Thoracoscopic elongation of the esophagus in long gap esophageal atresia

Long gap esophageal atresia in which a primary anastomosis cannot be achieved remains a challenge. Elongation of the esophagus by traction on the 2 ends has been previously described. With the advent of thoracoscopic repair of esophageal atresia, there have thus far been no reports of thoracoscopic repair of long gap esophageal atresia. This paper describes the first successful repair of long gap esophageal atresia by thoracoscopic traction of the 2 esophageal ends and delayed thoracoscopic anastomosis.     

Heterotopic pancreas of the esophagus and stomach associated with pure esophageal atresia

Esophageal atresia with or without tracheoeosphageal fistula is a frequent congenital malformation that may be associated with other congenital anomalies. The combination of heterotopic pancreas of the esophagus and pure esophageal atresia, however, is rare. We treated a patient with esophageal atresia without tracheoesophageal fistula (type A) associated with heterotopic pancreas of the esophagus and stomach who developed a gastric perforation.     

Successful two-stage thoracoscopic repair of long-gap esophageal atresia using simple internal traction and delayed primary anastomosis in a neonate: report of a case

The optimal method of treating long-gap esophageal atresia has not been established; however, the native esophagus is recognized as one of the best materials to use for bridging a long gap. Several case reports describe long-gap esophageal atresia being treated successfully via thoracotomy, by applying external traction sutures to the proximal and distal ends of the esophagus, thereby gradually elongating the esophagus prior to delayed primary anastomosis. However, this method carries a risk of infection and disruption of the esophageal ends. We devised a simple method of internal traction for esophageal elongation, which we performed as a two-step thoracoscopic procedure to treat a neonate with long-gap esophageal atresia.     

Early primary repair of long gap esophageal atresia: the VATER operation

Despite the numerous approaches described for the management of neonates with "long gap" esophageal atresia, controversy still exists as to the preferred method. Delayed primary anastomosis is probably the most frequently adopted practice, but often the native esophagus is abandoned, and the long gap is bridged by some form of esophageal replacement. A case is reported of a 1.38-kg newborn with pure esophageal atresia and a long gap undergoing early primary repair. The technique used in this patient and the various options available for management of long-gap esophageal atresia are discussed.     

Barotraumatic esophageal perforation by explosion of a carbonated drink bottle

We report a case of barotraumatic esophageal perforation caused by the explosion of a carbonated beverage containing plastic bottle into the mouth. A 6-year-old girl presented with sudden sharp pain in her mouth and upper abdomen after outburst of the plastic bottle. A computed tomography scan showed massive pneumomediastinum with diffuse edematous esophageal wall thickening and subcutaneous emphysema primarily in the neck. An esophagogram revealed a perforation of the middle portion of the esophagus with extravasation of contrast on left side. Surgical repair was performed successfully. The patient was discharged on postoperative day 15 after an uneventful postoperative course.     

Dynamic esophageal lengthening for long gap esophageal atresia: experience with two cases

This report describes two infants with long gap esophageal atresia managed by dynamic esophageal lengthening. Preliminary traction on the atretic ends of the esophagus permitted subsequent primary anastomosis under significant tension. One patient has done well, while the other developed an anastomotic stricture requiring resection. The esophagus was preserved in both infants.     

Esophageal atresia treated by electromagnetic bougienage and subsequent repair

There are some infants with esophageal atresia with or without tracheoesophageal fistula in whom the esophageal segments are too far apart to allow safe primary anastomosis without tension. During the past 20 yr the most widely used approach in these cases has been temporary marsupialization of the blindly ending upper esophagus to the neck, followed later by interposition of a segment of colon.¹ Howard and Myers² introduced manual bougienage for the upper pouch to elongate it and accomplish a delayed primary anastomosis. This technique was later used with some success in other institutions.³ Rehbein⁴ placed bougies in both esophageal segments and applied traction sutures threaded through the ends of the pouches that were pulled together slowly.This paper describes another method used in four infants with esophageal atresia. Metal bougies (“bullets”) were placed into the two ends of the esophagus. An electromagnetic field was then used to pull the bullets together to elongate the esophageal ends in order to allow esophageal anastomosis, which had been impossible previously. Cases 1 and 2 were discussed in a previous report⁵ and therefore will not be described in as much detail as Cases 3 and 4. Certain refinements in the method were developed in treating Cases 3 and 4. For example: (1) The sump suction tube attached to the upper-pouch bullet was brought out through a lateral pharyngotomy instead of the nose. (2) The stem of the lower-pouch bullet was brought through a small separate stab incision in the midline to direct it straight upward. Leakage around the gastrostomy site proved troublesome when it was brought through the same opening as the gastrostomy tube. (3) The lower-pouch bullet was placed “by feel” into the distal esophagus, not requiring anesthesia. Initially this was done under direct endoscopic visualization using anesthesia. (4) Placing of the lower-pouch bullet, which has a flexible steel stem, was accomplished by sliding a rigid metal tube over the flexible cable, using this as a handle to direct the bullet into the distal esophagus.     

A new method of primary engineering of esophagus using orthotopic in-body tissue architecture

PurposeTissue engineering of esophagus is required for management of long-gap esophageal atresia (LGEA). Collagenous connective tissue membranes fabricated by in-body tissue architecture (iBTA), called biosheets, can repair esophageal defects and generate tissues similar to native esophagus. However, iBTA requires second-stage surgery because of heterotopic preparation of biosheets. Our aim was to develop orthotopic iBTA for primary engineering of the esophagus by interposing a tubular mold to the esophageal defect.MethodThe cervical esophagus of six rats was transected. An acrylic tube (internal diameter 2.6 mm, length 7.0 mm) was inserted and fixed between the ends of the upper and lower esophagus, and a 3 mm-long esophageal defect was created. Four weeks later, the rats were sacrificed for histological analysis.ResultsPostoperatively the rats could intake liquid food. After four weeks, the esophageal defects were filled with regenerated tissues. Histologically the new esophageal walls stained positive for collagen type I. The inner surfaces were covered with stratified squamous epithelium that expressed pan-cytokeratin. In only one of six rats, regeneration of muscular-like tissue was suggested by positive immunohistochemical staining for desmin.ConclusionOrthotopic iBTA can regenerate a substitute esophagus with esophageal epithelium and collagenous wall. This technique may be a novel treatment for esophageal atresia with gaps of various lengths including LGEA.     

Congenital esophagobronchial fistula treated with thoracoscopic assisted surgery

A case of congenital esophagobronchial fistula in a 58-year-old woman was described. The patient had presented with repeated attacks of pulmonary infection from her childhood and had a history of recurrent cough after eating or drinking. Preoperative examinations including esophagogram by barium swallow revealed existence of a fistula between the upper thoracic esophagus and the right B3 bronchus. The fistula was recognized as type I of Braimbridge classification. Thoracoscopic assisted fistulectomy and diverticulectomy for esophagobronchial fistula with esophageal diverticulum were performed. The neck of the diverticulum and the fistula were divided with endo-stapling technique. Intraoperative esophagoscopy was found to be useful for the definite localization and complete excision of the fistula and the diverticulum and the avoidance of stenosis of the esophagus. Postoperative course was uneventful. It is to be considered that the present thoracoscopic assisted procedure with intraoperative esophagoscopy can be used as a standard operative procedure for esophagobronchial fistula with esophageal diverticulum.     

Esophageal atresia, duodenal atresia, and unilateral lung agenesis: a case report

The association of pure esophageal atresia, duodenal atresia, and unilateral lung agenesis has not been reported previously. Here the authors present a case of a newborn with this constellation of anomalies that underwent staged repair. The primary principle guiding treatment was the avoidance of iatrogenic injury to the single lung. Therefore, the order of operations proceeded as follows: (1) placement of a decompressing gastrostomy tube, (2) repair of the duodenal atresia, and (3) repair of the esophageal atresia. The congenital closed loop obstruction caused by the esophageal and duodenal atresias was beneficial in that it resulted in growth by stretching of the distal esophagus, allowing a tension-free primary repair of the esophageal atresia.     

The effect of intrauterine esophageal ligation on growth of fetal rabbits

Babies with pure esophageal or duodenal atresia weight less than normal babies at birth. Whether this is due to the obstruction to fetal swallowing or some other cause is not known. To determine how intrauterine interruption of swallowing affects fetal growth, we developed a model of esophageal atresia in the fetal rabbit. Twenty-five time-mated rabbits at 24 days gestation were anesthetized with halothane and ketamine. The uterus was exposed through a midline abdominal incision. The head and neck of the fetus in the distal end of one horn were isolated through a 2-cm hysterotomy. Biparietal diameter (BPD) was measured and the esophagus was isolated and ligated through a midline cervical incision. The fetus in the distal end of the opposite horn underwent sham operation. Four days later, cesarean section was done. The newborn rabbits were weighed, and crown/rump length and BPD were measured. Ligation of the esophagus was confirmed by re-exploration of the neck. Three does died under anesthesia and two aborted. From the remaining 20, 156 fetuses were recovered, of which 135 were alive. One set of operated fetuses was dead, leaving 19 pairs for analysis. There was a statistically significant reduction in weight gain (31.7 +/- 1.3 g to 29.1 +/- 0.9 g, P less than 0.05) following interruption of the esophagus but linear growth was unchanged. Obstruction to normal fetal swallowing may account for the low birth weight with normal head circumference reported in babies with esophageal and duodenal atresia.     

Benefits of the thoracoscopic approach for short- or long-gap esophageal atresia

OBJECTIVE: To evaluate the feasibility and results of thoracoscopy in various types of esophageal atresia (EA). MATERIALS AND METHODS: From April 2001 to August 2002, 5 patients with EA were treated by thoracoscopy. Their mean gestational age was 38 weeks and mean birth weight was 2700 g. Two patients had short-gap atresia with tracheo-esophageal fistula (type III according to Ladd's classification). Three had long-gap atresia: 2 with low fistula to the carina (type IV) and 1 without fistula (type I). Patients were placed in a prone position with the right side elevated at 80 degrees . Four intrapleural ports were necessary. The fistula when present was dissected and sutured with intrathoracic knots and esophageal anastomosis performed in the same manner. RESULTS: Positive airway pressure increased in all patients after insufflation but was kept in a safe range to prevent lung injury. An esophageal anastomosis was performed in 3 cases (2 short gaps and 1 long gap). Oral feeding started on day 6, and their mean length of hospital stay was 14 days. For one child with type IV EA, the anastomosis was impossible because of a long gap confirmed by an immediate thoracotomy. The ends were just approximated. A "spontaneous" fistula developed, and normal feeding was possible 2.5 months later. For the child with type I EA, the pouches could be only approximated at 2 months of age. A spontaneous fistula developed with a stenosis. A redo anastomosis by open surgery allowed for normal feeding. CONCLUSION: The thoracoscopic repair of an esophageal atresia is a reasonable choice for experienced surgeons treating patients, including those with long gaps.     

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.     

Prenatal diagnosis of esophageal atresia using sonography and magnetic resonance imaging

BACKGROUND: The diagnosis of esophageal atresia may be suspected on prenatal ultrasound scan in fetuses with a small or absent stomach or unexplained polyhydramnios. However, these findings are thought to have a low positive predictive value and clinical decisions affecting timing or site of delivery may be made erroneously. The authors evaluated the accuracy of fetal sonography followed by magnetic resonance imaging (MRI) for the diagnosis of this lesion. METHODS: Fetuses considered to be at risk for esophageal atresia based on detailed obstetric sonography underwent fetal MRI using a single-shot rapid-acquisition technique, and the T(2)-weighted images were evaluated prospectively. Scans were considered to be positive if the proximal esophagus was dilated, and the distal esophagus was not seen and negative if the esophagus was visualized throughout its length. RESULTS: Ten fetuses underwent MRI scanning. All had a small or absent stomach bubble with unexplained polyhydramnios. Four scans were considered to be negative for esophageal atresia; all 4 were found to have a normal esophagus after delivery. Six scans were considered to be positive; 5 had esophageal atresia (2 with tracheoesophageal fistula and 3 without), and one had a neurologic syndrome with a normal esophagus. CONCLUSIONS: Magnetic resonance imaging appears to be accurate for establishing or ruling out a prenatal diagnosis of esophageal atresia, and should be considered in fetuses who are at high risk based on ultrasound findings.     

Membranous type of esophageal atresia at the cardiac end of the esophagus: a case report

An 8-day-old female neonate was referred to pediatric surgical services for regurgitation of feeds since birth. Plain x-ray of the chest and abdomen with Ryle's tube in situ and contrast study confirmed the diagnosis of esophageal atresia at the cardiac end of the esophagus. The membrane at the cardiac end of the esophagus was excised employing a thoracoabdominal approach. This is the first case report of membranous type of esophageal atresia at the cardiac end of the esophagus to be reported in the English literature.     

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.     

Heterotopic gastric mucosa of the upper esophagus following repair of esophageal atresia with tracheoesophageal fistula

A term female newborn underwent uncomplicated repair of esophageal atresia with tracheoesophageal fistula (type C) then coarctation of the aorta. Subsequently, she developed symptomatic esophageal strictures, which required serial dilations. In addition, she suffered feeding intolerance from esophageal dysmotility and gastroesophageal reflux disease, necessitating Nissen fundoplication with gastrostomy. At 6 years of age, surveillance esophagogastroduodenoscopy revealed mild stenosis and heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis. This is the second report of heterotopic gastric mucosa of the upper esophagus at the level of the anastomosis following repair of esophageal atresia with tracheoesophageal fistula.     

应用显微外科技术重建食管45例

１９８０年１月～１９９７年１２月，对４５例食管病变采用显微外科技术进行重建，其中男３５例，女１０例。多种原因致食管狭窄２１例，食管重建后吻合口瘘或狭窄７例，晚期食管癌１７例。采用部分带蒂空肠游离移植２４例，空肠游离移植１５例，空肠瓣游离移植２例，前臂皮瓣游离移植４例。经６个月～１７年随访，有８例死于晚期食管癌，成活３７例均能经口进食，良性病变者均能恢复工作。该术式对晚期食管癌不能经口进食的患者，提高了生活质量，并为化疗、放疗提供了条件     

Successful treatment of congenital esophageal web by endoscopic electrocauterization and balloon dilatation

We report a 3-year-old boy who presented with a foreign body impacted in the esophagus and had a poor tolerance of solid food since he was 5 to 6 months old. In the last 2 years, he developed progressive dysphagia, anorexia, vomiting, and poor weight gain. An esophagoscopy and barium esophagogram revealed an esophageal web in the distal third of the esophagus. Three courses of endoscopic balloon dilatation resulted in transient improvement in his dysphagia and vomiting; a follow-up barium esophagogram and esophagoscopy showed limited improvement of the esophageal stenosis. Two courses of endoscopic electrocauterization and balloon dilatation improved the clinical symptoms and esophageal stenosis.     

Argon plasma coagulator in a 2-month-old child with tracheoesophageal fistula

A 2?month-old boy was admitted to the authors' hospital because of regurgitation and persistent cough during breastfeeding. A chest X-ray examination and a barium esophagogram disclosed small amounts of barium passing in the trachea, suggesting a tracheoesophageal fistula (TEF). Bronchoscopy combined with upper gastrointestinal (GI) endoscopy performed with the patient under general anesthesia confirmed the fistula. The TEF was treated by injection of 1?ml Glubran 2 from the esophageal side. A nasogastric tube was placed for feedings, and 7?days later, a barium esophagogram showed a reduction of caliber but not complete closure of the TEF. Unsuccessful fistula obliteration with Glubran was attributed to technical difficulties in catheterization of the fistula orifice, mainly resulting from its close proximity to the upper esophageal sphincter and to its small caliber. Therefore, an argon plasma coagulator (APC) probe with a circumferentially oriented nozzle was used from the esophageal side as an alternative technique to fulgurate the residual fistula orifice (see video). A nasogastric tube was placed for feedings. Oral feeding was started 7?days later when a barium esophagogram confirmed complete fistula closure. At the 2-year follow-up visit, the boy was asymptomatic, and the barium esophagogram was negative. This report describes a case in which esophagoscopy gave a clear view of the fistula due to its direction from esophagus to trachea. Complete fistula obliteration was not obtained with Glubran. However, APC was successfully used to close the residual fistula orifice. The authors suggest that APC can be used as an alternative endoscopic technique to repair TEF when other techniques fail.