“Thoracic gastrostomy”—a new technique for feeding gastrostomy in wide-gap esophageal atresia and tracheo-esophageal fistula

Introduction Initial management of wide-gap esophageal atresia and tracheo-esophageal fistula, especially in developing countries, often involves ligation of the fistula, proximal esophagostomy and a gastrostomy. The conventional gastrostomy requires an abdominal incision and has several complications. The authors present an alternative technique of gastrostomy that does not require an abdominal incision.Method Through a standard right thoracotomy, the fistula is divided and tracheal end closed. If primary anastomosis is not possible due to wide gap, the lower esophageal pouch is mobilised and brought out as a stoma on the left posterior chest wall, lateral to the paraspinal muscles in the 7th or 8th intercostal space. A feeding tube is passed through the stoma into the stomach. The thorax is closed with a drain. Proximal esophagostomy is performed in the neck. The thoracic stoma is intermittently intubated for feeding until the child is ready for gastric transposition.Results The technique was successfully used in 5 patients. Feeding through the stoma could be established in 4. One patient had stomal retraction and died of resultant sepsis. One patient has subsequently undergone gastric transposition and one more is waiting for it. Two patients died of unrelated causes before esophageal replacement could be carried out.Discussion This is an alternative technique for feeding gastrostomy. We have named the procedure as Thoracic Gastrostomy because the stoma is located on the chest but functions as a gastrostomy. The advantages include avoidance of a laparotomy and its complications, easy feeding by intermittent intubation, and availability of a virgin stomach for future gastric transposition.     

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.     

Primary reversed gastric tube reconstruction in long gap esophageal atresia

Background/purpose

Esophageal reconstruction in long-gap esophageal atresia (EA) poses a technical challenge with several surgical options. The purpose of this study was to review the authors’ experience with the reversed gastric tube (RGT) in esophageal reconstruction.

Methods

This series describes 7 babies with pure EA treated at 2 centers between 1989 and 2001. Data, gathered by retrospective chart review, included clinical details of the esophageal and associated malformations, technique and timing of repair, early and late complications, and long-term follow-up. Institutional review board (IRB) approval of this study has been obtained.

Results

Seven babies were included. Associated malformations were present in 4: trisomy 21 in 2 and imperforate anus in 2. After gastrostomy tube placement, patients were treated with gastrostomy tube feedings and continuous upper pouch suction. Median gap length was 5.5 vertebral segments (range, 3 to 9). RGT with a posterior mediastinal esophagogastric anastomosis was performed at median age of 62 days (range, 38 to 131). There were no anastomotic leaks. Three patients had strictures, one required resection. Exclusive oral nourishment was achieved in 5 patients by 6 months of age. At last follow-up (mean, 4.5 years), 6 patients were receiving oral nutrition exclusively, and all were maintaining growth curves.

Conclusions

In long gap EA, early esophageal reconstruction using an RGT can be performed with minimal morbidity and promising short-term results.     

A new variant of esophageal atresia with distal tracheo-antral fistula associated with congenital intrathoracic stomach and situs inversus

Esophageal atresia (EA) with distal tracheoesophageal fistula (TEF) is the most common anatomic pattern within congenital anomalies of the esophagus. Also, more than 50% of the infants with esophageal atresia have other congenital malformations. To our knowledge, this is the first case report of EA with distal tracheo-antral fistula associated with congenital intrathoracic stomach and situs inversus (SI).     

Endoscopic balloon dilatation of esophageal strictures in infants and children: 17 years' experience and a literature review

Purpose: Whereas endoscopic balloon dilatation (EBD) of benign esophageal strictures is an established mode of therapy in adults, this has not been accepted universally in the pediatric population. The aim of this study is to report the safety, efficacy, and long-term results of EBD for children in the authors’ center.Methods: Between 1986 and 2002, a total of 77 children (median age, 1.8 years; range, 2 months to 20 years) were treated by EBD for various causes: 2 had achalasia, and 75 had esophageal strictures (postesophageal atresia repair, 63; reflux esophagitis, 7; postfundoplication, 2; caustic injury, 3). Dilatations were performed using flexible endoscopy and fluoroscopic screening under general anesthesia.Results: A total of 260 dilatations were carried out with the mean number of EBD per patient being 3.4 (range, 1 to 19). A mean period of 5 months (maximum, 28 months) for each patient was required. Four complications of esophageal perforations (1.5%) were observed, but only one required surgical repair because of persistent leakage. The remaining patients have undergone long-term follow-up (median follow-up, 6.6 years), and all are asymptomatic.Conclusions: This large series has shown that EBD can provide a safe and effective mean of relieving esophageal strictures with good long-term results.     

Gastric smooth muscle contractility changes in the esophageal atresia rat model: an in vitro study

Purpose: The aim of the study was to investigate the gastric smooth muscle reactivity in the Adriamycin-induced esophageal atresia (EA) rat model.Methods: The fetuses were divided into 3 groups. The control group was exposed to saline. The second group was comprised of fetuses that were exposed to Adriamycin but did not have EA (Adriamycin-no-EA group). The third group was comprised of fetuses that were exposed to Adriamycin and had EA (Adriamycin-EA group). Gastric fundus strips were studied in vitro for their contractile response to receptor activation in the 3 groups.Results: Contractile responses of gastric smooth muscle to carbachol and KCl were increased in the Adriamycin-EA group compared with the Adriamycin-no-EA group. Also serotonin-induced contractile response in the Adriamycin-EA group decreased compared with the Adriamycin-no-EA group. Relaxation of gastric smooth muscle strips to isoproterenol was comparably unaffected in the Adriamycin-EA and Adriamycin-no-EA groups. Likewise, no change in the response to agonist studies was observed between the control and Adriamycin-no-EA groups. The relaxant response to papaverine was not different in the 3 groups.Conclusions: This study found changes of receptor-dependent and receptor-independent contraction of the gastric fundus smooth muscle in the fetuses with EA. Therefore, impaired contractile responses may be, at least in part, a contributing factor in the abnormal gastric motility seen in EA.     

Multimodality treatments with endoscopic mucosal resection of esophageal squamous cell carcinoma with submucosal invasion

Background and study aims: A standard treatment for esophageal squamous cell carcinoma (SCC) with submucosal invasion is considered to be radical resection at present. In this study, we evaluated the efficacy of multimodality treatments with endoscopic mucosal resection (EMR) of esophageal SCC with submucosal invasion. Method: Eighteen cases of SCC with submucosal invasion were treated with EMR. Lymphatic invasion was found in 11 cases (67%), and there were no cases of blood vessel invasion. EMR was performed prior to any other treatment. Chemotherapy and/or radiotherapy were added if indicated by the histopathological features. Results: There were no cases of local recurrence. Lymph-node recurrence was detected in 1 case treated with EMR alone. There were no cases of cancer death. The overall survival rate was 83% in all patients.Conclusions: Multimodality treatments with EMR were effective in treating esophageal SCC with submucosal invasion.     

林州居民食管癌p53基因突变谱分析与不同地区食管癌和其他类型肿瘤的比较

目的：分析河南省林州市与其他地区食管癌前病变和鳞状细胞癌p53突变谱,探讨食管癌变的发病因素。方法：采用生物信息学和Monte Carlo方法,依据IARC p53突变数据库、Curic研究院p53突变数据库和郑州大学医学院癌症研究所实验室的资料,用FileMark Pro3.0软件系统建立局部资料库进行分析。结果：林州食管癌高发区食管鳞癌碱基替换的发生率低于其他地区食管鳞癌的发生率（32.8 vs 39.8%),但CpG位点G：C→A：T的发生率高于其他地区食管癌（29.6% vs 16.4%)。林州食管癌突变位点具有明显的特征,主要发生在273（占所有错义突变的11.3%)、175（9.7%)、159（6.5%)和282（6.5%)位密码子的CpG位点上。林州地区食管鳞癌p53突变与其他地区食管鳞癌以及头颈部鳞癌p53突变相比,差异有显著性（P=0.02)。结论：林州食管癌p53突变具有内、外源致癌原所致突变的特征,提示慢性炎症、饮食习惯和接触致癌原,可能是林州居民发生食管鳞癌的主要危险因素。     

The incidence and causes of erectile dysfunction after pelvic fractures associated with posterior urethral disruption

PURPOSE: Erectile dysfunction is a common sequel of pelvic fractures, particularly those associated with posterior urethral injury when it can be neurogenic or arteriogenic due to damage to the cavernous nerves or branches of the pudendal arteries. We studied erectile function of patients with posterior urethral injuries due to pelvic fractures. MATERIALS AND METHODS: Patients referred for posterior urethral reconstruction and strictures due to pelvic fractures were evaluated before reconstruction. All patients underwent nocturnal penile tumescence testing, and if those results were abnormal, penile duplex ultrasound with intracavernous injection was performed. Patients with normal vascular function on duplex ultrasound were diagnosed with neurogenic erectile dysfunction. Those patients with abnormal arterial function on duplex ultrasound underwent arteriography to further define the extent and location of arterial damage. RESULTS: The study included 25 consecutive patients with posterior urethral strictures and a mean age of 28.6 years. Of the patients 18 (72%) had erectile dysfunction as demonstrated by nocturnal penile tumescence and all underwent penile duplex ultrasound. Ultrasound confirmed normal vascular response in 13 of the 18 patients and they were diagnosed with probable neurogenic erectile dysfunction. The remaining 5 patients (28%) with erectile dysfunction had an abnormal arterial response, and significant arterial pathology was confirmed by arteriography. CONCLUSIONS: Erectile dysfunction is common in patients with pelvic fractures associated with urethral injury. We believe that erectile function should be assessed and documented in such patients before attempting urethroplasty. In the majority of these patients erectile dysfunction is caused by disruption of the cavernous nerves with sparing of arterial inflow.     

食管癌患者血清CEA、SCC和Cyfra21-1含量检测及临床意义

目的：探讨血清肿瘤标志物癌胚抗原(CEA)、鳞状细胞癌相关性抗原(SCC)和角化素蛋白片段19(Cyfra21-1)在食管癌的诊断、治疗和预后判断及随访中的作用。方法：以电发光免疫测定法(ECLIA)和微粒酶联免疫测定法(MEIA)检测206例食管癌患者术前和其中71例术后血清中CEA、Cyfra21-1和SCC的水平。检测结果采用SPSS10．0统计软件进行t检验和X^2检验。结果：肿瘤体积愈大、病期愈晚、肿瘤浸润愈深,患者术前血清CEA、SCC和Cyfra21-1总体水平愈高,早期患者水平较低。三者中,CEA和Cyfra21-1的个体差异较大,Cyfra21-1相关性最好。术后检测血清的71例中,92．9％的患者三种血清标志物降至正常。全组患者CEA和Cyfra21-1的阳性率分别为29．1％和45．1％,两者联合检测阳性率为57．3％。165例手术切除者Ⅰ、Ⅱ、Ⅲ期的CEA阳性率分别为16．6％、26．8％和30．8％;Cyfra21-1分别为27．8％、37．5％和50．5％;两者联合检测阳性率分别为38．9％、50．0％和63．7％。结论血清CEA、SCC、Cyfra21-1联合检测可用于食管癌的辅助诊断以及对病期及预后的判断。三者中Cyfra21-1更有意义。