Esophageal replacement with reversed gastric tube. Utilization for bleeding esophageal varices in a four-year-old child

Development of Bio-artificial Esophageal Tissue Engineering Utilization for Circumferential Lesion Transplantation: A Narrative Review

The esophagus is the gastrointestinal tract's primary organ that transfers bolus into the stomach with peristaltic motion. Therefore, its lesions cause a significant disturbance in the nutrition and digestive system. Esophageal disease treatment sometimes requires surgical procedures that involve removal and circumferential full-thickness replacement. Unlike other organs, the esophagus has a limited regeneration ability and cannot be transplanted from donors. There are various methods of restoring the esophageal continuity; however, they are associated with certain flaws that lead to a non-functional recovery. As an exponentially growing science, tissue engineering has become a leading technique for the development of tissue replacement to repair damaged esophageal segments. Scaffold plays a significant role in the process of tissue engineering, as it acts as a template for the regeneration of growing tissue. A variety of scaffolds have been studied to replace the esophagus. Due to the many tissue quality challenges, the results are still inadequate and need to be improved. The success of esophageal tissue regeneration will finally depend on the scaffold's capability to mimic natural tissue properties and provide a qualified environment for regeneration. Thereby, scaffold fabrication techniques are fundamental. This article reviews the recent developments in esophageal tissue engineering for the treatment of circumferential lesions based on scaffold biomaterial engineering approaches.

Surgical techniques for esophageal replacement in children

PURPOSE

Surgical techniques for esophageal replacement (ER) in children include colon interposition, gastric tube, gastric transposition, and jejunal interposition. This review evaluates the merits and demerits of each.

METHOD

Surgical techniques, complications, and outcome of ER are reviewed over last seven decades.

RESULTS

Colon interposition is the time-tested procedure with minimal and less serious complications. Long-term complications include reflux, halitosis, colonic segment dilatation, and anastomotic stricture, sometimes requiring surgical interventions especially for dilatation and reflux. Gastric tube is technically more risky, and associated with early serious complications like prolonged leak in neck or mediastinum, graft necrosis, and ischemia leading to stricture of the tube. Long-term results are good. Gastric transposition is much simpler, can be performed in emergency and in newborns. It involves a single anastomosis in the neck. Post-operative complications include gastric stasis, bile reflux, restricted growth, and decreased pulmonary functional capacity. Jejunal interposition has not been used extensively due to short mesentery but long-term results are good in expert hands.

CONCLUSION

Colon is the most preferred and safest organ for ER. Stomach is a vascular and muscular organ with lower risk of ischemia. Gastric tube is a demanding technique. Jejunum or ileum is alternative for redo cases.

Regenerative Medicine Strategies for Esophageal Repair

Pathologies that involve the structure and/or function of the esophagus can be life-threatening. The esophagus is a complex organ comprising nonredundant tissue that does not have the ability to regenerate. Currently available interventions for esophageal pathology have limited success and are typically associated with significant morbidity. Hence, there is currently an unmet clinical need for effective methods of esophageal repair. The present article presents a review of esophageal disease along with the anatomic and functional consequences of each pathologic process, the shortcomings associated with currently available therapies, and the latest advancements in the field of regenerative medicine with respect to strategies for esophageal repair from benchtop to bedside.

Minimally invasive repair of a late stricture in a reversed gastric tube

Ingestion of caustic agents may result in severe scarring and stricture formation of the esophagus. Reversed gastric tube esophagoplasty is an option for definitive surgical management of severe esophageal stricture refractory to medical treatment. Delayed complications from this procedure have rarely been reported. We present a case involving a patient who developed a delayed gastric stricture three decades after receiving a reversed gastric tube esophagoplasty. A historical review of the reversed gastroplasty is presented as well.

The reversed gastric tube for esophageal replacement in children

The reversed gastric tube provides a relatively simple method of esophageal replacement in children. A thirty year experience of this technique is described together with the long-term results in 34 patients. Complications such as anastomotic leakage and stricturing have responded well to treatment and only one patient died. The reversed gastric tube remains a useful alternative to other methods of esophageal substitution.

The outcome of colonic replacement of the esophagus in children

An analysis of 112 children undergoing colonic replacement of the esophagus over a 30-year period is presented. The indication for esophageal replacement was atresia in 92 children and intractable stricture (peptic, caustic, or congenital) in 20. The procedure consisted of a transthoracic replacement of the entire esophagus in 82 cases and a partial replacement in 18, while a retrosternal replacement was used in ten cases. Two colon loops had to be abandoned prior to reconstruction due to irreversible ischemic damage. There were 15 deaths (13.4%)--all in the atresia group. Failure of the colonic graft was encountered in 16 patients (14.3%) and accounted for six of the deaths. Leakage of the proximal esophago-colonic anastomosis occurred in 54 cases (48.2%). Strictures of this anastomosis developed in 34 cases (30.3%). A total of 20 patients required operative revision of the anastomosis. The final outcome was excellent in 43 of 77 cases followed up for up to 24 years postoperatively (55.9%), good in 27 cases (35%), and only fair in seven cases (9.1%).

Spontaneous anastomosis of the esophagus in esophageal atresia

An operative technique is described for the management of babies with esophageal atresia, where primary anastomosis is either impossible or unsuccessful. The procedure has been performed on six patients. One infant subsequently required resection of a resultant stricture, and one developed a recurrent tracheoesophageal fistula. All six infants required several esophageal dilatations. No patient required dilatation beyond the age of 5 months and all are now swallowing normally and thriving.

Gastric tube interpostion: a satisfactory alternative to the colon for esophageal replacement in children

The gastric tube was used as the primary method of esophageal reconstruction in 15 infants and children, 9 with isolated esophageal atresia and 6 with lye stricture. The youngest patient was 8 months old and the oldest, 5 years old at the time of the procedure. The technique of gastric tube construction is described. There have been both major and minor complications but the gastric tube has proved very satisfactory as a conduit from mouth to stomach. Growth and development have been acceptable in all 15 children, although most remain in the lower percentiles for growth and height, a condition that usually predates the esophageal substitution. In our institution the gastric tube is the preferred method of esophageal substitution.

Circular myotomy of the esophagus: clinical application in esophageal atresia

Three infants born with esophageal atresia that was repaired by end-to-end anastomosis combined with a circular myotomy on the upper segment are reported. The distance between the free surgical margins of the esophagus ranged between 1.5 and 4.5 cm. The esophageal myotomy was used to reduce the tension on the anastomosis. The suture line healed in each patient without clinical or roentgenographic evidence of breakdown. Follow-up of these patients ranged between 10 months and 3 years. Roentgenographic evaluation of their esophageal motility showed efficient peristaltic activity in the distal esophageal segment. Two of the patients had a subsequent history of impaction of solid particles in the upper esophageal segment at the age of 13 months and 2 years. The possibility that the circular myotomy contributed to this increased incidence of impaction is raised.

Reversed gastric tube (RGT) esophagoplasty for failure of colon, jejunum and prosthetic interpositions

Reversed gastric tube (RGT) esophagoplasty is preferred by the author as the primary procedure for esophageal replacement. Many patients undergoing RGT esophagoplasty, however, have previously had multiple operative procedures. A particularly challenging problem in esophageal reconstruction is the patient who has already had unsuccessful intestinal or prosthetic interposition operations in attempts to reconstruct the esophagus. In such patients, it has been possible to replace the esophagus by means of the RGT operation. Of 67 RGT esophagoplasties, 9 patients (13.4%) had previous interposition operations that had failed. Six had undergone colon interposition; 2 of these had strictured, 1 had partially sloughed leaving a cervical salivary fistula, and in 1 the proximal end was never patent. In each instance, bypass with RGT was performed without resecting the colon transplant. The colon had necrosed and was removed in 2 patients. Of the remaining 3 patients, in 1 a plastic esophageal prothesis had sloughed and two had free jejunal transplants, 1 of which had impaired vascularity and the other had fibrosed. The specific techniques used to reconstruct the esophagus by reversed gastric tube esophagoplasty, as they relate to this particular group of patients, are described.