical stenosis because of persistent fibrotic esophagus, requiring cervical revision (1). One needed dilatations for mild dysphagia. After a follow-up period of 10 to 29 months, all patients are asymptomatic, gaining weight, and feeding well.

Conclusions

These preliminary data suggest that LECIN is feasible and can be safely performed with very low morbidity in children. Further studies with larger series and follow-up are expected.     

Fundal tube esophagoplasty for esophageal reconstruction in atresia

Purpose: This is a report of 4 patients with long gap/pure esophageal atresia, who, after an initial gastrostomy and cervical esophagostomy at birth, were treated with a new technique called fundal tube esophagoplasty.Methods: The technique consisted of mobilization of the distal esophageal stump, division of the left gastric artery, and mobilization of upper half of stomach. Both walls of the stomach were incised in the region of the fundus starting on the lesser curvature in such a way that a tube was created out of the fundus, and the native esophageal stump appears to be an extension of this neoesophagus. This neoesophagus was brought to the neck by the retrosternal route and in a second stage, esophago-esophageal anastomosis was made. Thal’s fundoplication was added in 2 cases.Results: All the stages have been completed successfully in 4 babies. They have been followed up for periods ranging from 8 to 24 months after restoration of esophageal continuity. All the children are thriving.Conclusions: Fundal tube esophagoplasty (1) serves to provide a neoesophagus of natural caliber, (2) utilizes native esophagus in reconstruction, (3) does not produce a space-occupying problem in the mediastinum, and (4) preserves the gastric reservoir function. In this early experience, it appears to fulfill all the requirements of a good esophageal substitute.     

Colon interposition for esophageal replacement: a single-center experience

Background Gastric tube interposition has become the method of choice for esophageal replacement after esophagectomy. Colon interposition, on the other hand, is widely considered to be a method of last resort, associated with high morbidity and mortality. The present study reviews our experience with colon interposition for esophageal replacement.Patients Nineteen consecutive patients undergoing colon interposition for esophageal replacement between 1 January 1994 and 31 July 2001 were reviewed. Outcome was compared with international publications on colon interposition as well as with our results following gastric tube interposition (fundus rotation gastroplasty).Results Fourteen men and five women with a median age of 68 years (range 44–78) underwent colon interposition for benign (n=9) and malignant (n=10) lesions. Eighteen patients underwent trans-hiatal esophagectomy with cervical anastomosis, and one patient underwent thoraco-abdominal esophagectomy with intrathoracic anastomosis. Surgical morbidity was 36.8% (7/19). Anastomotic insufficiency and fatal mediastinal bleeding occurred in one patient each (5.3%). No cases of graft necrosis were observed, and no re-operations were necessary. In-hospital mortality was 15.8% (3/19), twice due to surgical complications (abdominal sepsis, mediastinal bleeding) and once due to pulmonary and cardiac failure. As a late complication, four patients (21.1%) developed anastomotic strictures that necessitated repeated endoscopic dilatation.Conclusions Gastric tube interposition remains the method of choice for esophageal replacement. Colon interposition, however, is a valuable alternative with a good long-term function. Early mortality, however, remains a matter of serious concern.     

Colonic interposition for esophageal replacement in children remains a good choice: 33-year median follow-up of 65 patients

Introduction

Gastric pull-up has become the predominant technique for esophageal replacement because of allegedly deficient results of colon grafts. This retrospective study examines the long-term results in a large series of colonic interpositions.

Patients and Method

One hundred six children (median, 2.9 years; range, 0.32-15 years) had their esophagus replaced between 1965 and 2008, of which 96 had colon grafts. Those survivors who were 18 years and older were contacted and, if willing, interviewed, examined, and had their functional ability rated using the Karnofsky index.

Results

Ninety-six children had undergone a colon graft, and of these, 9 (9.3%) died. There were 65 long-term survivors whose indications for surgery included caustic injury (n = 32), failed tracheoesophageal fistula repair (n = 16), pure esophageal atresia (n = 14), and others (n = 3). The graft was either retrosternal (n = 49) or mediastinal (n = 16 patients). Twelve patients were unavailable for long-term assessment. After a median follow-up of 33.3 (11-41) years, 23 (43%) of 53 individuals experienced mild symptoms of reflux; scoliosis, 12 (22%) of 53, and/or other complications, 15 (27%) of 53 required further surgery.Thirty-two patients (60%) with Karnofsky indexes of 80% or higher felt healthy, 19 (36%) had mild life-style limitations (index, 40%-80%), and 2 had indexes less than 40%. Most patients live normal lives.

Conclusions

Colon conduits restored gastrointestinal continuity with limited mortality and considerable morbidity but good functional outcome and health perception in the long-term. Our study suggests that colon grafts are no worse than gastric pull-ups in the long-term.     

Isolated isoperistaltic gastric tube interposition for esophageal replacement in children

Various surgical procedures are used for esophageal substitution in children. With the gastric tube (GT) esophagoplasty procedures, main complications in the long term are related to gastric content reflux and acid production from the GT itself. A case of children operated on with a new procedure of isoperistaltic isolated GT interposition with favorable short- and long-term functional results is presented.     

Colon interposition for the replacement of the esophagus in children.

Thirty-two new cases of colon interposition for esophageal reconstruction are presented. Only one late death occurred in this series, which was unrelated to the colon interposition. Fifteen severe complication were observed in five patients with preexisting esophageal atresia and previously complicated courses following disastrous primary esophageal repairs. The most common complication was pneumonia which occurred 13 times. Five late strictures responded well to dilatation or revision. Long-term weight gain was compared between a group of colon transplant patients and a group of patients with repaired esophageal atresia. Although the esophageal atresia group followed the 25th percentile and the colon interposition group followed the 3rd percentile on the growth curve, no significant difference existed in weight gain over 12 yr.     

结肠代食管重建术

虽然食管切除后胃是首选的替代器官,但当胃已被切除或有病变时,则结肠代食管通常为第一选择。因而,结肠代食管是食管重建不可或缺的手术方式。本文就结肠代食管的历史、解剖、技术要点及应用前景作一阐述,供大家参考。     

Stapled tapering coloplasty to manage colon interposition graft redundancy for long gap esophageal atresia

Long gap esophageal atresia continues to be a therapeutic challenge for the pediatric surgeon. Although numerous methods have been described to achieve esophageal continuity in infants with esophageal atresia, esophageal replacement is often required if these methods fail. A common method of esophageal replacement in children is the use of a colon graft. Complications include cervical anastomotic leak, stricture, redundant intrathoracic colon with stasis, and cologastric reflux. We present an 11-year-old male with swallowing difficulties because of redundancy of the colon after undergoing colon interposition for long gap atresia. The patient underwent a successful transhiatal mobilization of the intrathoracic colon and stapled tapering coloplasty. The patient currently remains symptom-free.     

Use of Polyflex Airway stent in the treatment of perforated esophageal stricture in an infant: a case report

Anastomotic stricture is a common sequela after primary repair of esophageal atresia with esophagoesophagostomy. Esophageal perforation secondary to dilatation of the stricture, and refractory stricture are not uncommon. We present a case using a Polyflex Airway stent (Boston Scientific, Natick, MA) as an alternative treatment of esophageal stricture and perforation in an infant.     

Magnetic compression anastomosis (magnamosis) in a porcine esophagus: Proof of concept for potential application in esophageal atresia

Background

Magnetic compression anastomosis (magnamosis) is the process of forming a sutureless anastomosis of the gastrointestinal tract using two magnetic Harrison rings. It has been shown to be effective in stomach, small bowel and colon, but has not been implemented in the esophagus. A pure esophageal atresia porcine model was developed to test the concept.

Colon interposition in children

Since 1960 we have performed 80 colonic interpositions on 79 children. We present a retrospective review of their progress. Sixty-nine interpositions were for long-gap oesophageal atresia, while the remainder followed oesophagectomies, eight for strictures and two others. Overall, the transthoracic route was used in 69 per cent of cases, while 29 per cent were retrosternally placed and one was retropleural. The mean follow-up was 11.08 years. The mortality rate was 12 per cent, with one-third of deaths unrelated to the operation. Graft failure, which occurred on eight occasions (10 per cent), was due to ischaemia in four, intractable stricture in two and stomal ulceration in two. Leakage from the proximal anastomosis occurred in 31 per cent of cases and stricture formation in 27 per cent. Thirty per cent of patients complained of acid reflux, of whom one-third developed stomal ulceration. We present data concerning other complications, including long-term recurrent respiratory infections, malabsorption, gastrointestinal haemorrhage, diarrhoea, intestinal obstruction and redundancy of the graft. Staging the procedure did not affect the outcome, however the higher incidence of serious complications encountered following retrosternal interposition finally led us to abandon this procedure in favour of the transthoracic route. There has been little improvement in the growth rate, but in terms of swallowing ability the outcome was satisfactory in 94 per cent of cases.     

婴幼儿食管化学烧伤后狭窄的外科治疗

报告１９８０年至１９９４年应用保留结肠左动脉升支顺蠕动间置横结肠，行结肠下咽腔吻合治疗婴幼儿食管开口以下化学烧伤后狭窄６例的结果，旨在探讨婴幼儿食管良性狭窄的外科治疗方法。本组病例全部一期手术成功，无吻合口瘘及其他并发症发生。随访３～５年，无吻合口狭窄，病儿发育正常。作者认为，横结肠重建食管，结肠下咽腔吻合是治疗婴幼儿全食管良性狭窄较理想的手术方法。     

Trimetazidine reduces the degree of fibrosis in alkali burns of the esophagus

Purpose

The aim of this study was to investigate the efficacy of trimetazidine (TMZ), an antioxidant agent, on the prevention of stricture development after esophageal caustic injuries in rat.

Methods

Thirty rats were divided into 3 equal groups. A standard esophageal caustic burn was produced by application of 37.5% NaOH for a period of 90 seconds followed by water rinse. Group A (sham) animals were uninjured. Group B rats were injured but untreated. Group C rats were injured and received TMZ (5 mg/kg/d) via intraperitoneal route. Efficacy of the treatment was assessed in 28 days by measuring stenosis index and histopathologic damage score and by determining tissue hydroxyproline content.

Results

The stenosis index in the TMZ-treated group was significantly lower than the untreated group, similarly in the sham laparotomy group (stenosis index: 0.34 ± 0.10, 0.94 ± 0.21, 0.38 ± 0.05, respectively; P < .05). The hydroxyproline level (microgram per milligram of wet tissue) was significantly lower in the TMZ-treated group compared with untreated group, similarly in the sham laparotomy group (1.06 ± 0.14, 1.33 ± 0.08, 0.68 ± 0.15 μg/mg wet tissue, respectively; P < .05). In the untreated group, histopathologic damage score was significantly higher than TMZ-treated group (P < .05).

Conclusions

Trimetazidine reduces the degree of fibrosis and ameliorates histopathologic damage in experimental model of corrosive esophagitis in rats.     

Transcervical myotomy for wide-gap esophageal atresia

A primary end-to-end anastomosis of the esophagus can be accomplished in the wide-gap esophageal atresia by obtaining extra esophageal length through circular myotomy of the proximal esophageal pouch. However, a very short proximal esophageal pouch may not be accessible through the standard thoracic incision, precluding this procedure. An infant is reported in whom the inaccessible proximal pouch was exteriorized into the neck through a concomitant cervical incision, allowing three circular myotomies to be performed with ease. The proximal esophagus was then reintroduced into the chest cavity and a primary esophagoesophagostomy performed without difficulty.     

Delayed blind-pouch apposition,guide wire placement,and nonoperative establishment of luminal continuity in a child with long gap esophageal atresia

Delayed primary esophago-esophagostomy is the most physiologically attractive approach to establish luminal continuity in children with pure esophageal atresia. However, excessive tension on the mobilized esophageal ends can lead to anastomotic separation and severe leakage. To circumvent these complications, the blind pouches of a 2-month-old child were approximated unopened when, during the extrapleural thoracotomy, a conventional anastomosis was not feasible. A suture was passed through the tip of the 2 ends and made to exit through the mouth and the gastrostomy. After healing occurred, the suture was replaced under fluoroscopic control by a Seldinger-type wire. A vein dilator then was passed over the wire, establishing the continuity between the esophageal segments. Subsequent dilatations increased the anastomosis to the desired diameter. Leakage and an additional thoracotomy were avoided, and the hospital stay was shortened. The child, now 6 years old, is well and swallows normally.