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Ishikawa M, Tomita H, Ito Y, Tsukizaki A, Abe K, Shimotakahara A, Shimojima N, Hirobe S. Analysis of gap length as a predictor of surgical outcomes in esophageal atresia with distal fistula: a single center experience. Pediatr Surg Int 2024; 40:99. [PMID: 38581456 DOI: 10.1007/s00383-024-05678-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/19/2024] [Indexed: 04/08/2024]
Abstract
PURPOSE Long-gap esophageal atresia (LGEA) is still a challenge for pediatric surgery. No consensus exists as to what constitutes a long gap, and few studies have investigated the maximum gap length safely repairable by primary anastomosis. Based on surgical outcomes at a single institution, we aimed to determine the gap length in LGEA with a high risk of complications. METHODS The medical records of 51, consecutive patients with esophageal atresia (EA) with primary repair in the early neonatal period between 2001 and 2021 were retrospectively reviewed. Three, major complications were found in the surgical outcomes: (1) anastomotic leakage, (2) esophageal stricture requiring dilatation, and (3) GERD requiring fundoplication. The predictive power of the postsurgical complications was assessed using receiver operating characteristic analysis, and the area under the curve (AUC) and the cutoff value with a specificity of > 90% were calculated. RESULTS Sixteen patients (31.4%) experienced a complication. The AUC of gap length was0.90 (p < 0.001), and the gap length cutoff value was ≥ 2.0 cm for predicting any complication (sensitivity: 62.5%, specificity: 91.4%). CONCLUSION A gap length ≥ 2.0 cm was considered as defining LGEA and was associated with an extremely high complication rate after primary repair.
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Affiliation(s)
- Miki Ishikawa
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan.
| | - Hirofumi Tomita
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Yoshifumi Ito
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Ayano Tsukizaki
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Kiyotomo Abe
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Akihiro Shimotakahara
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Naoki Shimojima
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
| | - Seiichi Hirobe
- Department of Surgery, Tokyo Metropolitan Children's Medical Center, 2-8-29 Musashidai, Fuchu, Tokyo, 183-8561, Japan
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Friedmacher F. Delayed primary anastomosis for repair of long-gap esophageal atresia: technique revisited. Pediatr Surg Int 2022; 39:40. [PMID: 36482208 PMCID: PMC9732069 DOI: 10.1007/s00383-022-05317-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 11/22/2022] [Indexed: 12/13/2022]
Abstract
The operative management of patients born with long-gap esophageal atresia (LGEA) remains a major challenge for most pediatric surgeons, due to the rarity and complex nature of this malformation. In LGEA, the distance between the proximal and distal esophageal end is too wide, making a primary anastomosis often impossible. Still, every effort should be made to preserve the native esophagus as no other conduit can replace its function in transporting food from the oral cavity to the stomach satisfactorily. In 1981, Puri et al. observed that in newborns with LGEA spontaneous growth and hypertrophy of the two segments occur at a rate faster than overall somatic growth in the absence of any form of mechanical stretching, traction or bouginage. They further noted that maximal natural growth arises in the first 8-12 weeks of life, stimulated by the swallowing reflex and reflux of gastric contents into the lower esophageal pouch. Since then, creation of an initial gastrostomy and continuous suction of the upper esophageal pouch followed by delayed primary anastomosis at approximately 3 months of age has been widely accepted as the preferred treatment option in most LGEA cases, generally providing good functional results. The current article offers a comprehensive update on the various aspects and challenges of this technique including initial preoperative management and subsequent gap assessment, while also discussing potential postoperative complications and long-term outcome.
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Affiliation(s)
- Florian Friedmacher
- Department of Pediatric Surgery, University Hospital Frankfurt, Goethe University Frankfurt, Theodor-Stern-Kai 7, 60590 Frankfurt, Germany
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Bedi N, Grewal A, Bhatti W. Single institution experience with esophageal atresia over 9 years with a review of literature: Where do we stand? CHRISMED JOURNAL OF HEALTH AND RESEARCH 2020. [DOI: 10.4103/cjhr.cjhr_16_19] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
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Awad K, Jaffray B. Oesophageal replacement with stomach: A personal series and review of published experience. J Paediatr Child Health 2017; 53:1159-1166. [PMID: 28799279 DOI: 10.1111/jpc.13653] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2017] [Revised: 05/22/2017] [Accepted: 05/28/2017] [Indexed: 12/22/2022]
Abstract
AIM To describe the outcomes of oesophageal replacement using stomach in children. METHODS All children undergoing oesophageal replacement in a regional centre were prospectively recorded in a customised database and subjected to continual follow up. Complications within 30 days were classified as early, and all other complications were classified as late. Outcomes were related to a comprehensive analysis of published experience where studies were classified as having long-term follow up if the median duration exceeded 5 years. RESULTS Ten children underwent oesophageal replacement using the stomach between 1998 and 2016. Indications were oesophageal atresia (6), caustic ingestion (2), foreign body ingestion (1) and oesophageal hamartoma (1). Two children died at 2 and 7 months after gastric transposition. All survivors are under review, with a median follow up of 8.5 years (range 3-14 years). Complications occurred in every case. Among survivors, three had early complications and eight had late complications. Early complications included anastomotic leak (2) and lung compression by stomach (1). Late complications were anaemia (8), anastomotic stricture (7), oesophagitis (5), dumping syndrome (2), perforation of a jejunostomy (1), para-gastric hiatal hernia (1), gastric outlet obstruction (1), Barrett's oesophagus (1), prolonged inability to swallow (1) and recurrent lower respiratory tract infections (1). Among 57 publications, only three achieved complete long-term follow up. The incidence of reported complications was higher when follow up was complete. CONCLUSIONS Oesophageal replacement by gastric transposition in children leads to serious chronic morbidity. Published experience masks this because of incomplete and short follow up.
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Affiliation(s)
- Karim Awad
- Department of Paediatric Surgery, The Great North Children's Hospital, Newcastle upon Tyne, United Kingdom.,Department of Paediatric Surgery, Ain Shams University Hospitals, Cairo, Egypt
| | - Bruce Jaffray
- Department of Paediatric Surgery, The Great North Children's Hospital, Newcastle upon Tyne, United Kingdom
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Long AM, Tyraskis A, Allin B, Burge DM, Knight M. Oesophageal atresia with no distal tracheoesophageal fistula: Management and outcomes from a population-based cohort. J Pediatr Surg 2017; 52:226-230. [PMID: 27894760 DOI: 10.1016/j.jpedsurg.2016.11.008] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Accepted: 11/08/2016] [Indexed: 01/08/2023]
Abstract
PURPOSE To describe the incidence and outcomes to one-year in infants born with oesophageal atresia (OA) with no distal tracheoesophageal fistula within a population cohort. METHODS A subgroup analysis of a prospective multicentre population cohort study was undertaken describing the outcomes of infants with OA and no tracheoesophageal fistula, (type A) and those with only an upper pouch fistula, (type B). MAIN RESULTS Twenty-one of 151 infants in the whole cohort were diagnosed with type A or B oesophageal atresia (14%). Fifteen were type A (71%) and six type B (29%). Infants with type B had a shorter gap length than those with type A: 2.5 vertebral bodies (2-3) vs. 5 (4-6) (p=0.008). All infants with type B OA underwent oesophageal anastomosis, 83% (n=5) as the primary procedure. All infants with type A, underwent staged management. Six (40%) had delayed primary anastomosis and eight required oesophageal replacement (53%). One infant died prior to reconstruction. The median time to delayed primary anastomosis in infants with type A or B OA was 82days (75-89days) (n=7). The median time to oesophageal replacement was 94days (89-147days) (n=8). Median length of stay for infants with type A or B OA from first operation to first discharge was 101days (31-123days). CONCLUSIONS Infants with type B OA had a shorter gap length and all were managed with oesophageal anastomosis. OA with no distal tracheoesophageal fistula is uncommon at a population level and frequently has a complex course. LEVEL OF EVIDENCE Rating: II.
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Affiliation(s)
- Anna-May Long
- National Perinatal Epidemiology Unit, Old Rd Campus, Oxford University, Oxford, UK
| | - Athanasios Tyraskis
- National Perinatal Epidemiology Unit, Old Rd Campus, Oxford University, Oxford, UK
| | - Benjamin Allin
- National Perinatal Epidemiology Unit, Old Rd Campus, Oxford University, Oxford, UK
| | - David M Burge
- Southampton Children's Hospital, Southampton General Hospital, Tremona Road, Southampton, UK; Southampton University, University Rd, Southampton, UK
| | - Marian Knight
- National Perinatal Epidemiology Unit, Old Rd Campus, Oxford University, Oxford, UK.
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Zani A, Cobellis G, Wolinska J, Chiu PPL, Pierro A. Preservation of native esophagus in infants with pure esophageal atresia has good long-term outcomes despite significant postoperative morbidity. Pediatr Surg Int 2016; 32:113-7. [PMID: 26520653 DOI: 10.1007/s00383-015-3821-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/09/2015] [Indexed: 01/28/2023]
Abstract
PURPOSE To evaluate long-term outcomes of pure esophageal atresia (EA) repair with preservation of native esophagus. METHODS Infants with pure EA treated at our institution (2000-2010) and with minimum 5-year follow-up were reviewed (REB:1000046653). Data analysed included demographics, management and outcomes and are reported as mean ± SD/median (range). RESULTS Of 185 infants with EA, 12 (7 %) had pure EA (gestational age: 36 ± 2.4 weeks, birth weight: 2353 ± 675 g). Ten had associated anomalies, including trisomy-21 (n = 2) and duodenal atresia (n = 1). SURGERY 1 patient (short gap) underwent primary thoracoscopic anastomosis, 11 had gastrostomy (Stamm, n = 5; image-guided, n = 6) as initial procedure. At definitive repair (age: 128 ± 91 days; weight 5.5 ± 2.3 kg): ten had primary anastomosis and 1 had Collis gastroplasty. No patient had esophageal replacement surgery. OUTCOMES three patients had gastrostomy dehiscence requiring re-operation. At post-operative esophagram, seven had anastomotic leak successfully treated conservatively. Seven patients developed strictures requiring balloon dilatations (median two dilatations, range 1-10), six received antireflux surgery. At 7-year follow-up (range 5-15 years), all patients had the gastrostomy closed and were on full oral feeds. CONCLUSIONS The management of pure EA continues to be challenging. The preservation of native esophagus is possible with significant morbidity. The long-term outcomes are favourable.
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Affiliation(s)
- Augusto Zani
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Giovanni Cobellis
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Justyna Wolinska
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Priscilla P L Chiu
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada
| | - Agostino Pierro
- Division of General and Thoracic Surgery, Physiology and Experimental Medicine Program, The Hospital for Sick Children, 1526-555 University Ave, Toronto, ON, M5G 1X8, Canada. .,University of Toronto, Toronto, Canada.
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Huh YJ, Kim HY, Lee SC, Park KW, Jung SE. Comparison of outcomes according to the operation for type A esophageal atresia. Ann Surg Treat Res 2014; 86:83-90. [PMID: 24761413 PMCID: PMC3994598 DOI: 10.4174/astr.2014.86.2.83] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2013] [Revised: 10/13/2013] [Accepted: 10/23/2013] [Indexed: 02/08/2023] Open
Abstract
Purpose The purpose was to evaluate outcomes according to different operative strategies of type A esophageal atresia (EA). Methods All patients who underwent surgery for type A EA between 1980 and 2011 were included. Patients were divided into 2 groups: E-E group included patients who received esophageal end-to-end anastomosis, whereas E-G group included patients who received esophago-gastric tube anastomosis. Results Twenty-two patients were included. The median gestational age was 37.5 weeks. The median birth weight was 2.5 kg. Twenty-one patients underwent gastrostomy as initial procedures, and one patient underwent primary esophageal end-to-end anastomosis. The median gap between both esophageal ends was six vertebral distance (VD). Seven patients underwent primary anastomosis of the esophagus, and 14 patients underwent gastric replacement. Three patients (13.6%) had anastomotic leakage and 10 patients (45.5%) had anastomotic stenosis. Most of the patients (90.9%) had gastroesophageal reflux, but only two patients required antireflux surgery. The median VD was significantly shorter in E-E group than in E-G group (3 VD vs. 6 VD). Stenosis was significantly more often in E-E group, but there was no significant difference in leakage and reflux symptoms. Conclusion The treatment for type A EA can include E-E anastomosis or E-G anastomosis, depending on the length of the end-to-end interval after performing gastrostomy. Appropriate tension and blood flow in the anastomosis site are essential for preventing postoperative stenosis and leakage, and esophageal replacement with gastric tube is believed to be feasible and safe in cases where excessive tension is present.
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Affiliation(s)
- Yeon-Ju Huh
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Hyun-Young Kim
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seong-Cheol Lee
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kwi-Won Park
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Sung-Eun Jung
- Division of Pediatric Surgery, Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Esophageal replacement by gastric tube. ANNALS OF PEDIATRIC SURGERY 2014. [DOI: 10.1097/01.xps.0000433919.71682.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
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9
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Bagolan P, Valfrè L, Morini F, Conforti A. Long-gap esophageal atresia: traction-growth and anastomosis - before and beyond. Dis Esophagus 2013; 26:372-9. [PMID: 23679026 DOI: 10.1111/dote.12050] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Long-gap esophageal atresia (LGEA) is still a major surgical challenge. Options for esophageal reconstruction include the use of native esophagus or esophageal replacement with stomach, colon, or small intestine. Nonetheless, there is a consensus among most pediatric surgeons that the preservation of the native esophagus is associated with better postoperative outcomes. Thus, every effort should be made to conserve the native esophagus. The present study is aimed at critically reporting our experience focused on a standardized protocol based on the preoperative assessment of the gap in all cases and reviewing the present literature because no consensus is available regarding many aspects of LGEA (from definition to treatment). All newborn infants treated since 1995 for esophageal atresia (EA), regardless of type, were included in the present study. Identification of LGEA patients (gap ≥3 vertebral bodies) was performed based on preoperative esophageal gap measurement. The selected patients were grouped based on EA type (A/B vs. C/D) and whether they were referred from an outside institution or not. Postoperative outcome was compared. Statistical analysis was performed with the Fisher's exact test and Mann-Whitney test as appropriate, with P < 0.05 considered statistically significant. Two hundred and nineteen patients have been consecutively treated between 1995 and 2012 with the following EA subtypes: type: A 25 (11.4%); B 6 (2.7%); C 182 (83.1%); D 3 (1.4%); E 3 (1.4%). Fifty-seven patients (26%) were classified as LGEA: type A-B, 31 (54.4%); type C-D, 26 (45.6%). Twenty seven (47%) of these patients were referred after at least one failed attempt at esophageal correction: type A-B, 15 (55%); type C-D, 12 (45%). Only one patient ultimately required esophageal substitution, with an overall survival rate of 94%. A standardized perioperative protocol enhances the possibility of preserving the native esophagus in cases of LGEA. Gap measurement can be accurately defined before surgery in all patients with EA. Esophageal anastomosis (either immediate or delayed repair) is almost always feasible; esophageal substitution should only be considered after a rigorous attempt at achieving end-to-end esophageal anastomosis.
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Affiliation(s)
- P Bagolan
- Department of Medical and Surgical Neonatology, Bambino Gesu' Research Children's Hospital, 00165 Rome, Italy.
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Tanaka Y, Uchida H, Kawashima H, Sato K, Takazawa S, Jimbo T, Iwanaka T. 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. Surg Today 2012. [DOI: 10.1007/s00595-012-0426-z] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome. Pediatr Surg Int 2012; 28:899-906. [PMID: 22875461 DOI: 10.1007/s00383-012-3142-2] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
PURPOSE Management of newborns with long-gap esophageal atresia (LGEA) remains a challenge for pediatric surgeons. Since spontaneous growth of the esophageal segments occurs without mechanical stretching, initial gastrostomy followed by delayed primary anastomosis (DPA) comprises treatment in most LGEA patients. This meta-analysis aimed to investigate the complications and long-term outcome in patients with LGEA managed by DPA. METHODS A systematic literature search was conducted for relevant articles published between 1981 and 2011, and a meta-analysis of complications and long-term outcome was performed. RESULTS Forty-four articles presented data on 451 newborns with LGEA managed by DPA. Most common variants were pure LGEA (194/451) and LGEA with tracheoesophageal fistula (257/451). Initial gap lengths ranged from 1.9 to 7.0 cm. At the time of DPA, performed at a mean of 11.9 weeks (range 0.5-54.0), the gap had decreased to 0.5-3.0 cm. Mean follow-up was 5.5 years (range 0.5-27.0). Frequent complications were anastomotic leaks/strictures, gastroesophageal reflux (GER), esophagitis and dysphagia. Relative risk for strictures was significantly higher in patients who previously had a leak (p < 0.0001) or GER (p < 0.0001). Patients with GER also had a significantly higher risk for esophagitis (p = 0.0283) and dysphagia (p = 0.0174). The majority of patients could eat without swallowing difficulties at follow-up. CONCLUSION DPA provides good long-term functional results. However, the high incidence of GER and associated strictures requires early intervention to prevent feeding problems.
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Type A esophageal atresia: a critical review of management strategies at a single center. J Pediatr Surg 2010; 45:865-71. [PMID: 20438915 DOI: 10.1016/j.jpedsurg.2010.02.004] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2010] [Accepted: 02/02/2010] [Indexed: 12/30/2022]
Abstract
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.
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Tamburri N, Laje P, Boglione M, Martinez-Ferro M. Extrathoracic esophageal elongation (Kimura's technique): a feasible option for the treatment of patients with complex esophageal atresia. J Pediatr Surg 2009; 44:2420-5. [PMID: 20006042 DOI: 10.1016/j.jpedsurg.2009.07.037] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2009] [Revised: 07/16/2009] [Accepted: 07/17/2009] [Indexed: 02/07/2023]
Abstract
AIM The aim of this study was to evaluate the outcome of all patients who underwent an extrathoracic esophageal elongation (EEE) (Kimura's technique) and determine its role, among other surgical options, for the treatment of patients with complex esophageal atresia (EA) who have a previously created esophagostomy. METHODS Between March 1997 and September 2008, we performed 20 EEEs. Twelve patients were males and 8 were females. The diagnoses were type C EA (n = 12), type A EA (n = 5), type B EA (n = 2), and type D EA (n = 1). Mean age at the initiation of the EEE was 10 months (range, 3-25 months). RESULTS At the time of this report, 15 of the 20 patients have finished the treatment, 4 patients are still in the process of elongation, and one patient (premature, with a birth weight of 685 g) died before the final esophageal reconstruction. Of the 15 patients who finished the treatment, 12 (80%) completed it satisfactorily and 3 (20%) had to be prematurely interrupted. (In 2 patients, despite multiple attempts, the upper pouch could not be adequately elongated, and in one patient, an early perforation of the upper pouch precluded further elongations.) Of the 12 patients who completed the treatment satisfactorily, 10 (83%) are asymptomatic and exclusively on oral alimentation, whereas 2 (17%) have a pseudodiverticulum and esophageal dysmotility (requiring supplemental alimentation through a gastrostomy). Five of the 12 patients have gastroesophageal reflux (2 required a Nissen fundoplication and 3 are being treated medically). CONCLUSIONS We believe that the EEE is a useful surgical option for a selected group of patients with complex long-gap EA who required a primary esophagostomy and also for patients with any type of EA who developed severe complications after a primary repair and required a secondary esophagostomy. With this technique, we avoided an esophageal replacement in 80% of cases, and given that the EEE does not invalidate a later esophageal replacement, we believe that the EEE is a feasible initial option for these patients.
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Affiliation(s)
- Natalia Tamburri
- National Children's Hospital Juan P. Garrahan, Buenos Aires, Argentina
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Holland AJA, Ron O, Pierro A, Drake D, Curry JI, Kiely EM, Spitz L. Surgical outcomes of esophageal atresia without fistula for 24 years at a single institution. J Pediatr Surg 2009; 44:1928-32. [PMID: 19853749 DOI: 10.1016/j.jpedsurg.2009.02.008] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/28/2008] [Revised: 02/02/2009] [Accepted: 02/02/2009] [Indexed: 12/29/2022]
Abstract
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.
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Affiliation(s)
- Andrew J A Holland
- Department of Pediatric Surgery, Institute of Child Health and Great Ormond Street Hospital for Children, University College London, London, UK.
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Abstract
PURPOSE To analyze the outcome in 192 children (116 males, 76 females) undergoing transposition since 1981. METHODS The most common indications for esophageal replacement included failed repair of different varieties of esophageal atresia (138), caustic injury (29), and peptic strictures (9). 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 by using blunt mediastinal dissection in 98 patients, with an additional 90 patients undergoing lateral thoracotomy. The retrosternal position was used in 4 patients. RESULTS There were no graft failures, including those who had previously had failed gastric tube or Scharli operations. Anastomotic leaks occurred in 12% (all but one resolved spontaneously). Anastomotic stricture, requiring dilation developed in 20%. Half of these patients had previously sustained caustic esophageal injury. There were 9 deaths in the group (4.6%). One death occurred intraoperatively, 5 in the early postoperative period, and there were 3 late deaths. In over 90% of our patients, the outcome was considered good to excellent in terms of absence of swallowing difficulties or other gastrointestinal symptoms. Many children 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 for more than 10 years. CONCLUSIONS Gastric transposition for esophageal substitution is an acceptable procedure. It is attended by 4.6% mortality and a 12% leak rate. A total of 20% of the patients needed anastomotic dilation for stricture. In the long term, good function has been maintained. Gastric transposition compares favorably with other methods of esophageal replacement.
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Affiliation(s)
- Lewis Spitz
- Department of Paediatric Surgery, Institute of Child Health, University College London, London, United Kingdom.
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Conforti A, Bagolan P. Re: Which is better for esophageal substitution in children, esophagocoloplasty or gastric transposition? A 27-year experience of a single center. J Pediatr Surg 2007; 42:1633-4; author reply 1634. [PMID: 17848265 DOI: 10.1016/j.jpedsurg.2007.05.048] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2007] [Accepted: 05/31/2007] [Indexed: 11/21/2022]
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Brantberg A, Blaas HGK, Haugen SE, Eik-Nes SH. Esophageal obstruction-prenatal detection rate and outcome. ULTRASOUND IN OBSTETRICS & GYNECOLOGY : THE OFFICIAL JOURNAL OF THE INTERNATIONAL SOCIETY OF ULTRASOUND IN OBSTETRICS AND GYNECOLOGY 2007; 30:180-7. [PMID: 17625804 DOI: 10.1002/uog.4056] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/16/2023]
Abstract
OBJECTIVE Prenatal diagnosis of esophageal obstruction is believed to improve the outcome for the affected newborn. However, the prenatal detection rate is only 10-40%, the diagnosis is usually not made before the third trimester and the false-positive rate has been high. This study investigated the prenatal detection rate and time of prenatal diagnosis at our center and its influence on outcome. In addition, incidence, detection rate and accuracy of the diagnosis in a large non-selected population were determined. METHODS All cases diagnosed pre- or postnatally with esophageal obstruction and examined prenatally by ultrasound at the National Center for Fetal Medicine in Norway during 1987-2004 were evaluated. RESULTS Of 48 cases with esophageal obstruction, 21 (44%) were diagnosed prenatally (median, 32 + 0 weeks). All 21 had a small or empty stomach, 20/21 (95%) had polyhydramnios and 9/21 (43%) had a visible esophageal pouch. Associated anomalies were present in 38/48 cases (79%). The karyotype was abnormal in 11/48 cases (23%). Ten (21%) pregnancies with lethal fetal conditions were terminated. Two fetuses died in utero. Ten infants with associated anomalies died within 3 months after birth. The 26/48 (54%) survivors included 16/21 cases with a prenatal diagnosis of esophageal obstruction and 9/10 cases with isolated esophageal obstruction. CONCLUSIONS The clinical signs of polyhydramnios were the most important factors for prenatal detection of esophageal obstruction. Consequently, the time of diagnosis was late and the detection rate was low (44%). An increased awareness of the possibility of esophageal obstruction, leading to targeted examinations whenever the suspicion is raised during pregnancy, might improve the prenatal detection rate and thereby provide a possibility to improve the outcome. Of the cases with isolated esophageal obstruction, 90% survived, irrespective of prenatal diagnosis.
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Affiliation(s)
- A Brantberg
- National Center for Fetal Medicine, Department of Obstetrics and Gynecology, St. Olav's Hospital, Trondheim University Hospital, Norwegian University of Science and Technology, Trondheim, Norway.
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Nasr A, Ein SH, Gerstle JT. Infants with repaired esophageal atresia and distal tracheoesophageal fistula with severe respiratory distress: is it tracheomalacia, reflux, or both? J Pediatr Surg 2005; 40:901-3. [PMID: 15991167 DOI: 10.1016/j.jpedsurg.2005.03.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
AIM OF STUDY Infants with repaired esophageal atresia and distal tracheoesophageal fistula (EA/TEF) are at risk for severe respiratory distress, which is related to tracheomalacia (TM), gastroesophageal reflux, or both. This usually mandates an operation for TM and/or a fundoplication procedure (FP). METHODS We retrospectively performed a 26-year review of 288 patients with repaired EA/TEF. Research Ethic Board approval was obtained. RESULTS Postoperatively, 22 (7.6%) infants with EA/TEF developed severe respiratory distress. Thirteen infants had an initial TM procedure and symptoms improved in 7 (54%). The 6 (46%) remaining patients with ongoing respiratory symptoms required an FP. Nine infants had an initial FP and the symptoms improved in 6 (67%). The remaining 3 (33%) patients with ongoing respiratory symptoms required a TM procedure. All patients improved with the second procedure. Several clinical parameters were assessed among the 4 patient groups (FP only, FP followed by TM procedure, TM procedure only, and TM procedure followed by FP); there were no significant differences noted. CONCLUSIONS Whereas 54% to 67% of infants improved with a TM procedure or FP, 33% to 46% required both surgical procedures. No clinical parameters were identified that could predict which procedure should be performed first.
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Affiliation(s)
- Ahmed Nasr
- Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, M5G 1X8, Canada
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Lopes MF, Reis A, Coutinho S, Pires A. Very long gap esophageal atresia successfully treated by esophageal lengthening using external traction sutures. J Pediatr Surg 2004; 39:1286-7. [PMID: 15300549 DOI: 10.1016/j.jpedsurg.2004.04.028] [Citation(s) in RCA: 31] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Esophageal atresia with a 6-cm gap or longer and a very short distal segment represents the extreme of this disorder's spectrum, the treatment of which can be challenging. Very often, several surgical procedures have to be carried out to maintain the patient's own esophagus. The authors report on a child born with isolated esophageal atresia without fistula and a very long gap (8.5 vertebral spaces in length). Delayed anastomosis was accomplished using a combination of various procedures that included a waiting period allowing for spontaneous esophageal growth, mobilization of the distal segment, and esophageal lengthening by external traction sutures. The aim of this report is to define the role of the traction method in the repair of this kind of atresia.
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20
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Bagolan P, Iacobelli Bd BD, De Angelis P, di Abriola GF, Laviani R, Trucchi A, Orzalesi M, Dall'Oglio L. Long gap esophageal atresia and esophageal replacement: moving toward a separation? J Pediatr Surg 2004; 39:1084-90. [PMID: 15213904 DOI: 10.1016/j.jpedsurg.2004.03.048] [Citation(s) in RCA: 65] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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 (> or =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.
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Affiliation(s)
- P Bagolan
- Neonatal Surgery Unit Department of Medical and Surgical Neonatology, Bambino Gesú Children's Hospital, Rome, Italy
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Abstract
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.
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Affiliation(s)
- Lewis Spitz
- Great Ormond Street Hospital for Children, London England, UK
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22
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Aziz D, Schiller D, Gerstle JT, Ein SH, Langer JC. Can 'long-gap' esophageal atresia be safely managed at home while awaiting anastomosis? J Pediatr Surg 2003; 38:705-8. [PMID: 12720175 DOI: 10.1016/jpsu.2003.50188] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Neonates with "long gap" esophageal atresia (EA) are often managed with gastrostomy and tube drainage of the proximal pouch for a number of months while awaiting definitive repair. Because of the risk of aspiration and need for complex nursing care, most remain hospitalized during this time. However, prolonged hospitalization utilizes scarce resources and may be difficult for many families. METHODS The authors report on 5 patients who were treated successfully at home while awaiting esophageal anastomosis. RESULTS Four patients had pure EA (one had a duodenal atresia), and one had a distal fistula. Gestational ages ranged from 31 to 41 weeks. All had a gastrostomy within days of birth. Age at definitive repair ranged from 6 to 12 months. Time at home while awaiting anastomosis ranged from 42 to 113 days. Care at home included nursing care, suction equipment and training, gastrostomy feeding, and ability to perform cardiopulmonary resuscitation. The only complications noted while at home consisted of ear infection in one patient and recurrent upper respiratory tract infections in another patient. CONCLUSIONS Selected patients with long gap esophageal atresia can be treated safely at home while awaiting esophageal anastomosis. Success of this approach depends on a motivated, reliable family, and adequate support from community health care providers.
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Affiliation(s)
- Dalal Aziz
- Division of General Surgery, Hospital for Sick Children and University of Toronto, Toronto, Ontario, Canada
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Thomas EJ, Kumar R, Dasan JB, Chandrashekar N, Agarwala S, Tripathi M, Bal CS. Radionuclide scintigraphy in the evaluation of gastro-oesophageal reflux in post-operative oesophageal atresia and tracheo-oesophageal fistula patients. Nucl Med Commun 2003; 24:317-20. [PMID: 12612473 DOI: 10.1097/00006231-200303000-00012] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Gastro-oesophageal reflux (GOR) is a major cause of morbidity in children who undergo surgical repair for oesophageal atresia with tracheo-oesophageal fistula (OA/TOF). We performed a retrospective analysis to determine the incidence of GOR on radionuclide scintigraphy in symptomatic and asymptomatic OA/TOF patients in the first post-operative year. A total of 124 patients (74 males, 50 females), with a mean age of 3.5 months (range, 20 days to 12 months), were studied. Of these 124 patients, 67 were symptomatic and 57 were asymptomatic. On radionuclide scintigraphy, 73 patients (48 symptomatic and 25 asymptomatic) had reflux. Of the 48 symptomatic patients with scintigraphic studies positive for reflux, 79.2% (38) had proximal reflux and 20.8% (10) had distal reflux, whereas, of the 57 asymptomatic patients, 48% (12) had proximal reflux and 52% (13) had distal reflux. There was a significantly higher incidence of GOR in symptomatic children than in asymptomatic children (P<0.01). In particular, there was a significantly higher incidence of proximal GOR in symptomatic children than in asymptomatic children (P<0.001). In conclusion, the severity and incidence of GOR were significantly higher in symptomatic than asymptomatic OA/TOF patients in their first post-operative year. Scintigraphic evidence of proximal reflux correlates with the presence of symptomatic GOR.
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Affiliation(s)
- E J Thomas
- Department of Nuclear Medicine, All India Institute of Medical Sciences, New Delhi, India
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Maksoud-Filho JG, Gonçalves MEP, Tannuri U, Maksoud JG. An exclusively intraabdominal distal esophageal segment prevents primary delayed anastomosis in children with pure esophageal atresia. J Pediatr Surg 2002; 37:1521-5. [PMID: 12407531 DOI: 10.1053/jpsu.2002.36176] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE The aim of this study was to evaluate the outcome of children with pure esophageal atresia (EA) managed by the strategy of delayed primary anastomosis and to find parameters to identify which of these children will have satisfactory esophageal growth to permit a successful primary esophageal anastomosis. METHODS Sixteen children with pure EA were treated by delayed anastomosis strategy from June 1992 to May 2001 at the Instituto da Criança-University of São Paulo Medical School. The treatment consisted of creating an early feeding gastrostomy, continuous upper pouch suction, and periodic radiologic/endoscopic assessments of the gap between the superior and inferior esophageal pouches. The first assessment was done 4 weeks after the initial gastrostomy. Subsequent assessments were done, when necessary, 4 to 10 weeks after the first one. Children with the gap between the pouches corresponding to 2 vertebral bodies or less were considered for primary repair. RESULTS The waiting period ranged from 8 to 14 weeks. Five children were considered for primary repair (31.3%). All of them had an end-to-end esophageal anastomosis performed without tension. Eleven children (68.7%) did not show significant esophageal growth after the waiting period and were not considered for primary esophageal anastomosis. Eight of them (50%) showed an entirely intraabdominal distal pouch at the first assessment. CONCLUSIONS (1) Infants with an exclusively intraabdominal distal pouch at the first evaluation will not reach sufficient elongation of the pouches and should be considered early as a candidate for esophageal replacement. (2) Combined radiologic/endoscopic assessment and the measurement of the gap in terms of vertebral bodies is a practical and reliable method to predict the feasibility of primary anastomosis. (3) Using these criteria, primary anastomosis could be accomplished in less than a third of cases.
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Affiliation(s)
- João Gilberto Maksoud-Filho
- Pediatric Surgery Division, Department of Pediatric Surgery, University of São Paulo Medical School, São Paulo, Brazil
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25
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Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia. Ann Surg 2002. [PMID: 12368682 DOI: 10.1097/00000658-200210000-00016] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To evaluate the authors' experience with gastric transposition as a method of esophageal replacement in children with congenital or acquired abnormalities of the esophagus. SUMMARY BACKGROUND DATA Esophageal replacement in children is almost always done for benign disease and thus requires a conduit that will last more than 70 years. The organ most commonly used in the past has been colon; however, most series have been fraught with major complications and conduit loss. For these reasons, in 1985 the authors switched from using colon interpositions to gastric transpositions for esophageal replacement in infants and children. METHODS The authors retrospectively reviewed the records of 41 patients with the diagnoses of esophageal atresia (n = 26), corrosive injury (n = 8), leiomyomatosis (n = 5), and refractory gastroesophageal reflux (n = 2) who underwent gastric transposition for esophageal replacement. RESULTS Mean +/- SE age at the time of gastric transposition was 3.3 +/- 0.6 years. All but two transpositions were performed through the posterior mediastinum without mortality or loss of the gastric conduit despite previous surgery on the gastric fundus in 8 (20%), previous esophageal operations in 15 (37%), and previous esophageal perforations in 6 (15%) patients. Complications included esophagogastric anastomotic leak (n = 15, 36%), which uniformly resolved without intervention; stricture formation (n = 20, 49%), all of which no longer require dilation; and feeding intolerance necessitating jejunal feeding (n = 8, 20%) due to delayed gastric emptying (n = 3), feeding aversion related to the underlying anomaly (n = 1), or severe neurological impairment (n = 4). No redo anastomoses were required. CONCLUSIONS Gastric transposition reestablishes effective gastrointestinal continuity with few complications. Oral feeding and appropriate weight gain are achieved in most children. Therefore, gastric transposition is an appropriate alternative for esophageal replacement in infants and children.
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Hirschl RB, Yardeni D, Oldham K, Sherman N, Siplovich L, Gross E, Udassin R, Cohen Z, Nagar H, Geiger JD, Coran AG. Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia. Ann Surg 2002; 236:531-9; discussion 539-41. [PMID: 12368682 PMCID: PMC1422608 DOI: 10.1097/01.sla.0000030752.45065.d1] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To evaluate the authors' experience with gastric transposition as a method of esophageal replacement in children with congenital or acquired abnormalities of the esophagus. SUMMARY BACKGROUND DATA Esophageal replacement in children is almost always done for benign disease and thus requires a conduit that will last more than 70 years. The organ most commonly used in the past has been colon; however, most series have been fraught with major complications and conduit loss. For these reasons, in 1985 the authors switched from using colon interpositions to gastric transpositions for esophageal replacement in infants and children. METHODS The authors retrospectively reviewed the records of 41 patients with the diagnoses of esophageal atresia (n = 26), corrosive injury (n = 8), leiomyomatosis (n = 5), and refractory gastroesophageal reflux (n = 2) who underwent gastric transposition for esophageal replacement. RESULTS Mean +/- SE age at the time of gastric transposition was 3.3 +/- 0.6 years. All but two transpositions were performed through the posterior mediastinum without mortality or loss of the gastric conduit despite previous surgery on the gastric fundus in 8 (20%), previous esophageal operations in 15 (37%), and previous esophageal perforations in 6 (15%) patients. Complications included esophagogastric anastomotic leak (n = 15, 36%), which uniformly resolved without intervention; stricture formation (n = 20, 49%), all of which no longer require dilation; and feeding intolerance necessitating jejunal feeding (n = 8, 20%) due to delayed gastric emptying (n = 3), feeding aversion related to the underlying anomaly (n = 1), or severe neurological impairment (n = 4). No redo anastomoses were required. CONCLUSIONS Gastric transposition reestablishes effective gastrointestinal continuity with few complications. Oral feeding and appropriate weight gain are achieved in most children. Therefore, gastric transposition is an appropriate alternative for esophageal replacement in infants and children.
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Affiliation(s)
- Ronald B Hirschl
- C.S. Mott Children's Hospital, University of Michigan Medical School, Ann Arbor, Michigan 48109-0245, USA.
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27
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Günşar C, Sencan A, Karaca I, Mir E. Isolated esophageal atresia with spontaneous recanalization: case report. J Pediatr Surg 2002; 37:1210-2. [PMID: 12149706 DOI: 10.1053/jpsu.2002.34478] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Isolated esophageal atresia is characterized by a long segment between the 2 esophageal pouches. The authors describe a case of pure esophageal atresia that showed spontaneous recanalization in the waiting period for primary esophageal anastomosis. Regurgitation of gastrostomy formula surprisingly was seen in her mouth. The patency of the esophagus was confirmed with thoracic computed tomography (CT) and an esophagogram. A strictured area in the proximal upper third of the esophagus was managed with baloon dilatation. She was discharged in normal condition, feeding by mouth, and with a normal esophagogram. This interesting event led us to speculate about a different type of pure esophageal atresia with the feasibility of the ends recanalizing after some events such as inflammation. This could be the subtype II5 of type 2 in Kluth's atlas of esophageal atresia in which they described 2 blind esophageal ends and a cyst occupying the intervening space. Another speculation about this subject is the presence of double membranes associated with esophageal atresia with a normal outer appearance of the esophagus as was first described by A. F. van Loosbroek.
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Affiliation(s)
- Cüneyt Günşar
- Department of Pediatric Surgery, Celal Bayar University Medical Faculty, Manisa, Turkey
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Schier F, Korn S, Michel E. Experiences of a parent support group with the long-term consequences of esophageal atresia. J Pediatr Surg 2001; 36:605-10. [PMID: 11283887 DOI: 10.1053/jpsu.2001.22299] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
PURPOSE The aim of this study was to study long-term effects of esophageal atresia based on data from the world's largest parent support group. METHODS A questionnaire was completed by 128 former patients, now aged 10 to 34 years (median, 14 years), who were all members of the support group. RESULTS Postoperative bougienage was performed in 70% of patients. The most frequently associated anomalies were skeletal (44%), with 18% of patients having a winged scapula. In 30% of patients, food became trapped; this entrapment continues, although with decreasing frequency. In 38% of patients, recurrent episodes of food lodging in the esophagus lasted only a few years, whereas 32% of patients never experienced any swallowing problems. The foods most often trapped were apples, meat, and bread. Most trapped food is removed by the induction of vomiting, without medical help. Unusual findings of this study were the avoidance of chocolate and sweets by 9% of patients and the habit of eating unorthodox food combinations in 13% of patients. Forty-six percent of patients have gastroesophageal reflux, and 7% have Barrett's esophagus. The most successful antireflux prevention was abstinence from eating late in the evening. Fundoplication was performed in 16% of patients; however, only 25% of these fundoplication operations were successful immediately. Eighty percent of patients had more than 4 lung infections or bronchitis episodes per year. Forty-four percent make noises, such as wheezing or whistling, when breathing or straining. Eighty-eight percent are of normal height, and 70% are of normal weight. Eighty-nine percent of patients attended regular schools, and 52% were above-average students. CONCLUSIONS Very few pediatric surgeons have had the opportunity to follow into adulthood such a large group of patients with esophageal atresia. Patients themselves feel lost when they undergo the transition from pediatric to adult medical treatment. A support group is able to provide an information database, which helps overcome the isolation because of the rareness of the disease and the separation of patients into different medical specialties. Surgeons should be aware of the difficulties that patients and parents face in later life and should seek cooperation with a support group. J Pediatr Surg 36:605-610.
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Affiliation(s)
- F Schier
- Department of Paediatric Surgery, University Medical Centre Jena, Bachstr. 18, 07740 Jena, Germany
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Abstract
BACKGROUND/PURPOSE Long gap esophageal atresia may require months of preoperative management before definitive repair. When 2 recent patients prompted the authors to consider preoperative home care, no published protocol could be identified. This survey is undertaken to determine pediatric surgeons' experience with preoperative home care for long gap atresia. METHODS A total of 543 surgeons were asked if any patients with long gap atresia had been treated preoperatively at home. For patients sent home, information on nursing care, insurance issues, complications, and timing or type of repair was requested. RESULTS A total of 380 surveys (70%) were returned. A total of 165 surveys representing 348 patients were included. Forty-one of 165 surgeons (25%) treated 63 of 87 patients (72%) with long gap atresia and an intact upper pouch at home. Home nursing care was provided for 44 patients (70%): 16 (36.4%) night shift, 2 (4.5%) day shift, 3 (6.8%) 24 hour, and 23 (52.3%) intermittent care. No complications referable to preoperative home care were reported. CONCLUSIONS Significant hesitancy and practice variance exists regarding preoperative home care of patients with long gap esophageal atresia. Many surgeons are satisfied with the safety and cost effectiveness of this technique, although a prospective, multicenter trial is needed to study it in a randomized, controlled fashion.
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Affiliation(s)
- C M Hollands
- Miami Children's Hospital, Division of Pediatric Surgery, FL, USA
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30
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Davison P, Poenaru D, Kamal I. Esophageal atresia: primary repair of a rare long gap variant involving distal pouch mobilization. J Pediatr Surg 1999; 34:1881-3. [PMID: 10626882 DOI: 10.1016/s0022-3468(99)90340-8] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
This report describes a rare type IIIb variant of long gap pure esophageal atresia treated with delayed primary repair. Preoperative imaging showed a distal pouch with a unusually long tapering end, and a 5-vertebral body gap. Delayed exploration with mobilization of the distal pouch allowed for successful primary repair without the need of myotomy. The characteristic radiological appearance of this rare variant enables its preoperative recognition and warrants attempting primary repair with a good expectation of success.
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Affiliation(s)
- P Davison
- Department of Surgery, Queen's University, Kingston, Ontario, Canada
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31
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Brown AK, Roddam AW, Spitz L, Ward SJ. Oesophageal atresia, related malformations, and medical problems: a family study. AMERICAN JOURNAL OF MEDICAL GENETICS 1999; 85:31-7. [PMID: 10377010 DOI: 10.1002/(sici)1096-8628(19990702)85:1<31::aid-ajmg7>3.0.co;2-d] [Citation(s) in RCA: 33] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Oesophageal atresia (OA) and tracheo-oesophageal fistula (TOF) are life-threatening malformations of generally undefined cause. Previous reports of familial cases suggest a genetic contribution. The pattern of inheritance appears non-Mendelian, i.e., multifactorial. Individuals with OA/TOF often have other malformations and medical problems. The aim of this study was to determine the association in OA/TOF cases and healthy control subjects of associated malformations, midline defects, and medical conditions. We also investigate the relationships of these conditions in the relatives of the cases and controls. The results show that infants with OA/TOF frequently have VACTERL anomalies (vertebral, 17%; anal, 12%; cardiac, 20%; renal, 16%; limb, 10%) and other midline defects (cleft lip and palate, 2%; sacral dysgenesis, 2%; urogenital anomalies, 5%). The following medical problems were also reported: oesophageal dysmotility, 21%; gastro-oesophageal reflux, 22%; chest infections, 6%; and autonomic dysfunction, 0.5%. The first-degree relatives of children with OA are much more likely to have one of the aforementioned malformations or medical conditions when compared with the control group: one or more VACTERL anomalies (P < 0.01), gastro-oesophageal reflux (P < 0.05), recurrent respiratory infections (P < 0.05), and autonomic dysfunction (P < 0.001). The more distant relatives also show an increased incidence of such problems although in this case the data must be viewed with caution. The results confirm that the associated malformations and related medical problems occur significantly more frequently in the relatives of individuals with OA/TOF. These families may prove valuable for linkage analysis in an attempt to determine the genetics of OA/TOF.
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Affiliation(s)
- A K Brown
- Department of Human Anatomy and Genetics, University of Oxford, England
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Tannuri U, Tannuri AC, Fukutaki MF, de Oliveira MS, Muoio VM, Massaguer AA. Effects of circular myotomy on the healing of esophageal suture anastomosis: an experimental study. REVISTA DO HOSPITAL DAS CLINICAS 1999; 54:9-16. [PMID: 10488595 DOI: 10.1590/s0041-87811999000100003] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
For esophageal reconstruction in newborns with esophageal atresia, esophageal reunion with an end-to-end anastomosis is the ideal procedure, although it may result in leaks and strictures due to tension on the suture line, mainly in cases with a wide gap between the ends. Circular myotomy (Livaditis' procedure) is the best method to elongate the proximal esophageal pouch and reduce anastomotic tension. This experimental investigation in dogs was undertaken to attempt to verify that circular myotomy decreases the anastomotic leak rate in newborns with wide gap esophageal atresia, and to analyze whether the technique promotes morphologic changes in the anastomotic scar. A pilot study demonstrated that it is necessary to resect more than 8 cm (40% of the total esophageal length) in order to obtain high leak rates. In the experimental project, such resection was performed in dogs divided into two groups (control group, anastomosis only, and experimental group, anastomosis plus circular myotomy in the proximal esophageal segment). The animals were killed in the 14th postoperative day, submitted to autopsy, and were evaluated as to the presence of leaks and strictures, as well as to the features (macroscopic and microscopic aspects) of the anastomosis. Leak rates were the same in both groups. Morphometric analysis revealed that in animals in the experimental group, the anastomotic scar was thinner than the control animals, and the isolated muscular manchette distal to the site of myotomy was replaced by fibrous tissue. Correspondingly, a decreased number of newly formed small vessels were noted in the experimental animals, compared to control animals. We concluded that circular myotomy does not decrease the incidence of anastomotic leaks, and it also promotes deleterious changes in anastomotic healing.
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Affiliation(s)
- U Tannuri
- Pediatric Surgery Laboratory (LIM-30), University of São Paulo Medical School, Brazil
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Bergmeijer JH, Hazebroek FW. Prospective medical and surgical treatment of gastroesophageal reflux in esophageal atresia. J Am Coll Surg 1998; 187:153-7. [PMID: 9704961 DOI: 10.1016/s1072-7515(98)00116-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
BACKGROUND Gastroesophageal reflux is a major cause of anastomotic complications after repair of esophageal atresia. For this reason, we evaluated a prospective, postoperative treatment protocol with the emphasis on comparing medical and operative treatment. STUDY DESIGN From 1994 to 1995, 26 consecutive patients underwent correction of esophageal atresia in the Sophia Children's Hospital. These patients were enrolled in a decision-making protocol meant to establish the effect of medical treatment on gastroesophageal reflux and stricture formation, the relation between anastomotic tension and reflux, and the question of whether performing a Nissen fundoplication was justified. Patients who showed reflux on the first postoperative x-ray were given medical treatment. Reflux was assessed after 6-12 weeks by x-ray and 48-hour pH-metry (24 hours with and 24 hours without medication). Evaluations were repeated at 18 weeks, 6 months, and 1 year. Twenty-three patients were followed for > or = 1 year. RESULTS Twenty-four patients had classic esophageal atresia combined with tracheoesophageal fistula. Two had isolated atresia and underwent a colonic interposition. One of the others died of severe cerebral hemorrhage early after the operation. Twenty-two of the remaining 23 showed reflux on the first postoperative x-ray and were given medical treatment. The mean 3.8% total mild reflux time (range, 0.0-11.0%) decreased to a mean of 1.47% (range, 0.0-6.8%). Medical treatment given according to protocol did not influence severe reflux. Eleven of 23 patients showed stricture formation, requiring a mean of four dilatation procedures (range, 1-9). Defining a real stricture as one needing three or more dilatations, as seen in seven patients, the following results were seen: four nonrefluxing patients (proved by x-ray and pH-metry) needed a mean of 4.2 dilatations (range, 3-7), and three refluxing patients (proved by x-ray and pH-metry) needed a mean of 7.3 dilatations (range, 5-9). Three of seven patients with anastomotic tension had proved gastroesophageal reflux; reflux was also diagnosed in 8 of 15 patients without any tension on the anastomosis. Nine of 23 patients underwent a Nissen fundoplication according to the protocol. In four of them, this was decided because of severe reflux-associated respiratory problems; in one, for resistant stenosis after a Livaditis procedure; and in one with normal pH-metry, the procedure was done on clinical grounds. The latter patient needed an aortopexy at a later stage. A late fundoplication was performed in two patients for persistent gastroesophageal reflux unresponsive to medical treatment, and in one for persistent stenosis and reflux. In all patients, the outcomes were successful, without complications. CONCLUSIONS Medical treatment of gastroesophageal reflux after repair of esophageal atresia has a distinct effect on the duration of reflux and could have a positive effect on the occurrence and treatment of stenosis. There is no clear relation between the occurrence of reflux and tension on the anastomosis. Nissen fundoplication according to the protocol was done appropriately in eight of nine patients.
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Affiliation(s)
- J H Bergmeijer
- Department of Pediatric Surgery, Sophia Children's Hospital/University Hospital Rotterdam, The Netherlands
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Affiliation(s)
- P Puri
- Children's Research Centre, Our Lady's Hospital for Sick Children, Dublin, Ireland
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Affiliation(s)
- H B Othersen
- Department of Surgery, Medical University of South Carolina, Charleston 29425, USA
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Foker JE, Linden BC, Boyle EM, Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg 1997; 226:533-41; discussion 541-3. [PMID: 9351721 PMCID: PMC1191075 DOI: 10.1097/00000658-199710000-00014] [Citation(s) in RCA: 161] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
OBJECTIVE To determine whether or not a true primary repair, without myotomies and with the gastroesophageal junction below the diaphragm, can be accomplished across the esophageal atresia (EA) spectrum. Our hypothesis is that the esophageal anastomosis can withstand significant tension. The consequences, particularly for those patients with a very long gap atresia, were assessed. SUMMARY OF BACKGROUND DATA Difficulties arise roughly in proportion to the size of the gap between esophageal segments. Reported surgical complications remain frequent, and particularly at the far end of the EA spectrum, not all children are left with a satisfactorily functioning esophagus or esophageal substitute. METHODS The outcomes of all infants who had a true primary repair of EA from 1976-1997 were determined. Surgically, the methods used to achieve a reliable true primary repair were expanded to accomplish this, even for a very long gap EA. RESULTS From 1976-97, 70 infants with or without associated tracheoesophageal fistula (TEF) had primary repairs performed with no surgery-related deaths and 11% later deaths. No interpositions were performed since 1983. There were no discernible anastomotic leaks and one late recurrent TEF related to the early use of balloon dilation. Ten infants had gaps of 5.0-6.8 cm and, among these, four had gaps of 5.5-6.8 cm that could not be pulled together initially. Traction sutures in the esophageal ends, however, produced sufficient lengthening within 6-10 days for a true primary repair. Very long gap repairs produced more reflux (10 of 10 required a fundoplication versus 24 of 70 overall) and more dilations to relieve strictures. Two infants underwent stricture resection with no recurrence. On follow-up, all patients over 2 years of age were eating well or satisfactorily, and none had a gastrostomy tube. CONCLUSIONS (1) The esophageal anastomosis can withstand considerable tension and allows a reliable true primary repair for the full EA spectrum. (2) Growth is rapid and traction sutures will produce significant esophageal lengthening within days. (3) With increasing tension, gastroesophageal reflux (GER) and strictures are more common; however, both are treatable. Follow-up reveals the benefits of true primary repair over other solutions.
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Affiliation(s)
- J E Foker
- Department of Surgery, University of Minnestoa, Minneapolis 55455, USA
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Tsai JY, Berkery L, Wesson DE, Redo SF, Spigland NA. Esophageal atresia and tracheoesophageal fistula: surgical experience over two decades. Ann Thorac Surg 1997; 64:778-83; discussion 783-4. [PMID: 9307473 DOI: 10.1016/s0003-4975(97)00752-2] [Citation(s) in RCA: 70] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Despite improvements in survival, for infants born with esophageal atresia tracheoesophageal fistula, or both, the morbidity associated with repair of these anomalies remains high. METHODS This report retrospectively analyzes 81 patients with esophageal atresia, tracheoesophageal fistula, or both presenting to our institution between 1975 and 1995, with a focus on anastomotic complications. RESULTS There were 46 male and 35 female patients with a mean gestational age of 37 weeks and mean birth weight of 2443 g. Forty-four patients underwent primary esophageal anastomoses, 7 underwent delayed primary anastomoses, 12 patients underwent staged repairs, and 5 underwent repair of H-type fistulas. Among 62 patients with anastomoses, complications included stricture in 25/62 patients (40%), leakage in 12/62 patients (19%), and recurrent tracheoesophageal fistulas in 6/62 patients (10%). Stricture rates for esophagoclonic anastomoses versus esophagoesophageal anastomoses were 4/8 cases (50%) versus 21/54 cases (39%). This difference was not statistically significant. All esophagoesophageal strictures were managed successfully with dilations; three of four esophagocolonic strictures required anastomotic revision. The leakage rate for esophagocolonic anastomoses versus esophagoesophageal anastomoses was 6/8 cases (75%) versus 6/54 cases (11%). This difference was statistically significant (p = 0.0003). Two patients required revision of their colon grafts secondary to necrosis. Eighteen of 81 patients (22%) died. Operative mortality was 9/74 (12%). Causes of death included associated anomalies (n = 15), recurrent aspiration and sepsis secondary to missed fistula (n = 1), and unknown (n = 2). CONCLUSIONS Although the morbidity associated with surgical repair of these anomalies is high, this does not affect the overall survival. The high complication rate associated with colonic interposition suggests that one should preserve the native esophagus as a primary conduit whenever feasible.
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Affiliation(s)
- J Y Tsai
- Department of Surgery, New York Hospital-Cornell Medical Center, New York 10021, USA
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Zer M, Freud E, Grozovski S. Oesophageal plastic repair for symptomatic ballooning following circular oesophageal myotomy and correction of oesophageal atresia. Thorax 1997; 52:487-8. [PMID: 9176545 PMCID: PMC1758553 DOI: 10.1136/thx.52.5.487] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
Two patients with refractory anastomotic stenosis and symptomatic ballooning of the upper oesophageal pouch following repair of long gap oesophageal atresia are described. In both cases a circular myotomy had been used to elongate the proximal oesophageal segment at the time of primary repair. Both patients were successfully treated by Y-V plasty of the oesophageal stenosis and tailoring of the dilated segment.
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Affiliation(s)
- M Zer
- Department of Pediatric Surgery, Schneider Children's Medical Center of Israel, Petah Tiqva, Israel
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Abstract
The case history is presented of a patient with neurofibromatosis with a chest wall defect present from birth. Abnormal rib development had resulted in a flail segment with painful paradoxical movement and unsightly costal cartilage protrusion. Chest wall reconstruction using Marlex mesh resulted in an excellent cosmetic and functional repair.
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Affiliation(s)
- A G Heriot
- Department of Cardiothoracic Surgery, Papworth Hospital, Cambridge, UK
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Use of Vicryl mesh to support the esophageal wall after circular myotomy (Livaditis procedure) in long-gap esophageal atresia - an experimental study. Pediatr Surg Int 1996; 11:539-43. [PMID: 24057844 DOI: 10.1007/bf00626061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/26/1996] [Indexed: 10/26/2022]
Abstract
Circular esophageal myotomy (CEM) is currently a well-accepted technique for elongation of the upper esophageal pouch in cases of long-gap esophageal atresia (EA). Esophageal pseudodiverticulum is a frequent and perhaps underreported sequela of this technique, characterized by ballooning or outpouching of the esophageal mucosa in the myotomized area. The present study was designed to seek a supplement for the CEM technique in order to avoid possible pseudodiverticulum formation in the myotomized area. We created an animal model to simulate the anatomic conditions present after primary repair of EA facilitated by CEM. Three groups of dogs underwent either cervical (1 group) or thoracic (2 groups) esophageal myectomy. In the cervical and first thoracic groups, the denuded mucosa was left without any support. In the second thoracic group, the denuded mucosal area was wrapped with polyglactin 910 (Vicryl) mesh. In all three groups the esophagus was narrowed by a Marlex mesh ring 3 cm distal to the myectomized zone, simulating a condition resulting from anastomotic narrowing. The dogs underwent barium swallows under fluoroscopy at different postoperative periods and were killed 4 or 6 months after surgery. The esophagi were removed for gross and radiologic investigation under maximal insufflation as well as for histologic assessment. The proposed canine model proved to be useful for study of the myectomized esophagus, mimicking the anatomy and conditions after CEM in long-gap EA repair. Wrapping the denuded mucosa with Vicryl mesh fortified the weakened esophageal wall, thus diminishing the likelihood of future pseudodiverticulum development. In light of the simplicity of the technique and the absence of any evident risk or complications, we recommend that the use of Vicryl mesh wrap be considered during CEM to reinforce the esophageal wall.
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Abstract
Establishment of esophageal continuity in the presence of an isolated esophageal atresia frequently requires deferred esophageal substitution. The author describes the use of Collis gastroplasty as an esophageal lengthening technique for the distal esophagus. This technique permitted the performance of primary repair of the esophagus in an infant with a 6-cm gap that otherwise would have required an esophageal substitution procedure. Morbidity after this procedure is comparable to that occurring after a number of established techniques.
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Affiliation(s)
- M Evans
- Division of Paediatric Surgery, University of Western Ontario, Canada
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Abstract
This review encompasses 50 years (1942 through 1991) and 69 newborns (43 boys, 26 girls). Half the babies were premature (weighing less than 2.5 kg), and about one third had other anomalies. The procedures used in this series were late primary anastomosis (17), gastric tube reconstruction (16), staging esophagostomy and gastrostomy (13), gastric pull-up (13), early primary anastomosis (4), and colon replacement (3). Four neonates received no treatment. The most common repair in the 1940s and 1950s was the gastric pull-up; the gastric tube was the most popular in the 1960s and 1970s. Delayed primary anastomosis has been the operation of choice since the 1980s. Over the last decade, it has become apparent that primary repair is successful in three quarters of such infants if the wait is 3 months and/or the newborn weight has at least doubled. This repair appears to provide the best functional result, unless there is an anastomotic stricture. Before the 1970s, the survival rate was below 40%, but since the 1980s the rate has more than doubled, to 90% in our series, regardless of the type of repair used.
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Affiliation(s)
- S H Ein
- Division of General Surgery, Hospital for Sick Children, Toronto, Ontario, Canada
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