Image-guided percutaneous gastrostomy in neonates with esophageal atresia

Background

Neonates with esophageal atresia may require a gastrostomy before definitive repair. Most surgeons do this procedure using the Stamm technique through a laparotomy. The authors describe a new technique for percutaneous placement of a gastrostomy in these infants and report their preliminary results.

Methods

For children with esophageal atresia and a tracheoesophageal fistula (TEF), the air-filled stomach is localized fluoroscopically and accessed using a standard percutaneous technique. For those with pure esophageal atresia, a transhepatic needle is used to instil air into the stomach. Once the stomach is distended, the gastrostomy tube is inserted under fluoroscopy.

Results

Fourteen neonates with esophageal atresia had a percutaneous gastrostomy tube placed. Eleven had esophageal atresia and a TEF, and 3 had pure esophageal atresia with a gasless abdomen requiring the transhepatic approach. There were no intraoperative or major postoperative complications, but there were 5 minor early postoperative complications and 2 minor late postoperative complications.

Conclusions

Percutaneous gastrostomy insertion is a safe technique for neonates with esophageal atresia and can be used even in children with pure esophageal atresia who have a gasless abdomen. This technique does not require laparotomy and appears to be associated with a low rate of complications.     

Babies with esophageal and duodenal atresia: a 30-year review of a multifaceted problem

Purpose

The purpose of this study was to review newborns with esophageal atresia (EA) with and without distal tracheoesophageal fistula (TEF) combined with duodenal atresia (DA) or duodenal stenosis (DS) (web, windsock, diaphragm) to determine which clinical features and treatments give the best results.

Methods

Twenty-four newborns were reviewed from 1971 to 2000 inclusive. Seven had EA and 17 had EA with TEF; 15 had DA and 9 had DS. One died after receiving only a gastrostomy. Seven underwent repair of both defects in 1 stage, whereas 16 were repaired separately.

Results

Eighteen of 24 (75%) survived. The EA or EA with TEF was repaired first in 5, but the DA or DS was initially overlooked in 4 and 2 died. The DA or DS was repaired first in 11, and all survived. Of the 7 in whom both repairs were done at same setting, 4 survived. Of 6 nonsurvivors, 5 were repaired. Mortality from EA was greater than EA with TEF, and DA was greater than DS. Associated anomalies in 18 (75%) of 24 did not affect survival.

Conclusions

Staged repair (ideally within 1 week) is a safe suitable method of management. In EA, the coexistence of DA or DS must be considered because delay in diagnosis may adversely affect outcome. Mortality is a multifactorial phenomenon.     

Association of Shah-Waardenburgh syndrome: a review of 6 cases

Shah-Waardenburg syndrome (SWS) is a neurocristopathy and is characterized by Hirschsprung's disease (HD), deafness, and depigmentation of hairs, skin, and iris.

Objective

The aim of the article is to study the relative frequency of associations in 6 consecutive cases of SWS.

Methods

A review of 6 consecutive patients with SWS was performed to study the frequency of various components of the syndrome.

Results

Six patients had features of SWS. All patients had HD; of these, 3 had rectosigmoid HD, whereas 3 had extended HD. All patients had white forelock of hairs with skin depigmentation. One patient had sensorineural deafness, whereas other babies were less than 1 year, and thus, full evaluation of hearing deficiency was not assessed. Three patients had blue eyes, whereas other babies had normal iris pigmentation. Skin depigmentation was noted in 5 of the 6 patients. Three babies were seriously malnourished and showed higher association of enterocolitis.

Conclusion

Shah-Waardenburg syndrome is an uncommon association of HD. Depigmentation with a white forelock and skin manifestations are common, whereas blue iris, long segment disease, and enterocolitis are present in nearly half of the patients.     

Long gap esophageal atresia and esophageal replacement: moving toward a separation?

Background/Purpose

Treatment of long gap esophageal atresia (EA) is still a major challenge. Gastric transposition and colon interposition are the 2 most popular choices for esophageal replacement, but there is general agreement that the child’s own esophagus is the best. The aim of the study was to critically evaluate the feasibility and outcome of primary repair of long gap EA with or without tracheoesophageal fistula (TEF) by direct esophago-esophageal anastomosis as the only technique.

Methods

Seventy-one neonates with EA+/−TEF were considered. Nineteen cases were classified as long gap (≥3 cm). All infants underwent either primary or shortly delayed repair. In the latter group, a gastrostomy was performed along with an x-ray evaluation of the gap a few days before surgery (mean age, 46.4 days). To avoid disruptive anastomotic force, all infants were kept paralyzed and mechanically ventilated for an additional 6 days after esophageal anastomosis. Before starting feeding, postoperative esophagogram was done on day 7. Endoscopy was done routinely, starting 1 month after surgery; pH monitoring was conventionally performed at 1 year of age or even earlier, should gastroesophageal reflux disease (GERD) be suspected. Follow-up ranged from 11 months to 7 years.

Results

In all 19 long gap EA infants an esophago-esophageal anastomosis was performed. Six of them (31%) required an anterior esophageal flap to bridge residual gap. Complications included minor anastomotic leak in 2 cases and anastomotic stricture (<5mm) in 12 (80%) cases, which were treated with an average of 5 dilatations (1 of which with resection of the stricture). GERD occurred in 8 cases (53.3%), of which, 3 required fundoplication. None of the patients had esophageal swallowing difficulties or persistent dysphagia. Two children experienced food aversion. Mean hospital stay was 66.2 (22 to 230) days. There were 4 deaths (very low birth weight, 1; associated anomalies, 1; and late sepsis, 2).

Conclusions

Considering heat gap determination remains imprecise, it seems possible to conclude that in a well-established tertiary care level referral center: (1) long gap EA could be treated successfully with primary repair and anastomosis; (2) strictures and GER represent the most frequent postoperative problem, but additional procedures required seem “acceptable” to maintain the patient’s own esophagus and avoid replacement; (3) esophageal substitution in long gap EA should be reserved for cases in which a previous attempt of esophageal reconstruction failed.     

Esophageal replacement in the neonatal period in infants with esophageal atresia and tracheoesophageal fistula

Aim

The aim of the study was to assess the outcome after esophageal replacement using gastric pull-up performed in critically ill neonates with esophageal atresia (EA) and tracheoesophageal fistula.

Methods

During 1998 to 2005, gastric transposition was performed in 27 neonates (mean birth weight, 2.32 kg [1.86-3.0 kg]; mean age, 6.08 days) for post-EA and tracheoesophageal fistula leaks in 17, long gap in 6, and pure EA in 4, using transhiatal route in all. Pyloromyotomy as the drainage procedure was added for all 27 neonates. Patients were followed up at 3, 6, and 12 months for clinical evaluation, gastric clearance, duodenogastric reflux, and gastric pressure profile.

Results

Six neonates had ongoing serious chest infection, 3 had lung collapse, and 2 had associated congenital heart disease. Postoperative elective ventilation was provided to all neonates for 2 to 40 days (mean, 10.6 days). Nine neonates developed postoperative leaks in the neck; all healed spontaneously before discharge. Mean hospital stay was 32.6 days (range, 9-87 days). Four newborns died on postoperative days 9, 13, 15, and 29 because of existing severe sepsis in 3 and major congenital heart disease in 1. Functional evaluations were done at 3, 6, and 12 months postoperatively. Values at 6 months revealed normal gastric emptying in 16 of 23, presence of duodenal gastric reflux in 11 of 23, and mass contractions with significant rise in intragastric pressure after bolus feeds in 16 of 23 cases. Values at 12months revealed normal gastric emptying in 14 of 20, presence of duodenal gastric reflux in 8 of 20, and mass contractions with significant rise in intragastric pressure after bolus feeds in 13 (65%) of 20cases.

Conclusion

Gastric transposition could be a lifesaving alternative to diversion, even in the critically ill newborns after major leaks. However, it requires technical surgical expertise and an effective pain relief and neonatal intensive care.     

Mental health and psychosocial functioning in adolescents with esophageal atresia

Purpose

We examined mental health and psychosocial functioning in adolescents with esophageal atresia (EA) and searched for predictors of impaired outcome.

Methods

The study group comprised 21 adolescents with EA and 1 or both parents. A comparison group comprised 36 adolescents from the general population. Mental health, self-esteem, psychosocial functioning, and parental/family functioning were assessed by standardized questionnaires and semistructured interviews. Physical health was assessed by growth and clinical symptoms.

Results

Mental health and psychosocial functioning did not differ from the comparison group. Seven of 21 EA adolescents had special education. Dilatations of esophagus, birth weight, well-being, and maternal psychological distress were prognostic factors predicting mental health. Height, birth weight, well-being, dissociative symptoms, and family strain were prognostic factors predicting psychosocial functioning.

Conclusion

Adolescents with EA adjusted well, and mental health and psychosocial functioning did not differ from controls. Dilatations of esophagus and birth weight were significant predictors of mental health and psychosocial functioning.     

Repair of long gap esophageal atresia without anastomosis

Background/Purpose

Repair of long gap esophageal atresia represents a challenge. Several different techniques may be used. We describe 5 cases of long gap esophageal atresia managed successfully with suture approximation without anastomosis.

Methods

Retrospective review identified 5 newborns (4 males; 1 female) with long gap esophageal atresia treated with suture approximation and subsequent endoscopic and fluoroscopic placement of string for guided dilatations. Three babies had esophageal atresia without fistula, and 2 had the common type with proximal atresia and distal tracheoesophageal fistula. The babies with pure esophageal atresia had delayed repair, and those with the common type had repair 2 days after birth. All had a gastrostomy for feedings.

Results

All 5 babies recovered uneventfully. Three babies had spontaneous fistulization that allowed easy placement of guide wire and string. Two other babies required endoscopic and fluoroscopic combined fistula creation bypassing a long needle from the upper pouch to the lower one. Initially, all had string-guided dilatations that were subsequently converted to balloon dilatations. All babies had a functioning esophagus and did not need any further surgical intervention. An average of 8 postoperative dilatations were needed.

Conclusions

The baby's own functional esophagus is superior to any esophageal replacement. Familiarity with different techniques to preserve it is therefore important. Suture approximation without anastomosis is a safe technique that can be applied to long gap esophageal atresia. The downside of this technique is a prolonged hospital stay, multiple dilatations, prolonged fasting, and therapy to learn to eat orally.     

Surgical outcomes of esophageal atresia without fistula for 24 years at a single institution

Purpose

The aim of the study was to evaluate the surgical outcome of esophageal atresia (EA) without fistula for 24 years at a single tertiary center for pediatric surgery.

Methods

The study used a retrospective chart review of infants diagnosed with EA without fistula between 1981 and 2005.

Results

Of 33 patients with EA without fistula, 31 charts were available. Mean birth weight was 2327 g (range, 905-3390 g), and 71% were male. Most common associated anomalies were cardiac (n = 6; 19%) and renal (n = 5; 16%), followed by vertebral (n = 4; 13%) and anorectal (n = 2; 7%). The median initial esophageal gap was 5 vertebral bodies. Six had a primary repair, and 25 patients had esophageal replacement at a median age of 7 months. This involved gastric transposition in 20 (1 followed failed jejunal interposition), colonic interposition in 5, jejunal interposition in 1 (after a failed colonic), and repair at another center in 1. With a median review of 9 years, 21 patients had long-term sequelae with the need for multiple further surgical procedures including an antireflux procedure in 5. One patient died.

Conclusions

Management of EA without fistula remains challenging. Most patients required staged treatment that included esophageal replacement. The frequency of late complications indicates the need for programmed long-term review.     

Reflux in esophageal atresia, tracheoesophageal cleft, and esophagocoloplasty: Bianchi's procedure as an alternative approach

Purpose

Fundoplication has been used successfully to treat gastroesophageal reflux (GER) in the pediatric population. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurological impairment, and young infants. However, the results are poorer with children with severe pathologic lesion associated to reflux: tracheoesophageal cleft, esophagocoloplasty, and esophageal atresia (EA) with severe dysmotricity. In neurologically impaired children with neuromuscular incoordination and GER, Bianchi has proposed total esophagogastric dissociation (TED). The authors report the use of esophagogastric or esocologastric dissociation to control reflux in children with severe GER in other situations, such as EA, burn esophageal lesions having led to coloplasty and severe esotracheal cleft.

Methods

The authors reviewed the patients operated on for an esogastric or cologastric disconnection between 1997 and 2002. It is a single center retrospective study. The initial diagnosis, previous surgical procedure, postoperative course, and follow-up results were studied.

Results

Between September 1999 and June 2003, 13 TEDs were performed in 6 boys and 7 girls. The mean age for TED procedure was 35 months (range 14 days to 218 months). Indication for TED was severe persistent reflux in, respectively, 9 cases of EA (7 with coloplasty and 2 with preservation of the native esophagus after atresia repair, associated in 1 case with an esotracheal cleft), 2 cases of esotracheal cleft type III, and 2 cases of esophagocoloplasty for caustic burns. Six patients had undergone previous fundoplications (1-4 procedures) that failed, whereas the remaining patients underwent TED as the primary antireflux procedure.The average follow-up was 26 months (range 1 month to 4 years). There were no complication during the immediate postoperative course. Three children died at 3, 4, and 12 months after the procedure from acute respiratory failure.Respiratory status was improved in 8 children, and recurrent bronchitis was noted in 1 child. Regarding the digestive status, gastrostomy was closed at 18 and 24 months in 2 children, and partial nocturnal enteral nutrition (200 to 900 mL/d) through the gastrostomy remains necessary in the other children.

Conclusion

Total esophagogastric dissociation procedure improves the respiratory consequences of severe GER, particularly in children for whom other surgical treatments have failed. The long-term safety of this operation remains to be determined especially regarding the consequences of a gastrointestinal Roux-en-Y loop procedure.     

Type A esophageal atresia: a critical review of management strategies at a single center

Purpose

The purpose of was to study the short- and long-term outcomes in the management of isolated esophageal atresia with different operative strategies.

Methods

All patients undergoing type A atresia repair over a 15-year period were included. Demographic data, birth weight, gestational age, incidence of associated anomalies, management, and long-term outcomes were studied.

Results

Fifteen patients with type A atresia (9 male) were treated in the study period. The mean gestational age was 35.5 weeks (range, 27-39 weeks), and the mean birth weight was 2179 g (range, 670-3520 g). Eight babies had associated anomalies. Thirteen patients underwent gastrostomy as the initial procedure, and 2 underwent the Foker procedure. In the delayed management group, 9 patients underwent primary anastomosis, with 2 patients needing proximal pouch myotomy. Two patients underwent a Collis gastroplasty. Two patients underwent a cervical esophagostomy and a gastric tube replacement at 4 months and 1 year, respectively. Eight patients (60%) in this group had anastomotic leaks. All patients are currently on prokinetics and proton pump inhibitors. Seven required antireflux surgery. The median length of hospital admission was 4 months (range, 3-19 months). The native esophagus was preserved in 13 (85%) of 15 babies. All patients are alive, and 14 of 15 are capable of feeding orally.

Conclusions

Type A esophageal atresia continues to be associated with significant morbidity despite advances in surgical technique and intensive care.     

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.     

Feeding status after pediatric laryngotracheal reconstruction

Objective

To determine the influence of pediatric laryngotracheal reconstruction (LTR) on postoperative feeding status and longitudinal weight gain after surgery.

Study Design

Case series with chart review.

Setting

Tertiary care pediatric hospital.

Subjects and Methods

We identified 30 consecutive pediatric patients undergoing LTR from November 2005 to October 2008. Demographics, stenosis grade, surgical procedure, decannulation status, preoperative feeding status and weight, discharge feeding status, and weights at follow-up were collected. Weights were plotted on standardized growth charts at surgery, during the early postoperative period (1-3 months), and during the late postoperative period (10-14 months). Growth percentiles were compared by the use of Wilcoxon signed rank test.

Results

Twenty-eight patients (97%) maintained or advanced their feeding status after LTR. Twenty-one patients (72%) were oral feeders at surgery. All of these patients continued the same oral diet postoperatively. Five patients (17%) were dependent on gastrostomy before and after surgery. Three patients (10%) were fed via naso- or orogastric tubes at surgery. Two of these patients were discharged on an oral diet, and one required a gastrostomy tube. The median growth percentiles at the time of surgery, early postoperative, and late postoperative periods were nine, 18, and 32, respectively. Differences between percentiles at the time of surgery compared with early (P = 0.081) and late follow-up (P = 0.074) were not significant. In patients who were not dependent on gastrostomy, there was a significant increase in growth percentile at early follow-up (P = 0.026).

Conclusion

The performance of LTR does not influence feeding status. An early increase in median growth percentile is observed in oral feeders, but overall long-term median growth percentiles remain stable after LTR.     

Preoperative tracheobronchoscopy in newborns with esophageal atresia: does it matter?

Background/Purpose

Despite surgical refinements, perioperative use of tracheobronchoscopy (TBS) as part of surgical approach to esophageal atresia (EA) is still controversial. The purpose of this study was to evaluate the influence of preoperative TBS in newborns with EA in preventing complications and improving diagnosis and surgical treatment.

Methods

In the period ranging from 1997 to 2003, 62 patients with EA underwent preoperative TBS. The procedure was carried out with flexible bronchoscope maintaining spontaneous breathing. When a wide carinal fistula was found, this was mechanically occluded by Fogarty catheter and cannulated with rigid bronchoscopy. Type of EA, surgical procedure variations caused by TBS, and associated anomalies not easily detectable were recorded.

Results

Before TBS, the Gross classification of the 62 patients was as follows: type A, 9 patients; type B, none; type C, 51 patients. At TBS, however, 3 of 9 type A patients had an unsuspected proximal fistula (type B). These 3 patients, plus the 2 with H-type fistula, were repaired through a cervical approach. In 4 patients, previously undetected malformations of the respiratory tree (2 aberrant right upper bronchus and 2 hypoplastic bronchi) were found at TBS. Carinal fistulas in 14 type C patients were occluded by Fogarty catheter to improve ventilation during repair. No complications were observed. Overall, TBS was clinically useful in 28 (45.2%) of 62 patients, including 15 (24.2%) of 62 infants in whom it was crucial in modifying the surgical approach.

Conclusion

Tracheobronchoscopy is a useful and safe procedure and should be recommended in tertiary centers for babies with EA before surgical repair.     

Laparoscopic vs percutaneous endoscopic gastrostomy tube insertion: a new pediatric gold standard?

Background/Purpose

Gastrostomy tube insertion is frequently performed in children. Percutaneous endoscopic gastrostomy (PEG) insertion, considered by many to be the “gold standard,” is unavoidably associated with a risk of intestinal perforation and frequently requires a second anesthetic for its replacement with a low-profile “button.” We hypothesized that a laparoscopic technique with low-pressure insufflation would yield comparable outcomes, a lower procedural complication rate, and require fewer anesthetics per patient.

Methods

A retrospective review of all surgeon-placed gastrostomy tubes (exclusive of those associated with fundoplication or other procedures) between January 2002 and December 2003 was undertaken. Data collected included type of procedure (PEG vs laparoscopic), indication, patient demographics (including neurologic comorbidity), operative time, complications (procedure-specific and nonspecific), and number of procedural anesthetics to “achieve” a low-profile tube. Groups were compared by univariate and multiple logistic regression analyses.

Results

One hundred nineteen gastrostomy tubes (26 laparoscopic = 21.8%) were inserted. The PEG and laparoscopic gastrostomy groups were comparable from the perspectives of age, size, indications for tube placement, and operative time. The complication rate after PEG placement was significantly higher than after LG (14% vs 7.7%; P = .023), and 72 (77.4%) of PEG patients required a second anesthetic for tube change.

Conclusions

Laparoscopic gastrostomy tube insertion is safe and easy to perform, with outcomes comparable to that of PEG tube insertion. It obviates the need for a second procedural anesthetic and may emerge as the gold standard for gastrostomy tube placement.     

The efficacy of ozone therapy in experimental caustic esophageal burn

Introduction

Ozone has been proposed as an antioxidant enzyme activator, immunomodulator and cellular metabolic activator. This study was designed to investigate the efficacy of ozone therapy in the prevention of esophageal damage and stricture formation developed after esophageal caustic injuries in the rat.

Materials and Methods

Forty-five rats were allocated into three groups; sham-operated, un-treatment and treatment groups. Caustic esophageal burn was created by instilling 15% NaOH in the distal esophagus. The rats were left untreated or treated with 1 mg/kg/day ozone intraperitoneally. All rats were sacrificed at 28 days. Efficacy of the treatment was assessed by measuring the stenosis index (SI) and histopathologic damage score, and biochemically by determining tissue hydroxyproline content (HP), superoxide dismutase (SOD), glutathione peroxidase (GPx), malondialdehyde (MDA) and protein carbonyl content (PCC) in esophageal homogenates.

Results

Whereas seven (47%) rats died in the un-treatment group, all rats in the sham-operated and the treatment group survived during the study. SI, the histopathologic damage score, was significantly lower in the ozone-therapy group than the un-treatment group. HP levels were significantly higher in the un-treatment group than the group treated with ozone. Caustic esophageal burn increased MDA and PCC levels and also decreased SOD and GPx enzyme activities. In contrast, ozone therapy decreased the elevated MDA and PCC levels and also increased the reduced SOD and GPx enzyme activities.

Conclusion

Ozone has a preventive effect in the development of fibrosis by decreasing tissue damage and increasing the antioxidant enzyme activity in an experimental model of corrosive esophageal injury.     

Comparison of pharyngeal stenosis between hypopharyngeal patients undergoing primary versus salvage laryngopharyngectomy

Objective

To survey the risk factors of pharyngeal stenosis after laryngopharyngectomy in patients with advanced hypopharyngeal cancers.

Study Design

Case series with chart review.

Setting

Tertiary medical center.

Subjects and Methods

Pharyngeal stenosis rates and risk factors were compared between two groups of laryngopharyngectomy patients: a group that underwent concurrent chemoradiation therapy followed by surgical salvage, and a surgery initiated group with adjuvant chemoradiation.

Results

Of 160 patients, 25 developed pharyngeal stenosis, which was diagnosed by barium esophagography with a pooling of barium contrast above the neopharyngeal inlet. These patients required nasogastric tube feeding or gastrostomy feeding because an oral liquid diet could not meet their nutritional needs. Primary closure and old age were risk factors for pharyngeal stenosis. Pharyngeal stenosis did not affect survival in patients with advanced hypopharyngeal cancer who underwent laryngopharyngectomy.

Conclusion

Primary closure reconstruction is discouraged in patients over the age of 65 years.     

Can laparoscopic antireflux surgery improve the quality of life in children with neurologic and neuromuscular handicaps?

Purpose

Children with neurologic and neuromuscular handicaps frequently have various symptoms related to gastroesophageal reflux (GER) disease. The long-term efficacy of antireflux surgery remains controversial in such children with GER. The clinical results of such patients who underwent laparoscopic fundoplication were examined in the current study.

Methods

Between 1997 and 2003, laparoscopic fundoplication was performed in 56 handicapped children (mean age, 6 years), and gastrostomy was performed concurrently in 52. The main symptoms were emesis/hematemesis in 40 and respiratory symptoms, including repeated respiratory infection and distress, in 31.

Results

There were no severe postoperative complications or operative mortality. Emesis/hematemesis was controlled adequately in those without recurrence. Respiratory symptoms were controlled unsuccessfully in 16 patients (52%), 8 of whom required further respiratory care including nasal airway tube, tracheostomy, and laryngotracheal separation. Recurrence of GER disease occurred in 10 patients, 7 of whom underwent a second Nissen fundoplication successfully. Thirteen died within the median follow-up period of 14 months.

Conclusions

Laparoscopic fundoplication is effective in controlling emesis/hematemesis, but its efficacy is limited in terms of respiratory problems in handicapped children. Further refinements in diagnostic and treatment strategies are mandatory to improve the quality of life in such patients.     

Gastric transposition in children--a 21-year experience

Purpose

The purpose of this study was to analyze the outcome in 173 children (104 M, 69 F) undergoing transposition since 1981.

Methods

The most common indications for esophageal replacement included failed repair of different varieties of esophageal atresia (127), caustic injury (23), and peptic strictures (8). A total of 81% of the patients were referred from other hospitals (50% from other countries). Age at operation ranged from 7 days to 17 years. The gastric transposition was performed using blunt mediastinal dissection only in 90 patients with an additional 81 patients undergoing lateral thoracotomy. The retrosternal position was used in 2 patients.

Results

There were no graft failures including those who had previously failed gastric tube or Scharlilike operations. Anastomotic leakage occurred in 12% (all but 1 resolved spontaneously). Anastomotic stricture requiring dilatation occurred in 19.6%. Half of these patients had previous caustic esophageal injury. There were 9 deaths in the group (5.2%). One death occurred intraoperatively, 5 in the early postoperative period, and there were 3 late deaths. In more than 90% of our patients, the outcome was considered good to excellent in terms of absence of swallowing difficulties or other gastrointestinal symptoms. Many, however, preferred to eat small frequent meals. Poor outcome was particularly associated with multiple previous attempts at esophageal salvage. There was no deterioration in the function of the gastric transposition in those patients followed up for more than 10 years.

Conclusions

Gastric transposition for esophageal substitution is an acceptable procedure. It is attended by 5% mortality and a 12% leak rate. A total of 19.6% of the patients needed anastomotic dilatation for stricture. In the long term, good function has been maintained. Gastric transposition compares favorably with alternative methods of esophageal replacement.     

Management of patients with combined tracheoesophageal fistula,esophageal atresia,and duodenal atresia

INTRODUCTION

Patients with combined esophageal atresia (EA), tracheoesophageal fistula (TEF), and duodenal atresia (DA) pose a rare management challenge.

PRESENTATION OF CASE

Three patients with combined esophageal atresia (EA), tracheoesophageal fistula (TEF), and duodenal atresia safely underwent a staged approach inserting a gastrostomy tube and repairing the EA/TEF first followed by a duodenoduodenostomy within one week. None of the patients suffered significant pre- or post-operative complications and our follow-up data (between 12 and 24 months) suggest that all patients eventually outgrow their reflux and respiratory symptoms.

DISCUSSION

While some authors support repair of all defects in one surgery, we recommend a staged approach. A gastrostomy tube is placed first for gastric decompression before TEF ligation and EA repair can be safely undertaken. The repair of the DA can then be performed within 3–7 days under controlled circumstances.

CONCLUSION

A staged approach of inserting a gastrostomy tube and repairing the EA/TEF first followed by a duodenoduodenostomy within one week resulted in excellent outcomes.     

Gastrostomy insertion in children: percutaneous endoscopic or percutaneous image-guided?

Background/Purpose

Gastrostomy insertion in children can be performed in many ways, but which is the best technique remains uncertain. This study evaluates the outcome of percutaneous endoscopic gastrostomy (PEG) and image-guided gastrostomy (IG).

Methods

We reviewed children who had either PEG (n = 136) inserted by pediatric surgeons or IG (n = 195) inserted by interventional radiologists in our hospital between May 2004 and July 2008. Gastrostomy-related complications were given scores ranging from 20 for major complications (eg, peritonitis, gastrointestinal bleed, and visceral injury) to 1 for minor (eg, site infection and tube migration), and total score per month of follow-up was calculated per patient.

Results

Conversion to laparoscopic or open gastrostomy was more frequent in PEG versus IG (P = .001). Fewer PEG patients (28%) had complications than did IG (47%) (P = .001). One PEG patient developed a gastrocolic fistula. In the IG group, 2 patients had transverse colon puncture, 1 had intraperitoneal tube detachment, and 1 had upper gastrointestinal bleeding. When scored and adjusted by length of follow-up, PEG had lower scores compared with IG, indicating a better outcome (P = .03). These findings were supported by zero-inflated Poisson regression analysis.

Conclusion

Major complications were rare and observed more frequently after IG. Minor complications were observed in both procedures but were significantly less common in PEG.