Use of a microporous polytetrafluoroethylene catheter balloon to treat refractory esophageal stricture: a novel technique for delivery of mitomycin C

Purpose

Endoluminal application of mitomycin C shows promise as a nonsurgical approach to treating recalcitrant stricture but requires precise delivery to prevent mitomycin-mediated injury to adjacent normal mucosa. We describe a novel technique that uses a microporous polytetrafluoroethylene catheter balloon to endoluminally deliver mitomycin C to the target tissue while minimizing nontarget drug application.

Materials and Methods

A newborn infant with proximal tracheoesophageal fistula and distal atresia underwent an uncomplicated repair. However, he developed recurrent esophageal stricture resistant to multiple attempts at pneumatic dilations. An image-guided endoluminal radiologic approach that uses microporous polytetrafluoroethylene catheter balloon was developed to precisely deliver mitomycin C to the mucosal lining of the stricture post-dilation.

Results

After uncomplicated pneumatic dilation under fluoroscopic guidance, we used a microporous balloon catheter to endoluminally deliver mitomycin C topically to the mucosa at the level of stricture. Three weeks post procedure, repeat esophagram showed resolution of the stricture with unobstructed flow of contrast material to the stomach. The patient had no observable side effects from mitomycin C application.

Conclusion

Image-guided therapies based on balloon dilation and drug-eluting microporous balloon techniques offer a safe, precise, and comprehensive approach to the treatment of recalcitrant esophageal strictures.     

Endoscopic management of congenital esophageal stenosis

Background/Purpose

Congenital esophageal stenosis (CES) is a rare malformation. Endoscopic dilations represent a therapeutic option. This study retrospectively evaluated the efficacy and safety of a conservative treatment of CES.

Patients and Methods

Patients diagnosed with CES since 1980 by a barium study or endoscopy were reviewed. Endoscopic ultrasonography (Olympus UM-3R-20-MHz radial miniprobe, Olympus Corporation, Tokyo, Japan), available from 2001, allowed for the differential diagnosis of tracheobronchial remnants (TBR) and fibromuscular hypertrophy (FMH) CES. All children underwent conservative treatment by endoscopic dilations (hydrostatic and Savary).

Results

Forty-seven patients (20 men) had CES. Fifteen were associated with esophageal atresia; and 8, with Down syndrome. Mean age at the diagnosis was 28.3 months (range, 1 day to 146 months). Symptoms were solid food refusal, regurgitation, vomiting, and dysphagia. Congenital esophageal stenosis was located in the distal esophagus. Endoscopic ultrasonography demonstrated TBR and FMH in 6 patients. One hundred forty-eight dilations in 47 patients were performed. The stenosis healed in 45 (95.7%). Complications were 5 (10.6%) esophageal perforations, hydrostatic (3/32, or 9.3%), and Savary (2/116, or 1.7%). At follow-up, 1 patient with FMH CES and 1 patient with TBR CES required operation for persistent dysphagia.

Conclusions

The conservative treatment yielded positive outcomes in CES. Endoscopic ultrasonography allows for a correct diagnosis of TBR/FMH CES. A surgical approach should be reserved for CES not responsive to dilations.     

Custom dynamic stent for esophageal strictures in children

Background

Esophageal stenting represents a new strategy to avoid multiple dilations owing to stenosis relapse. Our custom stent improves esophageal motility unlike the widespread self-expandable plastic esophageal stents. The aim of the study was to confirm the efficacy of treatment with silicone custom stents in esophageal stenosis (ES) in pediatric patients.

Methods

A silicone stent of 7-, 9-, or 12.7-mm external diameter is built coaxially on a nasogastric tube that guarantees the correct position. The 2 ends are tailored to allow food passage between stent and esophageal wall. All patients received dexamethasone (2 mg/kg per day) for 3 days and ranitidine/proton-pump inhibitors. Study approval was obtained from our ethical board.

Results

From 1988 to 2010, 79 patients with ES, mean age 35.4 months (3-125 months), underwent esophageal hydrostatic/Savary dilations and custom-stent placement, left in place for at least 40 days. Stenting was effective in 70 (88.6%) of 79 patients. Fifty percent of the patients with effective treatment received only one dilation for stent placement. Fourteen patients received more stents successfully. There was one stent-related major complication.

Conclusion

Our custom stent improves treatment in ES. In caustic injuries, ES stenting represents the first option. In postsurgical ES, we stent after at least 5 dilations.     

Anastomotic stricture after surgical repair of esophageal atresia: frequency, risk factors, and efficacy of esophageal bougie dilatations

Aims

The aim of this study was to evaluate the frequency and risk factors of postoperative anastomotic stricture, and the efficacy and complications of esophageal bougie dilatations for symptomatic anastomotic stricture in a population of children with esophageal atresia.

Patients and Methods

The medical records of 62 children operated on for esophageal atresia type III (Ladd and Gross) over a 5-year period were retrospectively reviewed.

Results

Anastomotic stricture developed in 23 (37%) of patients. Anastomotic tension during primary repair of esophageal atresia was associated with subsequent stricture formation (P < .05). Patients required esophageal dilation at a mean age of 149 days (range, 30-600 days). Stricture resolution occurred after a mean of 3.2 dilatations per patient (range, 1-7). Dilation was successful in 87% of patients. Three patients continued to present mild (n = 1) to severe (n = 2) dysphagia, mainly related to esophageal dysmotility. No complications were observed during or after the dilatation sessions.

Conclusions

Anastomotic stricture, secondary to the surgical treatment of esophageal atresia, remains a frequent complication in patients with esophageal atresia. Esophageal dilation with Savary-Gilliard bougies is a safe and effective procedure in the management of strictures.     

Esophageal strictures in children with recessive dystrophic epidermolysis bullosa: an 11-year experience with fluoroscopically guided balloon dilatation

Background

Recessive dystrophic epidermolysis bullosa (RDEB) is an inherited blistering skin disorder that is associated with significant esophageal strictures, resulting in dysphagia and nutritional failure. Although endoscopically guided balloon dilatation is a widely used treatment, the use of an endoscope carries the risk of oropharyngeal trauma. To minimize this risk, we have eliminated its use.

Method

We reviewed the charts of all RDEB patients who underwent balloon dilatation for esophageal strictures between August 1993 and March 2005. Balloon dilatation procedures were performed under anesthesia and with fluoroscopic control.

Results

We performed 92 dilatations on 25 RDEB patients. Most patients reported immediate relief of symptoms, rapid recovery, and resumption of adequate food intake within 1 day. The mean interval between dilatations was 1 year. Six patients (24%) have required only 1 dilatation, and 1 of these 6 has had a dilatation-free interval of 25 months. One patient with a history of multiple dilatations has remained dilatation-free for 5 years. No procedure-related complications have occurred.

Conclusions

Fluoroscopically guided balloon dilatation is a gentle, safe, effective, and repeatable technique that should be considered as a first line of treatment.     

The use of a retrievable self-expanding stent in treating childhood benign esophageal strictures

Background/Purpose

Esophageal stenting is a popular form of treatment of esophageal strictures in adults but is not widely used in children. The aim of the current study was to investigate whether esophageal stents could be used safely and effectively in the treatment of esophageal stenosis in children.

Methods

Covered retrievable expandable nitinol stents were placed in 8 children with corrosive esophageal stenosis. The stents were removed 1 to 4 weeks after insertion.

Results

The stents were placed in all patients without complications and were later removed successfully. After stent placement, all patients could take solid food without dysphagia. Stent migration occurred in one patient and so the insertion procedure was repeated to reposition the stent. During the 3-month follow-up period after stent removal, all children could eat satisfactorily. After 6 months, 2 children required balloon dilation (3 times in one and 5 times in the other). The dysphagia score improved in all patients.

Conclusions

The use of the covered retrievable expandable stent is an effective and safe method in treating childhood corrosive esophageal stenosis.     

Intraoperative manometry during laparoscopic Heller myotomy improves outcome in pediatric achalasia

Background

Achalasia is a rare disorder with less than 5% of patients diagnosed in childhood. Although Heller esophagocardiomyotomy is a proven intervention, incomplete myotomy can lead to clinical failure. Intraoperative esophageal manometry has been used to ensure adequacy of myotomies in adults. The purpose of the present study was to review our experience in the management of children with achalasia.

Methods

A retrospective review was conducted on the medical records of patients with achalasia diagnosed between November 1999 and March 2007. Patient demographics and interventions were recorded. Outcomes after surgical intervention and esophageal dilation were assessed. Mean follow-up was 3.5 ± 0.6 years. Intraoperative manometry was used over the past 3 years.

Results

Nineteen patients were treated for achalasia. The average age at diagnosis was 13.8 ± 0.8 years. Most patients underwent esophageal dilation (14/19), receiving on average 2.1 ± 0.3 dilations. One patient experienced a contained perforation that was treated conservatively. Eleven patients underwent myotomy, as primary therapy (n = 5) or after recurrence of symptoms after dilation (n = 6). Six patients underwent intraoperative manometry. More patients who underwent Heller myotomy without intraoperative manometry had recurrence of symptoms (80% vs 0%, P < .05).

Conclusion

Inadequate myotomy is a potential cause for recurrent symptoms after esophagocardiomyotomy in childhood achalasia. Intraoperative esophageal manometry is a safe technique that may improve the success rate of surgery by confirming the adequacy of myotomy thereby decreasing recurrence of symptoms.     

Critical aortic stenosis in early infancy: surgical treatment for residual lesions after balloon dilation

Background

The optimal management for critical aortic stenosis in early infancy continues to challenge cardiologists and cardiac surgeons. We present a review of our experience with the surgical treatment of residual aortic valve disease after percutaneous balloon dilation for critical aortic stenosis in early infancy.

Methods

Since 1989, 11 of the 38 patients who survived aortic balloon dilation (28.9%) have undergone surgical treatment for residual aortic valve dysfunction. Median time from aortic balloon dilation to surgical intervention was 7 months (range 1 to 56 months). Residual aortic stenosis was the predominant problem in 8 patients and aortic regurgitation was predominant in 2 patients.

Results

Aortic valvuloplasty was possible in 5 children; pulmonary autograft replacement of the aortic valve was performed in 6 children. Two children underwent a Ross-Konno procedure because of annulus hypoplasia and severe left ventricular outflow tract obstruction. Two early deaths occurred after a Ross-Konno procedure, both with findings of severe left ventricular fibroelastosis at the pathologic examination. Median follow-up time was 5 years (range 1 month to 11.9 years). No late deaths occurred. One patient with moderate-severe aortic valve regurgitation after aortic valvuloplasty underwent a successful Ross operation. All 9 patients are asymptomatic and are in good clinical condition.

Conclusions

We are convinced that the best aortic valve in the pediatric age group is the native one, provided it can function acceptably. However, in cases where conservative surgical treatment fails to yield a functional aortic valve, replacement of the valve is indicated, and the best aortic valve substitute in infants is the pulmonary autograft because of its potential for growth.     

The management of treatment-related esophageal complications in children and adolescents with cancer

Background and Purpose

Serious treatment-induced esophageal strictures and tracheoesophageal fistulae are rare in the pediatric oncology population. This report details our experience with their management.

Methods

We retrospectively reviewed our experience with pediatric oncology patients treated for esophageal complications over a 23-year period. Serious complications were defined as development of strictures requiring dilatation or an esophageal fistula. Fifteen patients were identified, 5 of which had been previously reported.

Results

Thirteen patients developed esophageal stricture, and 2 progressed to tracheoesophageal fistulae. The remaining 2 patients developed tracheoesophageal fistulae without antecedent stricture. The median interval from cancer diagnosis until development of esophageal complications was 3.5 years (range, 0.4-11.8 years). Before development of esophageal complication, 14 patients (93%) were treated with mediastinal radiation and 7 (47%) for candidal esophagitis.Strictures were most commonly located in the distal esophagus (5), then midesophagus (3), cervical esophagus (3) and diffusely (2). A median of 5 dilatations (range, 1-50) were necessary before patients were able to resume a normal diet. The origin of tracheoesophageal fistulae was the midesophagus (3) and distal esophagus (1). All 4 patients with fistulae were treated with esophageal division and diversion followed by esophagocoloplasty.

Conclusions

Esophageal strictures and fistulae may occur because of cancer therapy in childhood. Prevention includes early treatment of esophagitis especially Candida mucositis, and minimization of radiation dose to the esophagus. Strictures usually respond to dilatation, but fistulae require esophageal diversion and secondary reconstruction.     

Esophageal foreign bodies in the pediatric population: our first 500 cases

Background

Children with esophageal foreign bodies are frequently seen by pediatric surgeons. Choking and dysphagia are common presentations; however, esophageal perforation has been reported. Historically, rigid esophagoscopy with extraction of the foreign body has been the recommended treatment. Alternatively, Foley balloon extraction is a safe and effective approach.

Methods

Over a 16-year period, 555 children presented with an esophageal foreign body. Retrospective analysis of the medical record was undertaken. Statistics were by univariate analysis.

Results

Two hundred ninety-eight boys and 257 girls presented with a mean age of 3.24 years. Dysphagia (37%) and drooling (31%) were the most common symptoms. Foreign bodies were lodged in the superior esophagus in 73%, and 88% of the objects were coins. Balloon extraction with fluoroscopy was performed in 468 children. Eighty percent of the objects were successfully removed with a mean fluoroscopy time of 2.2 min, and 8% were advanced into the stomach. The overall success rate was 88%, with failures necessitating rigid esophagoscopy under general anesthesia. Children younger than 1 year were the most likely to fail (25% failure rate). Airway aspiration never occurred. Significant savings in patient charges were observed with this approach.

Conclusions

Balloon extraction of pediatric esophageal foreign bodies is a safe and cost-effective procedure. This technique is applicable for infants, children, and adolescents. Experienced practitioners should be able to achieve greater than 80% success rate.     

Thoracoscopic repair of tracheoesophageal fistulas: a case-control matched study

Introduction

To date, there is no comparative study of thoracoscopic repair (TR) vs conventional open repair (COR) for tracheoesophageal fistula (TEF). The aim of the study was to compare the 2 techniques in neonates with TEF.

Methods

A multi-institutional case-control study of cases of TEF was undertaken. The minimum follow-up was 6 months. Patients were considered for TR based on surgeon's preference. Cases were frequency matched on a 1:1 ratio based on gestational age and weight. Outcomes of interest were operative time, postoperative leaks, and postoperative stricture development. Statistical analysis using univariate analysis was performed.

Results

Twenty-three neonates underwent TR. There were no differences between TR and COR groups with regard to weight and gestational age. The distribution of associated anomalies was similar in both groups. The mean operative time was 149.4 and 179 minutes in TR and COR, respectively (P = .18). Three patients were converted to COR. There were 4 leaks in TR and 3 in COR (P = .728). Inversely, 2 patients in the TR group developed a stricture necessitating dilation as compared with 4 patients in the COR group (P = .414).

Conclusion

Thoracoscopic repair of TEF is safe and comparable with conventional open repair.     

Robotically assisted esophago-esophagostomy in newborn pigs

Purpose

Repair of esophageal atresia and tracheoesophageal fistula (TEF) in the newborn is challenging when done as an open procedure but only a few surgeons have attempted this with minimally invasive surgery (MIS). Surgical robots that hold MIS instruments have wrists and provide tremor filtration and motion scaling, which might be expected to facilitate complex procedures in small spaces such as an esophageal anastomosis in a newborn.

Methods

Seven newborn pigs weighing 2 to 3 kg were used as a model. The authors performed an esophageal resection and end-to-end anastomosis using the Zeus Microwrist Robotic Surgical System. The authors monitored the following data-Zeus robotic set-up time, operating time, esophageal dissection time, and anastomosis time. After 1 month, the animals were anesthetized to perform esophagram and than were killed.

Results

In these very small animals the space available for performing an anastomosis is very limited, approximately 2 cm³. Two pigs each died 18 days postoperatively. One animal could not eat and died during esophageal dilation. The second pig died of unrelated enteritis. Neither had evidence of anastomotic leak at autopsy. The esophagram of the 5 pigs that survived for 30 days showed no narrowing or proximal dilation in 2. In 3 there was some stenosis requiring dilation. Histopathology was done on each operated animal. Two of the anastomoses were well healed, and 5 showed only focal small ulceration.

Conclusions

Robotic assistance facilitates an MIS approach to the upper esophagus even in the limited space of the infant chest.     

Lack of distal esophageal contractions is a key determinant of gastroesophageal reflux disease after repair of esophageal atresia

Background/Purpose

The objective of this study is to investigate the characteristics of esophageal motor activity responsible for the development of gastroesophageal reflux (GER) in patients with esophageal atresia (EA).

Methods

The subjects consisted of 29 patients with EA (1 month to 19 years). Computerized esophageal manometry was conducted to investigate esophageal contractions at swallow. A topographic esophageal manometric analysis was conducted in each subject, providing 3-dimensional displays to reveal the pressure continuum representing esophageal contractions.

Results

Significant contractions in the middle esophagus just below the anastomosis were absent in all subjects. Contractions in the distal esophagus were conspicuously absent in 17 subjects. Of these 17, 6 had already undergone fundoplication, and 9 had symptomatic GER requiring fundoplication subsequent to this study. The remaining 12 patients had contractions in the distal esophagus and did not require medical/surgical intervention. A lack of distal esophageal contractions was significantly correlated with the development of GER (P < .001). There was a significant difference in esophageal acid exposure between the 2 groups (median, 38% vs 4%, P < .001).

Conclusion

Lack of distal esophageal contractions indicating an impaired clearing capacity is considered a potential key determinant of GER in patients with EA.     

Esophageal pathology in patients after treatment for head and neck cancer

Objective

To determine the prevalence of esophageal pathology following treatment for primary head and neck cancer (HNCA).

Study Design

Case series with planned data collection.

Setting

Academic medical practice.

Subjects and Methods

Subjects comprised HNCA survivors. Esophagoscopy was prospectively performed on 100 patients at least three months after treatment for HNCA. Patient demographics including cancer stage, cancer treatment, use of reflux medications, symptoms surveys, and esophageal findings were prospectively determined.

Results

The mean age of the cohort was 64 (± 10) years; 75 percent were male. The mean time between the end of treatment and endoscopy was 40 (± 51) months. Eighty-one percent of HNCA was advanced stage (3 or 4). The distribution of site of the primary HNCA was as follows: oropharynx (38%), larynx (33%), oral cavity (17%), unknown primary (10%), hypopharynx (1%), and nasopharynx (1%). Treatment modalities included surgery alone (15%), surgery with radiation (34%), radiation alone (6%), chemoradiation alone (24%), and chemoradiation with surgery (20%). The findings on esophagoscopy included peptic esophagitis (63%), stricture (23%), candidiasis (9%), Barrett metaplasia (8%), gastritis (4%), and carcinoma (4%). Only 13 percent had a normal esophagoscopy.

Conclusion

Esophageal pathology is extremely common in patients treated for HNCA. These findings support routine esophageal screening after HNCA treatment.     

Surgical treatment of esophagogastric dysfunction forty years after reverse gastric tube esophagoplasty for congenital esophageal anomaly

Background

In 1968, Burrington first described use of the reverse gastric tube esophagoplasty for esophageal replacement in children with esophageal atresia or acquired stenosis. There are few documented cases of long-term follow-up of these patients.

Case Report

We describe a 41-year-old female who presented with progressive dysphagia 40 years after reverse gastric tube for a congenital esophageal stenosis as an infant. Repeated endoscopic dilations were unsuccessful in relieving her symptoms, and she subsequently underwent a modified Ivor-Lewis esophagogastrectomy with resection of the reverse gastric tube and reconstruction using her remaining gastric remnant.

Conclusions

This report describes what we believe to be the longest recorded follow-up after reverse gastric tube esophagoplasty and highlights the potential for long-term complications after surgery for congenital anomalies.     

Maternal diabetes and risk of esophageal atresia

Background

The etiology of esophageal atresia is poorly understood. The incidence of some congenital malformations is increased in children of mothers with diabetes, but the role of maternal diabetes in esophageal atresia development in the infant is unknown. We hypothesized that maternal diabetes increases the risk of esophageal atresia in the infant.

Methods

A population-based, matched case-control study, nested within a cohort of neonates born in Sweden in January 1, 1982 through December 31, 2007, was undertaken. Conditional logistic regression was used to calculate relative risks, expressed as odds ratios with 95% confidence intervals. Adjustment for confounding was made through matching and by multivariable regression.

Results

Among 2,625,436 newborn infants in the study cohort, there were 780 cases of esophageal atresia, and 7,800 infants were matched and randomly selected as controls. Exposure to preexisting or gestational diabetes was more frequent in the mothers of the case group (n = 18; 2.3%) than in those of the control group (n = 103; 1.3%). The adjusted risk of esophageal atresia was 70 % higher among infants of women with diabetes than among women without diabetes (odds ratio, 1.7; 95% confidence interval, 1.0-2.9).

Conclusions

Maternal diabetes might increase the risk of esophageal atresia in the child.     

Radionuclide imaging study of long-term pulmonary function after lobectomy in children with congenital cystic lung disease

Purpose

We evaluated the long-term pulmonary function after lobectomy for congenital cystic lung disease, in both infants and children, using radionuclide imaging (RI).

Methods

We performed a retrospective review of 93 patients who underwent resection of cystic lung lesions between 1974 and 2001. The results of postoperative lung volume/perfusion scintigraphy at 1 (n = 64), 5 (n = 32), and 10 years (n = 18) after surgery (V1, 5, 10/Q1, 5, 10) and mean transit time (MTT—a marker for air-trapping) at 1, 5, and 10 years after surgery (MTT1, 5, 10) were compared with respect to age at operation, preoperative infection, underlying disease, and type of surgery.

Results

Patients who were younger than 1 year at the time of surgery showed a significantly lower MTT5 (1.09 ± 0.08) and MTT10 (1.15 ± 0.11) than patients who were older than 1 year at the time of surgery (MTT5, 1.49 ± 0.67; MTT10, 1.54 ± 0.33). The noninfected group had significantly higher Q10 and lower MTT10 values (P < .05) compared to the infected group. No significant differences were observed between patients with single lobe vs multiple lobe resection.

Conclusions

The optimal age for surgery in patients with congenital cystic lung disease appears to be less than 1 year.     

Esophageal smooth muscle reactivity is impaired in chronic reflux esophagitis by both receptor- and nonreceptor-mediated mechanisms

Aim

Esophagitis is associated with an impaired esophageal peristalsis. A few studies have been aimed at understanding the pathophysiology of abnormal peristaltic activity. The mechanism of impaired esophageal smooth muscle reactivity in the chronic gastroesophageal reflux (GER) model is investigated in vitro for the first time.

Materials and Methods

The chronic GER rat model was created by partial gastric outlet obstruction. The histopathological findings related to esophagitis were evaluated. Smooth muscle strips of the tunica muscularis mucosa of esophagus were studied in standard organ chambers. Carbachol- and KCl-induced contractile responses and serotonin- and papaverine- induced relaxant responses in both reflux and sham-operated control groups were determined.

Results

Histopathologically, chronic reflux esophagitis was observed in all specimens of the reflux group. Contractile (carbachol- and KCl-induced) smooth muscle responses were significantly decreased in the reflux group. When compared to control group, relaxant response of smooth muscle to serotonin was also significantly decreased in the reflux group. However, there was no difference in papaverine-induced relaxant responses between 2 groups.

Conclusions

Our study describes the effects of chronic GER on rat esophageal smooth muscle contractility in vitro. We found that both receptor- (carbachol, serotonin) and nonreceptor-mediated (KCl) esophageal smooth muscle reactivity were impaired in chronic reflux esophagitis. These changes may correspond to the functional motor abnormalities of the esophagus seen in patients with chronic reflux esophagitis.     

Upper Gastrointestinal Endosonography in Patients Evaluated for Liver Transplantation

Background

Endosonography (EUS), which merges endoscopic and ultrasound examinations, is a useful modality to display abnormal vessels that develop in the intrinsic circulation, frequently called “deep” varices. If these pathological veins exceed of 5 mm diameter, they significantly increase the risk of bleeding among patients with cirrhosis. In the most recent pilot study EUS proved useful to assess children for orthotopic liver transplantation (OLT).

Aim

We performed a cross-sectional study of EUS on 33 (22 males and 11 females) adult cirrhotic subjects being assessed for OLT.

Materials/Methods

We used an echoendoscope at 7.5 MHz/12 MHz/20 MHz to evaluate the esophagus and stomach, including “deep” periesophageal/perigastric varices (adjacent to the muscularis propria) and paraesophageal/paragastric varices (outside the muscularis propria). “Deep” varices were considered to be large if >5 mm.

Results

On endoscopy, 26 (79%) patients showed esophageal varices (EV), including 11 (33%) with large (>5 mm) varices. Gastric varices (GV) were observed in 13 (39%) subjects, with 3 patients displaying large (>5 mm) varices. On EUS large “deep” EV (both para and periesophageal) were observed in 12 (36%) subjects, among whom 5 (42%) did not have large varices on endoscopy. Large “deep” GV were found on EUS in 12 (36%) subjects. On endoscopy 4 of them (33%) showed no varices and 3 (25%) had small GV.

Conclusions

EUS offers a precise evaluation of portal hypertension in OLT candidates. “Deep” potentially dangerous varices, which are undetected with routine endoscopy, were noted in a significant proportion of patients. The role of EUS in prioritizing subjects for OLT must be evaluated in a prospective study.     

Feasibility of thoracoscopic U-clip esophageal anastomosis: an alternative for esophageal atresia reconstruction

Background

The authors propose that U-Clips can significantly decrease the technical difficulty of performing thoracoscopic esophageal reconstruction, thus, reducing operating time, the incidence of postoperative leak, and stricture rate.

Methods

After obtaining Institutional Animal Care and Use Committee approval, 3 4-kg female piglets underwent complete thoracoscopic esophageal transections. The esophagus was reconstructed thoracoscopically using S50 and S60 U-Clips over an 8F transanastomotic tube. Esophagrams were performed on postoperative day (POD) 7, 21, 44, and 77.

Results

Mean operating time was 57 minutes (45 to 75 min). Two of 3 piglets had no evidence of leak on POD 7 esophagrams. One animal had a small leak that resolved spontaneously on antibiotics. All 3 piglets tolerated a formula diet orally by POD 8. Over a 77-day survival period all 3 piglets had steady weight gain on an oral diet.

Conclusions

U-Clips are a feasible alternative to sutures for esophageal reconstruction in thoracoscopic surgery. Further study is warranted to investigate the full potential of U-Clips in minimally invasive pediatric surgery.