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Biro E, Sommer G, Leitinger G, Abraham H, Kardos DJ, Oberritter Z, Saxena AK. Ultrastructural changes in esophageal tissue undergoing stretch tests with possible impact on tissue engineering and long gap esophageal repairs performed under tension. Sci Rep 2023; 13:1750. [PMID: 36721004 PMCID: PMC9889733 DOI: 10.1038/s41598-023-28894-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Accepted: 01/27/2023] [Indexed: 02/02/2023] Open
Abstract
Esophageal biomechanical studies are being performed to understand structural changes resulting from stretches during repair of esophageal atresias as well as to obtain biomechanical values for tissue-engineered esophagus. The present study offers insights into ultrastructural changes after stretching of the ovine esophagus using uniaxial stretch tests. In vitro uniaxial stretching was performed on esophagi (n = 16) obtained from the abattoir within 4-6 h of 1-month-old lambs. Esophagi were divided into 4 groups (4 esophagi/group): control, Group1 (G1), Group2 (G2), Group3 (G3) stretched to 20%, 30% and 40% of their original length respectively. Force and lengthening were measured with 5 cycles performed on every specimen. Transmission electron microscopic (TEM) studies were performed on the 4 groups. During observational TEM study of the control group there were no significant differences in muscle cell structure or extracellular matrix. In all stretched groups varying degrees of alterations were identified. The degree of damage correlated linearly with the increasing level of stretch. Distance between the cells showed significant difference between the groups (control (μ = 0.41 μm, SD = 0.26), G1 (μ = 1.36 μm, SD = 1.21), G2 (μ = 2.8 μm, SD = 1.83), and G3 (μ = 3.01 μm, SD = 2.06). The diameter of the cells (control μ = 19.87 μm, SD = 3.81; G1 μ = 20.38 μm, SD = 4.45; G2 μ = 21.7 μm, SD = 6.58; G3 μ = 24.48 μm, SD = 6.69) and the distance between myofibrils (control μ = 0.23 μm, SD = 0.08; G1 μ = 0.27 μm, SD = 0.08; G2 μ = 0.4 μm, SD = 0.15; G3 μ = 0.61 μm, SD = 0.2) were significantly different as well ( p < 0.05 was considered to be significant). Esophageal stretching > 30% alters the regular intracellular and extracellular structure of the esophageal muscle and leads to disruption of intra- and extracellular bonds. These findings could provide valuable insights into alterations in the microscopic structure of the esophagus in esophageal atresias repaired under tension as well as the basis for mechanical characterization for tissue engineering of the esophagus.
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Affiliation(s)
- Ede Biro
- Department of Paediatrics, Division of Paediatric Surgery, University of Pécs Medical School, Jozsef Attila St. 7, Pécs, 7634, Hungary.
| | - Gerhard Sommer
- Institute of Biomechanics, Graz University of Technology, Graz, Austria
| | - Gerd Leitinger
- Research Unit Electron Microscopic Techniques, Division of Cell Biology, Histology and Embryology, Gottfried Schatz Research Center, Medical University of Graz, Graz, Austria
| | - Hajnalka Abraham
- Department of Medical Biology and Central Electron Microscopic Laboratory, University of Pécs Medical School, Pécs, Hungary
| | - Daniel J Kardos
- Department of Paediatrics, Division of Paediatric Surgery, University of Pécs Medical School, Jozsef Attila St. 7, Pécs, 7634, Hungary
| | - Zsolt Oberritter
- Department of Paediatrics, Division of Paediatric Surgery, University of Pécs Medical School, Jozsef Attila St. 7, Pécs, 7634, Hungary
| | - Amulya K Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, 369 Fulham Road, London, SW10 9NH, UK
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Nayar R, Varshney VK, Goel AD. Outcomes of Gastric Conduit in Corrosive Esophageal Stricture: a Systematic Review and Meta-analysis. J Gastrointest Surg 2022; 26:224-234. [PMID: 34506024 DOI: 10.1007/s11605-021-05124-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2021] [Accepted: 08/13/2021] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gastric conduit has emerged as the preferred treatment option for both esophageal bypass and replacement for corrosive stricture of the esophagus. There is a lack of consensus and a dearth of published literature regarding the short- and long-term complications of using a gastric conduit. This meta-analysis aims to evaluate the outcomes, morbidity, and complications associated with it. METHODS MEDLINE, Cochrane Library, and Google Scholar (January 1960 to May 2020) were systematically searched for all studies reporting short- and/or long-term outcomes and complications following the use of a gastric conduit for corrosive esophageal stricture. RESULTS Seven observational studies involving 489 patients (53.2% males, mean age ranging from 22.1 to 41 years) who had ingested a corrosive substance (acid in 74.8%, alkali in 20.7%, and unknown in the rest) were analyzed. Gastric pull-up was performed in 56.03% (274/489) of patients. Median blood loss in the procedure was 187.5 ml with a mean operative duration of 298.75 ± 55.73 min. The overall pooled prevalence rate of anastomotic leak was 14.4% [95% CI (6.2-24.0); p < 0.05, I2 = 67.38], and anastomotic stricture was 27.2% [95% CI (13-42.8); p < 0.001, I2 = 80.11]. Recurrent dysphagia according to pooled prevalence estimates occurred in 14.4% patients [95% CI (5.4-25.1); p < 0.05, I2 = 69.1] and 90-day mortality in 4.8% patients [95% CI (1.5-9.1%); I2 = 31.1, p = 0.202]. The dreaded complication of conduit necrosis had a pooled prevalence of 1.3% [95% CI (0.1-3.4%); I2 = 0, p = 0.734]. CONCLUSION The stomach can be safely used as the conduit of choice in corrosive strictures with an acceptable rate of complications, postoperative morbidity, and mortality.
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Affiliation(s)
- Raghav Nayar
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Basni Industrial Area, Phase-II, Jodhpur, 342005, Rajasthan, India
| | - Vaibhav Kumar Varshney
- Department of Surgical Gastroenterology, All India Institute of Medical Sciences, Basni Industrial Area, Phase-II, Jodhpur, 342005, Rajasthan, India.
| | - Akhil Dhanesh Goel
- Department of Community Medicine and Family Medicine, All India Institute of Medical Sciences, Jodhpur, Rajasthan, India
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Saxena AK, Biro E, Sommer G, Holzapfel GA. Esophagus stretch tests: Biomechanics for tissue engineering and possible implications on the outcome of esophageal atresia repairs performed under excessive tension. Esophagus 2021; 18:346-352. [PMID: 32816188 DOI: 10.1007/s10388-020-00769-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/22/2020] [Accepted: 08/13/2020] [Indexed: 02/03/2023]
Abstract
BACKGROUND Esophageal biomechanical studies are important to understand structural changes resulting from stretches during repair of esophageal atresias as well as to obtain values to compare with the biomechanics of tissue-engineered esophagus in the future. This study aimed to investigate light microscopic changes after uniaxial stretching of the ovine esophagus. METHODS In vitro uniaxial stretching was performed on esophagi (n = 20) of 1-month-old lambs within 4-6 h post-mortem. Esophagi were divided into 5 groups: control and stretched (1.1, 1.2, 1.3 and 1.4). Force and lengthening were measured with 5 cycles performed on every specimen using a PBS organ bath at 37 °C. Histological studies were performed on the 5 groups. RESULTS Low forces of ~ 2 N (N) were sufficient for a 1.2-1.25 stretch in the 1st cycle, whereas a three times higher force (~ 6 N) was needed for a stretch of 1.3. In the 2nd to 5th cycle, the tissue weakened and a force of ~ 3 N was sufficient for a stretch of 1.3. Histologically, in the 1.3-1.4 stretch groups, rupture of muscle fibers and capillaries were observed, respectively. Changes in mucosa and collagen fibers could not be observed. CONCLUSIONS These results offer norm values from the native esophagus to compare with the biomechanics of future tissue-engineered esophagus. Esophageal stretching > 1.3 leads to tears in muscle fibers and to rupture of capillaries. These findings can explain the decrease in microcirculation and scarring in mobilized tissue and possibly offer clues to impaired motility in esophagus atresias repaired under excessive tension.
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Affiliation(s)
- Amulya K Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster Hospital NHS Fdn Trust, Imperial College London, 369 Fulham Road, London, SW10 9NH, UK.
| | - Ede Biro
- Department of Pediatric Surgery, Medical University of Pecs, Pecs, Hungary
| | - Gerhard Sommer
- Institute of Biomechanics, Graz University of Technology, Graz, Austria
| | - Gerhard A Holzapfel
- Institute of Biomechanics, Graz University of Technology, Graz, Austria.,Norwegian University of Science and Technology, Trondheim, Norway
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Petrov RV, Bakhos CT, Abbas AE. Robotic substernal esophageal bypass and reconstruction with gastric conduit-frequently overlooked minimally invasive option. J Vis Surg 2019; 5:47. [PMID: 31157161 PMCID: PMC6538941 DOI: 10.21037/jovs.2019.04.02] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Modern esophagectomy includes the esophageal extirpation with immediate reconstruction of the gastrointestinal (GI) continuity via posterior mediastinal route. In the majority of cases tubularized stomach is chosen as the conduit of choice. Other conduits, such as colon or small bowel can be used for these purposes as well. In rare circumstances use of the alternative route for the conduit placement is required. Authors describe the technique of robotic substernal esophageal bypass and reconstruction of the esophageal continuity.
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Affiliation(s)
- Roman V Petrov
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Charles T Bakhos
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
| | - Abbas E Abbas
- Department of Thoracic Medicine and Surgery, Lewis Katz School of Medicine at Temple University, Philadelphia, PA, USA
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Saxena AK, Klimbacher G. Comparison of esophageal submucosal glands in experimental models for esophagus tissue engineering applications. Esophagus 2019; 16:77-84. [PMID: 30097829 DOI: 10.1007/s10388-018-0633-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 07/31/2018] [Indexed: 02/03/2023]
Abstract
OBJECTIVE Esophagus tissue engineering holds promises to overcome the limitations of the presently employed esophageal replacement procedures. This study investigated 5 animal models for esophageal submucosal glands (ESMG) to identify models appropriate for regenerative medicine applications. Furthermore, this study aimed to measure geometric parameters of ESMG that could be utilized for fabrication of ESMG-specific scaffolds for esophagus tissue engineering applications. METHODS Ovine, avian, bovine, murine, and porcine esophagus were investigated using Hematoxylin-Eosin (HE), Periodic Acid Schiff (PAS), and Alcian Blue (AB), with AB applied in 3 pH levels (0.2, 1.0, and 2.5) to detect sulphated mucous. Celleye® (version F) was employed to gain parametric data on ESMGs (size, perimeter, distance to lumen, and acini concentration) necessary for scaffold fabrication. RESULTS Murine, bovine, and ovine esophagus were devoid of ESMG. Avian esophagus demonstrated sulphated acid mucous producing ESMGs with a holocrine secretion pattern, whereas sulphated acid and neutral mucous producing ESMGs with a merocrine secretion pattern were observed in porcine esophagus. Distance of ESMGs to lumen ranged from 127-340 μm (avian) to 916-983 μm (porcine). ESMGs comprised 35% (avian) to 45% (porcine) area of the submucosa. ESMG had an area of 125000 μm2 (avian) to 580000 μm2 (porcine). CONCLUSION Avian and porcine esophagus possesses ESMGs. However, porcine esophagus correlates with data available on human ESMGs. Geometric and parametric data obtained from ESMG are valuable for the fabrication of ESMG-specific scaffolds for esophagus tissue engineering using the hybrid construct approach.
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Affiliation(s)
- Amulya K Saxena
- Department of Pediatric Surgery, Chelsea Children's Hospital, Chelsea and Westminster NHS Fdn Trust, Imperial College London, London, UK.
| | - Guenther Klimbacher
- Department of General and Visceral Surgery, Kepler Universitatsklinikum, Linz, Austria
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Abstract
BACKGROUND The indications of esophageal replacement (ER) in pediatric patients include long gap esophageal atresia (LGEA), intractable post-corrosive esophageal strictures (PCES), and some rare esophageal diseases. Various conduits and procedures are currently used worldwide with a lack of consensus regarding the ideal substitute to replace the esophagus replacement. The short-term outcomes of these advanced procedures are well known; there are few data available describing long-term functional outcomes of these patients with long life expectancy. OBJECTIVES The objective of this study is to investigate the long-term functional outcomes of the most widely used techniques for ER in pediatric patients based on a comprehensive literature search covering the last 10years. METHODS Eligible were all clinical studies reporting outcomes after esophagectomy in pediatric patients, which contained information on at least 3years of follow-up after the operation. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic web-based search using MEDLINE, the Cochrane Library and EMBASE databases was performed, reviewing all medical literature published between January 2006 and December 2015. RESULTS The scientific quality of the data was generally poor, converging toward only 14 full-text articles for the final analysis. The stomach was the preferred organ for esophageal replacement, where the tubulization of the stomach resulted in significant gastroesophageal reflux. Dysphagia symptoms were more seldom reported, but several authors presented growing figures with the length of follow-up. Dumping syndrome and delayed gastric emptying were only scarcely reported upon. Following colonic graft, chronic gastrocolic reflux affects these patients, in the range of 35-70.8%, while 4 studies reported any dysphagia from 2.7% to 50% of the children. Only one study reported the outcome of the use of a long jejunal segment, where presence of symptoms of functional obstruction was mentioned in 46% of cases. Very few if any data were available on a structured assessment of postprandial dumping and disturbed bowel functions. CONCLUSIONS Available data in pediatric patients, on the long-term functional outcomes after esophageal replacement with a gastric tube, colonic graft or a long jejunal segment, are of poor scientific quality. Although symptoms are frequently reported currently no conclusions can be drawn regarding potential advantages of one graft over another. TYPE OF STUDY Treatment study, systematic review. LEVEL OF EVIDENCE IV.
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Varshney VK, Nag HH, Vageesh BG. Laparoscopic and open transhiatal oesophagectomy for corrosive stricture of the oesophagus: An experience. J Minim Access Surg 2017; 14:23-26. [PMID: 28782741 PMCID: PMC5749193 DOI: 10.4103/jmas.jmas_201_16] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
Background: Oesophagectomy for corrosive stricture of the oesophagus (CSE) is rarely performed due to high risk of iatrogenic complications. The aims of this study were to review our experience of transhiatal oesophagectomy (THE) in patients with CSE as well as to compare results of open and laparoscopic methods. Materials and Methods: This is a retrospective analysis of prospectively maintained data of patients with CSE who underwent open transhiatal oesophagectomy (OTE) or laparoscopic-assisted transhiatal oesophagectomy (LATE) by a single surgical team from 2012 to 2016. All study patients had either failed endoscopic dilatation or had a long stricture which was not amenable to endoscopic dilatation. Results: Totally, 35 patients were included in the study, of which 19 (54.3%) were female. OTE was performed in 20 (57%) patients, and LATE was performed in 15 (43%) patients. Gastric and colonic conduits were used in 23 (65.7%) and 10 (34.3%) patients, respectively. Demographic and clinical parameters were comparable between LATE and OTE groups (P > 0.05). Median intra-operative blood loss, post-operative requirement of analgesic and hospital stay were lower in LATE group (P ≤ 0.05). There was no hospital mortality (30 days), but three patients (8.6%) died during a median follow-up of 36 months. Conclusion: THE is a safe procedure for patients with CSE, and LATE may be an alternative approach in selected patients.
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Affiliation(s)
- Vaibhav Kumar Varshney
- Department of GI Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - Hirdaya H Nag
- Department of GI Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
| | - B G Vageesh
- Department of GI Surgery, Govind Ballabh Pant Institute of Postgraduate Medical Education and Research, New Delhi, India
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Abstract
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.
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Abstract
This article focuses on esophageal replacement as a surgical option for pediatric patients with end-stage esophageal disease. While it is obvious that the patient׳s own esophagus is the best esophagus, persisting with attempts to retain a native esophagus with no function and at all costs are futile and usually detrimental to the overall well-being of the child. In such cases, the esophagus should be abandoned, and the appropriate esophageal replacement is chosen for definitive reconstruction. We review the various types of conduits used for esophageal replacement and discuss the unique advantages and disadvantages that are relevant for clinical decision-making.
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Affiliation(s)
- Shaun M Kunisaki
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children׳s Hospital, University of Michigan Medical School, 1540 E. Hospital Dr, SPC 4211, Ann Arbor, Michigan.
| | - Arnold G Coran
- Section of Pediatric Surgery, Department of Surgery, C.S. Mott Children׳s Hospital, University of Michigan Medical School, 1540 E. Hospital Dr, SPC 4211, Ann Arbor, Michigan
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Presternal Esophageal Bypass: Late Sequelae of an Old-Fashioned Operation. ACG Case Rep J 2017; 4:e6. [PMID: 28138450 PMCID: PMC5244873 DOI: 10.14309/crj.2017.6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/19/2016] [Accepted: 08/16/2016] [Indexed: 11/17/2022] Open
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Bal HS, Sen S. The use of ileocolic segment for esophageal replacement in children. J Indian Assoc Pediatr Surg 2016; 21:116-9. [PMID: 27365904 PMCID: PMC4895735 DOI: 10.4103/0971-9261.182584] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
AIMS To evaluate and describe the procedure and outcome of ileocolic replacement of esophagus. MATERIALS AND METHODS We review 7 children with esophageal injuries, who underwent esophageal replacement using ileocolic segment in Christian Medical College, Vellore, India between 2006 and 2014. RESULTS The ileocolic segment was used in 7 children with scarred or inadequate esophagus. There were 4 girls and 3 boys, who underwent esophageal replacement using isoperistaltic ileocolic segment in this period. Age at presentation varied from 1 month to 14 years with an average of 4.6 years. The indications for ileocolic replacements were corrosive strictures in 5, failed esophageal atresia repair in one and gastric volvulus related esophageal stricture in another. The average follow-up duration was 37 months. One child with corrosive stricture lost to follow-up and died 2 years later in another center. Other 6 children were free of dysphagia till the last follow-up. CONCLUSIONS Although the ileocolic segment is not commonly used for esophageal substitution, it can be useful in special situations where the substitution needs to reach the high cervical esophagus and also where the stomach is scarred and not suitable for gastric pull-up.
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Affiliation(s)
| | - Sudipta Sen
- Department of Pediatric Surgery, PSG Institute of Medical Science and Rescearch, Coimbatore, Tamil Nadu, India
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AbouZeid AA, Mohammad SA, Rawash LM, Radwan AB, El-Asmar KM, El-Shafei E. The radiological assessment of colonic replacement of the esophagus in children: A review of 43 cases. Eur J Radiol 2015; 84:2625-32. [PMID: 26431748 DOI: 10.1016/j.ejrad.2015.09.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2015] [Revised: 09/10/2015] [Accepted: 09/17/2015] [Indexed: 11/25/2022]
Abstract
PURPOSE To define the characteristic radiological features following colonic replacement of the esophagus in children. MATERIALS AND METHODS The upper gastro-intestinal contrast studies of 43 patients who underwent colonic replacement of the esophagus at our pediatric surgery unit were available for analysis. UGI contrast studies were performed routinely in the post-surgical period in 17 cases (first asymptomatic group), while the rest of contrast studies (26) belonged to a second group of out-patients complaining of dysphagia (18) or dyspepsia (8) following colonic replacement of the esophagus. Based on our observations, we proposed a grading system to describe the degree of colonic redundancy in the thorax. RESULTS Redundancy of the colonic conduit in the thoracic cavity was a common radiological finding (62.8%). The redundancy was mild (grade 1) in 18 patients, moderate (grade 2) in eight, and severe (grade 3) in only one patient. In 88.9%, the redundancy was in the right hemi-thorax. Patients presenting with postoperative dysphagia had a stricture at the site of the esophago-colic anastomosis in the neck, which should be differentiated from other sites of anatomical narrowing at the inlet and outlet of the thoracic cavity. Gastro-colic reflux was common among patients who underwent colonic replacement of the esophagus without an anti-reflux procedure. CONCLUSION Colonic replacement of the esophagus in children results in considerable anatomical alterations. Knowledge about the normal post-surgical changes and imaging features of the commonly encountered complications can increase the diagnostic confidence among radiologists and clinicians when dealing with these cases.
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Affiliation(s)
- Amr Abdelhamid AbouZeid
- Faculty of medicine, Department of Pediatric Surgery, Ain Shams University, Abbasia, Cairo 11657, Egypt.
| | | | - Leila Mohamed Rawash
- Faculty of medicine, Department of Radiodiagnosis, Ain-Shams University, Abbasia, Cairo 11657, Egypt.
| | - Ahmed Bassiouny Radwan
- Faculty of medicine, Department of Pediatric Surgery, Ain Shams University, Abbasia, Cairo 11657, Egypt.
| | - Khaled M El-Asmar
- Faculty of medicine, Department of Pediatric Surgery, Ain Shams University, Abbasia, Cairo 11657, Egypt.
| | - Ehab El-Shafei
- Faculty of medicine, Department of Pediatric Surgery, Ain Shams University, Abbasia, Cairo 11657, Egypt.
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Shahi AS, Behdad B, Esmaeili A, Moztarzadeh M, Peyvandi H. Esophageal stenting in caustic injuries: a modified technique to avoid laparotomy. Gen Thorac Cardiovasc Surg 2015; 63:406-12. [PMID: 25971235 DOI: 10.1007/s11748-015-0558-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2015] [Accepted: 05/01/2015] [Indexed: 01/21/2023]
Abstract
OBJECTIVE To compare the outcomes of a modified laparoscopic intraluminal stenting with the conventional laparatomic technique in patients with esophageal caustic injuries. METHODS A total of 103 patients with esophageal burns were included in this retrospective analysis. Patients were candidates for esophageal stenting to prevent future stenosis. According to patient preference, stenting was done with either the innovatory stent with the modified technique (52 patients) or the conventional method that required laparotomy (51 patients). The modified technique consists of placing an inflation balloon stent via laparoscopy. Overall mortality and complications after follow-up period (3 months) were compared between the two groups. RESULTS Two perioperative mortalities were seen, one in each group. Except one patient in the modified technique, all patients returned to normal intake after 3 months of follow-up. However, five patients of the modified group and three in the conventional group developed esophageal strictures (p > 0.05). Gastric outlet obstruction was observed in three patients of the modified group and one in the conventional group (p > 0.05). DeMeester scores showed that there was no gastro-esophageal reflux in both groups (p > 0.05). CONCLUSION Our results show that the modified technique can reach the efficacy of the conventional method without requiring laparotomy. Thus, far several studies have demonstrated the advantages of laparoscopy over laparotomy. Thus, and in line with the clinical guidelines of the Society of American Gastrointestinal and Endoscopic Surgeons, we recommend using the presented modified technique in patients with caustic esophageal injuries.
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Affiliation(s)
- Ali Sina Shahi
- School of Medicine, Shahid Beheshti University of Medical Sciences, Tehran, Iran
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Keene D, Myers J, Jones M. Successful preservation of non-functioning oesophageal substitution with jejunal roux loop drainage. JOURNAL OF PEDIATRIC SURGERY CASE REPORTS 2014. [DOI: 10.1016/j.epsc.2014.03.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
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Boukerrouche A. Isoperistaltic left colic graft interposition via a retrosternal approach for esophageal reconstruction in patients with a caustic stricture: mortality, morbidity, and functional results. Surg Today 2013; 44:827-33. [PMID: 24150095 DOI: 10.1007/s00595-013-0758-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2012] [Accepted: 03/04/2013] [Indexed: 02/05/2023]
Abstract
PURPOSE To report our results of treating esophageal caustic stricture with an isoperistaltic left colic graft interposed via a retrosternal route. METHODS We reviewed 70 patients who underwent substernal left colon interposition, performed retrosternally, for an esophageal caustic stricture, between January, 1999 and December, 2011. RESULTS The median operative time in this series was 3 h. A pharyngoplasty was performed in 10 patients (14.28 %), the thoracic inlet was found to be enlarged in 33 patients (47.1 %), and posterior cologastric anastomosis was performed in 58 patients (82.8 %). Two patients (2.8 %) died. Minor and major postoperative complications developed in 28 patients (40 %), including graft ischemia in 2 (2.8 %) and cervical anastomotic leakage in 14 (20 %). Five patients (7.14 %) developed a cervical anastomotic stricture. The functional results were satisfactory. CONCLUSION Retrosternal isoperistaltic left colic transplant interposition is an excellent long-term replacement for an esophageal caustic stricture. If performed by experienced surgeons, this procedure is effective for esophageal reconstruction.
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Affiliation(s)
- Abdelkader Boukerrouche
- Department of Digestive Surgery, Beni-Messous Hospital, University of Algiers, Algiers, Algeria,
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Isoperistaltic left colic graft interposition via a retrosternal approach for esophageal reconstruction in patients with a caustic stricture: mortality, morbidity, and functional results. Surg Today 2013. [DOI: org/10.1007/s00595-013-0758-3] [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]
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Javed A, Agarwal AK. Total laparoscopic esophageal bypass using a colonic conduit for corrosive-induced esophageal stricture. Surg Endosc 2013; 27:3726-32. [PMID: 23636519 DOI: 10.1007/s00464-013-2956-x] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2012] [Accepted: 03/29/2013] [Indexed: 12/15/2022]
Abstract
BACKGROUND The colon and the stomach are the most commonly used conduits for esophageal replacement in patients with esophageal strictures resulting from corrosive ingestion. The replacement surgeries have traditionally been performed by an open approach. While laparoscopic replacement surgery using a stomach conduit has been previously reported, a total laparoscopic bypass using a colonic conduit has not been previously described. We herein describe the surgical technique and results of laparoscopic esophageal bypass using a colonic conduit. METHODS Patients with corrosive stricture involving the esophagus with the proximal level at the hypopharynx, or those with concomitant gastric scarring, were selected. The surgery was performed with the patient in a supine position using five abdominal ports and a hockey stick/transverse skin crease neck incision. The main steps include colonic mobilization and assessment of the adequacy of the marginal vascular arcade, creation of a retrosternal tunnel, preparation of the colonic conduit, neck dissection, delivery of the colonic conduit into the neck and cervical pharyngo/esophagocolic anastomosis, and intra-abdominal cologastric and ileocolic anastomosis. RESULTS During the study period, 39 patients with corrosive stricture of the esophagus were managed surgically at our center with either gastric or colonic bypass. Of these, 22 patients underwent an open procedure (12 retrosternal colonic bypasses and 10 retrosternal gastric bypasses) and 17 patients underwent a laparoscopic procedure (13 retrosternal gastric bypasses and 4 retrosternal colonic bypasses). Patients with stricture at the hypopharynx (n = 2) or those in whom the stomach was contracted (n = 2) were considered for a laparoscopic esophagocoloplasty. The average duration of surgery of these latter four patients was 370 (380, 320, 360, and 420) min and the mean estimated blood loss was 100 mL. All patients could be ambulated on the first postoperative day and were allowed oral liquids by the 7th postoperative day. Compared with patients who underwent an open colonic bypass, there was significantly less need for analgesics. At a median follow-up of 5 (range 3-6) months, all patients are euphagic to solid diet and have excellent cosmetic results. CONCLUSION Laparoscopic colonic bypass is an achievable, safe, and effective procedure for the management of corrosive strictures of the esophagus.
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Affiliation(s)
- Amit Javed
- Department of GI Surgery, GB Pant Hospital and MAM College, Delhi University, New Delhi, 110002, India
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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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Laparoscopic retrosternal bypass for corrosive stricture of the esophagus. Surg Endosc 2012; 26:3344-9. [PMID: 22552862 DOI: 10.1007/s00464-012-2307-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2011] [Accepted: 04/02/2012] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Surgical management of corrosive stricture of the esophagus entails replacement of the scarred esophagus with a gastric or colonic conduit. This has traditionally been done using the conventional open surgical approach. We herein describe the first ever reported minimally invasive technique for performing retrosternal esophageal bypass using a stomach conduit. METHODS Patients with corrosive stricture involving the esophagus alone with a normal stomach were selected. The surgery was performed with the patient in supine position using four abdominal ports and a transverse skin crease neck incision. Steps included mobilization of the stomach and division of the gastroesophageal junction, creation of a retrosternal space, transposition of stomach into the neck (via retrosternal space), and a cervical esophagogastric anastomosis. RESULTS Four patients with corrosive stricture of the esophagus underwent this procedure. The average duration of surgery was 260 (240-300) min. All patients could be ambulated on the first postoperative day and were allowed oral liquids between the fifth and seventh day. At mean follow-up of 6.5 (3-9) months, all are euphagic to solid diet and have excellent cosmetic results. CONCLUSIONS Laparoscopic bypass for corrosive stricture of the esophagus using a gastric conduit is technically feasible. It results in early postoperative recovery, effective relief of dysphagia, and excellent cosmesis in these young patients.
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Kofler K, Ainoedhofer H, Tausendschön J, Höllwarth ME, Saxena AK. Esophageal smooth muscle cells dedifferentiate with loss of α-smooth muscle actin expression after 8 weeks of explant expansion in vitro culture: Implications on esophagus tissue engineering. Eur Surg 2011. [DOI: 10.1007/s10353-011-0617-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Effect of intraperitoneal erythropoietin on the degree of mucosal damage of left colon flaps in rats. Pediatr Surg Int 2010; 26:633-8. [PMID: 20179951 DOI: 10.1007/s00383-010-2584-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/09/2010] [Indexed: 10/19/2022]
Abstract
BACKGROUND Several modifications to an esophageal replacement approach have been described, using the left, the right, or the transverse colon as an interposition flap. Interposition of the left colon has become the most popular procedure. Intraoperative clamping of the arterial blood supply and venous drainage of the flap is a possible reason for ischemic flap failure. Thus, we designed a novel model to investigate whether erythropoietin (EPO), which has a tissue-protective effect in ischemia, would have any protective effect on prepared colon flaps in rats. METHODS A total of 56 rats were randomly divided into four main groups, consisting of sham, sham + EPO, colon flap, and colon flap + EPO, and each main group was divided into two sub-groups. In the colon flap and colon flap + EPO groups, the colon flap was prepared and the pediculated free flap fixed tautly to the anterior abdominal wall. The sub-groups were subjected to post-reoperative histopathological investigation on the first and the seventh days, respectively. RESULTS Our model was reliable for research related to colon interposition techniques. There was significant histopathological damage in the colon flap group both for the long and short limbs of the flap. On the other hand, EPO administration prevented the mucosal damage seen in the colon flap group. CONCLUSIONS This study suggests that a colon flap attached tautly to the abdominal side wall simulates colon transposition techniques and also shows that intraperitoneal EPO markedly decreases flap damage in rats with prepared colon flaps.
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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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Saxena AK, Baumgart H, Komann C, Ainoedhofer H, Soltysiak P, Kofler K, Höllwarth ME. Esophagus tissue engineering: in situ generation of rudimentary tubular vascularized esophageal conduit using the ovine model. J Pediatr Surg 2010; 45:859-64. [PMID: 20438914 DOI: 10.1016/j.jpedsurg.2010.02.005] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2010] [Accepted: 02/02/2010] [Indexed: 12/21/2022]
Abstract
PURPOSE Esophagus replacement using the present surgical techniques is associated with significant morbidity. Tissue engineering of the esophagus may provide the solution for esophageal loss. In our attempts to engineer the esophagus, this study aimed to investigate the feasibility of generating vascularized in situ esophageal conduits using the ovine model. METHODS Esophageal biopsies were obtained from lambs, and ovine esophageal epithelial cells (OEEC) were proliferated. The OEEC were seeded on to bovine collagen sheets preseeded with fibroblasts. After 2 weeks of maintaining the constructs in vitro, the constructs were tubularized on stents to create a tube resembling the esophagus and implanted into the omentum for in situ tissue engineering. The edges of the omentum were sutured using nonabsorbable suture material. The implanted constructs were retrieved after 8 and 12 weeks. RESULTS The omental wrap provided vascular growth within and around the constructs as they were integrated along the outer surface area of the scaffold. After removal of the stents, the engineered conduit revealed a structure similar to the esophagus. Histologic investigations demonstrated esophageal epithelium organization into patches on the luminal side and vascular ingrowths on the conduit's outer perimeter. CONCLUSION Our study demonstrated the seeding of OEEC on collagen scaffolds and formation of a rudimentary conduit resembling esophageal morphology after in situ omental implantation. Vascular coverage and ingrowth in the periphery of the construct could also be demonstrated. These findings hold future promise for the engineering of the esophagus with improved microarchitecture.
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Affiliation(s)
- Amulya K Saxena
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, A-8036 Graz, Austria.
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Burgos L, Barrena S, Andrés AM, Martínez L, Hernández F, Olivares P, Lassaletta L, Tovar JA. Colonic interposition for esophageal replacement in children remains a good choice: 33-year median follow-up of 65 patients. J Pediatr Surg 2010; 45:341-5. [PMID: 20152348 DOI: 10.1016/j.jpedsurg.2009.10.065] [Citation(s) in RCA: 57] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2009] [Accepted: 10/27/2009] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Gastric pull-up has become the predominant technique for esophageal replacement because of allegedly deficient results of colon grafts. This retrospective study examines the long-term results in a large series of colonic interpositions. PATIENTS AND METHOD One hundred six children (median, 2.9 years; range, 0.32-15 years) had their esophagus replaced between 1965 and 2008, of which 96 had colon grafts. Those survivors who were 18 years and older were contacted and, if willing, interviewed, examined, and had their functional ability rated using the Karnofsky index. RESULTS Ninety-six children had undergone a colon graft, and of these, 9 (9.3%) died. There were 65 long-term survivors whose indications for surgery included caustic injury (n = 32), failed tracheoesophageal fistula repair (n = 16), pure esophageal atresia (n = 14), and others (n = 3). The graft was either retrosternal (n = 49) or mediastinal (n = 16 patients). Twelve patients were unavailable for long-term assessment. After a median follow-up of 33.3 (11-41) years, 23 (43%) of 53 individuals experienced mild symptoms of reflux; scoliosis, 12 (22%) of 53, and/or other complications, 15 (27%) of 53 required further surgery. Thirty-two patients (60%) with Karnofsky indexes of 80% or higher felt healthy, 19 (36%) had mild life-style limitations (index, 40%-80%), and 2 had indexes less than 40%. Most patients live normal lives. CONCLUSIONS Colon conduits restored gastrointestinal continuity with limited mortality and considerable morbidity but good functional outcome and health perception in the long-term. Our study suggests that colon grafts are no worse than gastric pull-ups in the long-term.
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Affiliation(s)
- Laura Burgos
- Department of Pediatric Surgery, Hospital Universitario La Paz, 28046 Madrid, Spain
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St. Peter SD, Ostlie DJ. Laparoscopic Gastric Transposition with Cervical Esophagogastric Anastomosis for Long Gap Pure Esophageal Atresia. J Laparoendosc Adv Surg Tech A 2010; 20:103-6. [DOI: 10.1089/lap.2008.0364] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
| | - Daniel J. Ostlie
- The Children's Mercy Hospital and Clinics, Kansas City, Missouri
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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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Saxena AK, Kofler K, Ainödhofer H, Höllwarth ME. Esophagus tissue engineering: hybrid approach with esophageal epithelium and unidirectional smooth muscle tissue component generation in vitro. J Gastrointest Surg 2009; 13:1037-43. [PMID: 19277795 DOI: 10.1007/s11605-009-0836-4] [Citation(s) in RCA: 54] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/30/2008] [Accepted: 02/18/2009] [Indexed: 01/31/2023]
Abstract
PURPOSE The aim of this study was to engineer the two main components of the esophagus in vitro: (a) esophageal epithelium and (b) smooth muscle tissue. Furthermore, (a) survivability of esophageal epithelial cells (EEC) on basement membrane matrix (BMM)-coated scaffolds and (b) oriented smooth muscle tissue formation on unidirectional BMM-coated collagen scaffolds was investigated. METHODS Both EEC and smooth muscle cells (SMC) were sourced from Sprague-Dawley rats. The EEC were maintained in vitro and seeded onto BMM-coated 2-D collagen scaffolds. Similarly, smooth muscle cells were obtained using an explants technique and seeded on unidirectional 3-D BMM-coated collagen scaffolds. Cell-polymer constructs for EEC and SMC were maintained in vitro for 8 weeks. RESULTS Protocols to obtain higher yield of EEC were established. EEC formed a layer of differentiated epithelium after 14 days. EEC survivability on polymers was observed up to 8 weeks. Unidirectional smooth muscle tissue strands were successfully engineered. CONCLUSION Esophageal epithelium generation, survivability of EEC on BMM-coated scaffolds, and engineering of unidirectional smooth muscle strands were successful in vitro. The hybrid approach of assembling individual tissue components in vitro using BMM-coated scaffolds and later amalgamating them to form composite tissue holds promises in the tissue engineering of complex organ systems.
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Affiliation(s)
- Amulya K Saxena
- Department of Pediatric and Adolescent Surgery, Medical University of Graz, Auenbruggerplatz-34, 8036 Graz, Austria.
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Esophagus tissue engineering: in vitro generation of esophageal epithelial cell sheets and viability on scaffold. J Pediatr Surg 2009; 44:896-901. [PMID: 19433165 DOI: 10.1016/j.jpedsurg.2009.01.019] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2009] [Accepted: 01/15/2009] [Indexed: 12/16/2022]
Abstract
PURPOSE Management of long gap esophageal atresia poses challenges. The surgical techniques for esophageal replacement are associated with complications and high morbidity. The aim of this study was to develop protocols to obtain single layer sheets of esophageal epithelial cells (EECs) and to investigate their survival on collagen scaffolds. METHODS Esophageal epithelial cells were sourced from adult Sprague-Dawley rats. Briefly, the esophagus was treated with dispase to separate the epithelial layer and further trypsined to obtained EEC. The esophageal epithelial cells were cultured in vitro and seeded on to new generation of 3-dimensional collagen scaffolds. RESULTS Esophageal epithelial cells organized after 48 hours in culture and formed clusters after 72 to 96 hours. Organization of the EEC was completed after 7 days in culture and characteristic sheets of EEC with the histologic morphology of mature esophageal epithelium were obtained after 14 days of culture. Immunohistochemistry demonstrated pure EEC culture using cytokeratin (CK-14) markers. The esophageal epithelial cells transferred on to collagen polymers demonstrated excellent viability after 8 weeks of in vitro culture. CONCLUSION Successful protocols for EEC isolation and proliferation have been established. The engineering of sheets of EEC and the viability of EEC on collagen scaffolds for 8 weeks in vitro, which are prerequisites for esophagus tissue engineering, was demonstrated.
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Abstract
OBJECTIVE Exploring pros and cons of bridging long-gap esophageal atresia with an orthotopic jejunal pedicle graft. Retrospective series of 19 patients. METHODS From 1988 through 2005, 19 patients with long-gap esophageal atresia received a jejunal graft. Median age at reconstruction was 76 days. The technique involved an initial right-sided thoracotomy or thoracoscopy to confirm the diagnosis of long-gap esophageal atresia. Through a median laparotomy, a small pediculated jejunal graft was prepared and placed transmesocolically and transhiatally in an orthotopic position in the right chest. RESULTS All patients survived and none of the grafts were lost. Four intrathoracic and one intraabdominal leak occurred. One intrathoracic and one intraabdominal leak were surgically repaired. One early distal stenosis was reoperated as well. There were always signs of distal functional subobstruction, responding to dilation in all but one patient. Gastroesophageal reflux was not a problem except for one patient whose distal esophagus was eventually resected because of ongoing distal obstruction with dilation of the graft. Except for one patient, all patients are eating normally and most of them grow well. Respiratory problems were rare. Grafts did not become redundant and retained peristaltic activity. CONCLUSION Orthotopic jejunal pedicle graft reconstruction of the esophagus in children is a demanding operation with considerably early morbidity but good long-term results. It should be part of the pediatric surgical armamentarium for reconstruction of the esophagus.
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Affiliation(s)
- Klaas M A Bax
- Department of Pediatric Surgery, Erasmus MC-Sophia Children's Hospital, University Medical Center, Rotterdam, The Netherlands.
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Houben CH, Curry JI. Current status of prenatal diagnosis, operative management and outcome of esophageal atresia/tracheo-esophageal fistula. Prenat Diagn 2008; 28:667-75. [PMID: 18302317 DOI: 10.1002/pd.1938] [Citation(s) in RCA: 82] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Ultrasonographic features suggestive of esophageal atresia with or without tracheo-esophageal fistula (EA/TEF) are only in a small minority of fetuses with EA/TEF (<10%) identifiable on prenatal scans.The prenatal diagnosis of EA/TEF relies in principle, on two nonspecific signs: polyhydramnios and absent or small stomach bubble. Polyhydramnios is associated with a wide range of fetal abnormalities, but most commonly it pursues a benign course. Similarly the sonographic absence of a stomach bubble may point to a variety of fetal anomalies.The combination of polyhydramnios and absent stomach bubble in two small series offers a modest positive predictive value of 44 and 56% respectively. Prenatal scanning for EA/TEF identifies a larger proportion of fetuses with Edwards syndrome; there is also a higher proportion of isolated EA in comparison to postnatal studies.Current ultrasound technology does not allow for a definite diagnosis of EA/TEF and therefore, counseling of parents should be guarded.Postnatal diagnosis of EA is confirmed by the failure to pass a firm nasogastric tube into the stomach; on chest X-ray, the tube is seen curling in the upper esophageal pouch. Corrective surgery for EA/TEF is well established and survival rates of over 90% can be expected.
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Affiliation(s)
- C H Houben
- Department of Paediatric Surgery, Hospitals for Sick Children, Great Ormond Street, London WC1N 3JH, UK
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Abstract
BACKGROUND AND OBJECTIVES Tissues derived from the colon, stomach, and jejunum have been used to replace the esophagus in childhood to cure esophageal atresia or stricture secondary to gastroesophageal reflux or the ingestion of corrosive agents. The outcome in adulthood of colon interposition performed at an early age has yet to be satisfactorily assessed. The aim of this single-center retrospective study was to evaluate the long-term nutritional, digestive, and respiratory outcome of all patients (n = 32) who underwent colon interposition during childhood in our hospital (1970-2001). PATIENTS AND METHODS Medical records of these subjects were reviewed and their nutritional (weight, height, 24-hour food diary), digestive (questionnaire), and pulmonary function status evaluated. RESULTS Of the patients, 17 had esophageal atresia (7 males, median age at surgery 11 months, range 0.5-61) and 15 had ingested corrosive substances (10 males, median age at surgery 50 months, range 22-113). Complications occurred less than 1 year postoperatively in 53% and long-term complications (occurring >1 year after surgery) in 84%. Long-term complications were common: digestive symptoms were found in 85% (most frequently observed during the first 5 years of follow-up), abnormal lung function in 7 (58%) of those tested (n = 12), feeding difficulties in 50%, scoliosis in 35%, and nutritional complications in 25%. CONCLUSIONS Our study showed a high rate of sequelae following esophageal replacement. This highlights the need for multidisciplinary long-term follow-up into adulthood, and research into alternatives to colon interposition as treatment for esophageal strictures.
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Tannuri U, Maksoud-Filho JG, Tannuri ACA, Andrade W, Maksoud JG. Which is better for esophageal substitution in children, esophagocoloplasty or gastric transposition? A 27-year experience of a single center. J Pediatr Surg 2007; 42:500-4. [PMID: 17336187 DOI: 10.1016/j.jpedsurg.2006.10.042] [Citation(s) in RCA: 51] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND/PURPOSE Esophagocoloplasty and gastric transposition are 2 major methods of esophageal substitution in children. The purpose of this study is to review the authors' experience with these 2 techniques and compare the complications of these operations to determine whether 1 method emerges superior to the other. METHODS A total of 149 children underwent surgery: 115 children underwent esophagocoloplasty, and 34 children underwent gastric transposition. Most patients (113-75.8%) had long-gap esophageal atresia. The operative technique of esophagocoloplasty consisted of the interposition of the transverse colon maintained by a double vascular pedicle based on the left colic vessels and the marginal paracolic arcade. Gastric transposition was performed according to classical technique. The transposition of colon and stomach was performed using blunt mediastinal dissection in all patients without thoracotomy. Complications and mortality of the 2 groups of patients were compared. These complications were classified as minor (cervical anastomosis leak, abdominal evisceration, diarrhea, strictures, and reflux to the interposed viscera) and major (necrosis of transposed viscera, dehiscence of an intra-abdominal or intrapleural suture, torsion of transposed viscera, delayed gastric emptying requiring reoperation, and cologastric anastomosis stricture). RESULTS There were 2 graft necrosis, 1 (0.8%) in the esophagocoloplasty group and another (2.9%) in the gastric transposition group. Patients who underwent esophagocoloplasty experienced a greater incidence of minor complications (P = .001) and less major complications in comparison with the gastric transposition group (P = .001). All minor complications were treatable and had no consequences. No difference was noted between the 2 groups with regard to the mortality rate (0.9% and 5.9%, respectively, P > .05). CONCLUSIONS Esophagocoloplasty and gastric transposition are satisfactory means of esophageal substitution in children. Considering the incidence of major postoperative complications, esophagocoloplasty must be the first choice for esophageal replacement in children.
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Affiliation(s)
- Uenis Tannuri
- Pediatric Surgery Division and Laboratory of Pediatric Surgery, Instituto da Criança-Hospital das Clinicas, University of São Paulo Medical School, São Paulo CEP-05403-000, Brazil.
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Abstract
OBJECTIVE Reconstruction of the esophagus in children remains a challenge. Although jejunal grafts retain peristaltic activity, large series with long-term follow up are rare. We like to present our experience in a series of 24 children. METHODS In the period 1988 through 2005, 24 children received an orthotopic jejunal pedicle graft reconstruction of the esophagus. Nineteen had esophageal atresia (18 had no distal fistula; all but 1 had a jejunal graft as a primary procedure), 3 had an extensive caustic stricture, and 2 had a peptic stricture. All strictures had been dilated many times, and peptic strictures had been treated with antireflux surgery as well. Median age at reconstruction was 76 days in the esophageal atresia group. The technique involves a right-sided thoracotomy with preparation of the esophageal ends or resection of the diseased esophagus. At laparotomy, a small pediculated jejunal graft is prepared and placed transhiatally in an orthotopic position in the right chest. RESULTS All patients survived, and none of the grafts were lost. There were 5 intrathoracic leaks, 4 in the esophageal atresia group and 1 in peptic stricture group, requiring reoperation in 1. In the esophageal atresia group, there was 1 early distal stenosis requiring reoperation. In patients in which the distal esophagus was preserved (esophageal atresia and caustic stricture group), there were always signs of distal functional subobstruction, responding to dilatation in all but 1 patient. Gastroesophageal reflux was not a problem except for 1 patient with esophageal atresia, in whom the distal esophagus was resected because of ongoing distal obstruction with dilatation of the graft. Most patients eat and grow well, and respiratory problems were rare. CONCLUSION Orthotopic jejunal pedicle graft reconstruction of the esophagus in children is a demanding operation with considerably morbidity but good long-term results.
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Affiliation(s)
- N M A Bax
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center Utrecht, 3508 AB Utrecht, The Netherlands.
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Jiang YG, Lin YD, Wang RW, Zhou JH, Gong TQ, Ma Z, Zhao YP, Tan QY. Pharyngocolonic anastomosis for esophageal reconstruction in corrosive esophageal stricture. Ann Thorac Surg 2006; 79:1890-4. [PMID: 15919279 DOI: 10.1016/j.athoracsur.2004.12.046] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2004] [Revised: 12/15/2004] [Accepted: 12/28/2004] [Indexed: 10/25/2022]
Abstract
BACKGROUND The aim of our study is to observe the outcome of pharyngocolonic anastomosis in esophageal reconstruction for diffuse corrosive esophageal stricture involving hypopharynx. METHODS This is a retrospective report of the experience and results of 14 patients undergoing esophageal reconstruction with pharyngocolonic anastomosis without resection of the strictured intrathoracic esophagus. The left colonic segment was pulled up to the neck through the substernal space in all patients. RESULTS There was no operative or hospital death. Postoperative complications included cervical anastomotic leakage in 4 patients, rupture of abdominal incision in 1 patient, and aspiration pneumonia in 2 patients. The length of follow-up ranged from half a year to 10 years, with an average of 4 years. Anastomotic stenosis occurred in 2 patients. One patient was improved after dilatation and the other was relieved by plastic operation. One patient began to have vomiting after meals 7 months after surgery and was found to have redundant abdominal colon graft, which was corrected with a side-to-side anastomosis between the colon and the stomach. CONCLUSIONS A successful reconstruction for hypopharyngoesophageal stricture requires a sufficiently large hypopharyngocolonic anastomosis and a technique of good anastomosis. From our experience, this procedure is shown to be safe and effective.
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Affiliation(s)
- Yao-Guang Jiang
- Thoracic Surgery Department, Daping Hospital, Chongqing, China.
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Cigna E, Chen HC, Spanio S, Ozkan O, Chio SY, Tang YB, Coskunfirat OK. A new technique for substernal colon transposition with a breast dissector: report of 39 cases. J Plast Reconstr Aesthet Surg 2006; 59:343-6. [PMID: 16756247 DOI: 10.1016/j.bjps.2005.09.041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
This paper investigates the effectiveness of the breast dissector to create a substernal space for oesophageal reconstruction. The surgeon must be extremely careful while dissecting the tissue below the sternum in order to avoid pneumothorax. The endoscopically assisted preparation of the substernal route is safe but it requires appropriate training. A retrospective study on 68 patients who underwent oesophageal reconstruction was done analysing the patients' records. In 39 cases, the breast dissector was used. In 29 cases, the substernal tunnel was created with hand dissection only. All 68 colon segments were successfully transferred in the two groups of patients. In all 39 the cases where the breast dissector was used no pneumothorax followed. In 10 (34%) patients of the control group pneumothorax occurred. Concluding, no more pneumothorax has occurred during the substernal oesophageal reconstruction since we started using the breast dissector.
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Affiliation(s)
- E Cigna
- Department of Plastic Surgery, E-Da Hospital, I-Shou University, 1, E-Da Road, Jiau-shu Tsuen, Yon-chau Shiang 824, Kaohsiung County, Taiwan, ROC
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Abstract
A cumulative review of the prevalence of esophageal conduit necrosis is summarized in Table 4. The spectrum of conduit ischemia is broad and includes cases in which there is anastomotic leak or stricture as well as cases in which there is frank graft necrosis. Many of the studies that the authors reviewed do not specify the exact nature of postoperative ischemic complications or how they are defined. Therefore, postoperative conduit ischemia is reported globally. Based on the authors' review, average rates of ischemic complications for stomach, colon, and jejunum are 3.2%, 5.1%, and 4.2%, respectively. Results for colon and jejunum include results for both long- and short-segment grafting. Most reports that compare outcomes using different esophageal conduits demonstrate findings similar to the authors'. Davis and colleagues compared results with colon versus gastric conduit esophageal reconstruction. They found that operative mortality, anastomotic leaks, and conduit ischemia rates were all lower for the stomach than for the colon. Specifically, ischemia of the stomach conduit was 0.5%, compared with 2.4% for the colon conduit. Moorehead and Wong, in a large series of 760 esophagectomy patients in whom the stomach, colon, or jejunum was used for reconstruction, demonstrated that the stomach had the lowest incidence of conduit ischemia (1%), followed by jejunum (11.3%), then colon (13.3%). Some of the factors they identified as correlating with the risk of ischemia include length of conduit, technique of stomach graft preparation, whether anastomosis is in the neck or chest, and route of passage of the conduit. Mansour and colleagues compared their results using bowel interposition (either colon or jejunum) to reconstruct the resected esophagus. The authors report an overall mortality of 5.9%, and 3% conduit ischemia. All ischemia was noted in the colon conduits harvested from the left side. No ischemic complications were noted from jejunal segments. Briel and colleagues compared stomach versus colon conduit use after esophagectomy. They note an overall incidence of ischemia of 9.2%. In their series, the incidence of ischemia for stomach and colon was 10.4% and 7.4%, respectively. Anastomotic leak and stricture rates, both thought to be sequelae of ischemia, also were lower for colon conduit use than for stomach conduit. Multivariate analysis identified patient comorbidities as the only independent risk factor for conduit ischemia. The authors use their findings to support the preferential use of colon conduits rather than stomach conduits. The incidence of colon conduit ischemia (7.4%) is directly in line with all other published results, including the cumulative review by the authors of this article, whereas the rate of stomach conduit ischemia (10.4%) is considerable higher than in most other studies. Esophageal conduit necrosis is an uncommon but disastrous complication of esophageal surgery. Careful selection of patients for surgery, preoperative evaluation of the proposed conduit, and meticulous operative technique are the best defenses against conduit ischemia. Postoperatively, surgeons should have a high index of suspicion for this complication. Unexplained tachycardia, respiratory failure, leukocytosis, or any evidence for graft or anastomotic leak should prompt a search for conduit ischemia. The diagnosis is made by contrast esophagography, endoscopy, or direct operative inspection. There is no documented salvage technique once ischemia is identified. Treatment for mild cases may be supportive, with or without management of anastomotic leak. More severe cases of necrosis require débridement and conduit take-down with proximal esophageal diversion and placement of enteral feeding tubes. Reconstruction can be planned for later if possible. The majority of the data demonstrates that risk of ischemia is related to conduit type, length of conduit, comorbidities, and operative technique. The stomach has the lowest reported incidence of conduit ischemia, followed by the jejunum, and colon. In the future, methods to predict conduit ischemia more accurately at the time of surgery may further reduce the incidence of this disastrous complication.
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Affiliation(s)
- Jennifer K Wormuth
- Department of Surgery at the Union Memorial Hospital, Baltimore, MD 21136, USA
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Vogel AM, Yang EY, Fishman SJ. Hydrostatic stretch-induced growth facilitating primary anastomosis in long-gap esophageal atresia. J Pediatr Surg 2006; 41:1170-2. [PMID: 16769355 DOI: 10.1016/j.jpedsurg.2006.01.076] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
Abstract
We present a novel simple technique for stimulating distal esophageal pouch growth in a patient with isolated, long-gap esophageal atresia. In this case report, distal esophageal growth was achieved through daily intermittent pressurization via a surgically placed indwelling balloon catheter. The patient ultimately underwent successful, uncomplicated, tension-free, primary repair and remains asymptomatic.
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Affiliation(s)
- Adam M Vogel
- Department of Surgery, Children's Hospital Boston, Boston, MA 02115, USA
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Zhou JH, Jiang YG, Wang RW, Lin YD, Gong TQ, Zhao YP, Ma Z, Tan QY. Management of corrosive esophageal burns in 149 cases. J Thorac Cardiovasc Surg 2005; 130:449-55. [PMID: 16077412 DOI: 10.1016/j.jtcvs.2005.02.029] [Citation(s) in RCA: 52] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
OBJECTIVES We sought to present our experience in the management of esophageal burns. METHODS From April 1976 through October 2003, 149 patients with corrosive esophageal burns were included in this study. Treatment modalities consisted of modified intraluminal stenting in 28, colon interposition in 71, gastric transposition in 25, repair of cervical stricture with platysma myocutaneous flap in 17, and miscellaneous operations in 12 patients. Eleven of these patients underwent the above procedures twice at our institute. The remaining 7 patients were treated with conservative therapy. RESULTS Twenty-three patients recovered from intraluminal stenting, and 5 experienced stricture after stent removal. One of the 5 patients with failed stents responded to bougienage, and the remaining 4 patients required esophageal reconstruction later. Of the 71 colon interpositions, 5 patients died postoperatively, and complications consisted of proximal anastomotic fistula in 17, anastomotic stenosis in 6, and abdominal incision dehiscence in 2 patients. Postoperative complications in the 25 patients with gastric transpositions comprised anastomotic stricture in 2 patients and empyema in 1 patient. There was a cervical leak in 1 of the 17 patients undergoing the repair of cervical esophageal or anastomotic stricture with a platysma myocutaneous flap. One of the patients in the group undergoing 12 miscellaneous procedures died 8 months after surgical intervention. All the survivors currently eat regular diets. CONCLUSIONS Intraluminal stenting can prevent the formation of caustic esophageal stricture. The location of the cicatricial esophagus dictates whether to perform concomitant esophagectomy during esophageal reconstruction. Platysma myocutaneous flap repair is an excellent method for the treatment of severe cervical esophageal or anastomotic stricture.
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Affiliation(s)
- Jing-Hai Zhou
- Department of Thoracic Surgery, Daping Hospital, Third Military Medical University, Chongqing, People's Republic of China
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Uchida K, Inoue M, Konishi N, Kusunoki M. Esophageal stricture with a pseudodiverticulum caused by the unrecognized ingestion of a small foreign body in a child: report of a case. Surg Today 2005; 35:774-7. [PMID: 16133674 DOI: 10.1007/s00595-005-3016-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2003] [Accepted: 10/01/2004] [Indexed: 10/25/2022]
Abstract
A 2-year-old boy with a long history of vomiting, dysphagia, and weight loss was found to have a rigid stricture in the proximal esophagus. We performed esophageal repair using a Livaditis circular myotomy technique. The removed section of esophagus contained the inflammatory stricture with a pseudodiverticulum, caused by the unrecognized ingestion of a small, hard plastic sticker.
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Affiliation(s)
- Keiichi Uchida
- Second Department of Surgery, Mie University School of Medicine, Tsu, Mie, 514-8507, Japan
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Bax NMA, Van Renterghem KM. Ileal pedicle grafting for esophageal replacement in children. Pediatr Surg Int 2005; 21:369-72. [PMID: 15827751 DOI: 10.1007/s00383-005-1433-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/15/2005] [Indexed: 11/29/2022]
Abstract
Reconstruction of the upper esophagus in small children remains a challenge. Free jejunal interposition as frequently used in adults is much less appropriate in children because of the limited vessel size. The use of a jejunal pedicle graft in children has been described, but gaining enough length may be a problem. A pedicle graft of terminal ileum may be a better option, but this technique has never been described. We report a child with esophageal atresia and distal fistula who had a very short upper esophageal pouch. Primary repair was impossible. The fistula was ligated and a gastrostomy created. A second attempt at anastomosis was not successful either, and a cervical esophagostomy was created. The child was fed by gastrostomy and received sham feeding orally. When the child was 10 months old, the upper esophagus was successfully reconstructed with a pedicle graft of terminal ileum. Postoperatively there was a limited leak of the proximal anastomosis, which healed spontaneously. The distal anastomosis had to be dilated on a few occasions. With a follow-up of 1 year, the child is eating well without gastrostomy supplementation. On imaging, the ileal pedicle graft looks somewhat tortuous but contracts nicely. We feel that ileal pedicle graft reconstruction of the esophagus should be part of the instrumentarium of pediatric surgeons dealing with esophageal reconstruction.
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Affiliation(s)
- N M A Bax
- Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center, P.O. Box 85090, 3508AB Utrecht, The Netherlands.
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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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Ergün O, Celik A, Mutaf O. Two-stage coloesophagoplasty in children with caustic burns of the esophagus: hemodynamic basis of delayed cervical anastomosis--theory and fact. J Pediatr Surg 2004; 39:545-8. [PMID: 15065025 DOI: 10.1016/j.jpedsurg.2003.12.012] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
BACKGROUND/PURPOSE This study was carried out to survey the outcome in patients with corrosive burns of the esophagus who had undergone 2-stage coloesophagoplasty procedures. METHODS Records of 81 patients with staged cervical coloesophagostomy procedures have been reviewed. In all cases, colon was pulled through the retrosternal route in an antiperistaltic fashion. The native esophagus was left in place. After the cologastric anastomosis at the antral level, cervical anastomosis was delayed for a second stage. Complications related to the procedure, corrective interventions, and long-term results were evaluated. RESULTS In all patients, the retrosternal route was used for the replacement of the colon. The conduits were constructed from right colon in 20 (24.7%) and left colon in 61 (75.3%) patients. There were 3 leaks (3.7%) and 9 strictures (11%). Terminal necrosis of the cervical colonic piece occurred in 3 patients who had undergone resection of the sloughed terminal end, and all were further treated by right intrathoracic antehilar coloesophagostomies performed between the remaining parts of the transplanted colon and the upper thoracic esophagus. One of these patients had wound dehiscence with subsequent sepsis and died. CONCLUSIONS Terminal necrosis of the graft is not related to staging of the technique, but the decreased rate of cervical anastomotic strictures seem to be directly correlated with staging of cervical anastomosis. Possibly, an ischemic anastomosis at the terminal end of the graft after extensive mobilization and retrosternal placement is avoided with a delayed anastomosis performed after full restoration of the microcirculation.
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Affiliation(s)
- Orkan Ergün
- Department of Pediatric Surgery, Ege University Faculty of Medicine, Izmir, Turkey
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Abstract
OBJECTIVES To analyze the feasibility and safety of transhiatal approach for resection of corrosively scarred esophagus. BACKGROUND SUMMARY DATA: The unrelenting corrosive strictures of esophagus merit esophageal substitution. Because of the risk of complications in the retained esophagus, such as malignancy, mucocele, gastroesophageal reflux, and bleeding, esophageal resection is deemed necessary. Transthoracic approach for esophageal resection is considered safe. The safety and feasibility of transhiatal resection of the esophagus is not established in corrosive injury of the esophagus. PATIENTS AND METHODS Transhiatal approach was used for resection of the scarred esophagus for all patients between January 1986 and December 2001. The intraoperative complications, indications for adding thoracotomy, and postoperative outcome were studied in 51 patients. Follow-up period varied from minimum of 6 months to 15 years. RESULTS Esophageal resection was achieved in 49 of 51 patients whereas thoracotomy was added in 2 patients. In 1 of the patients tracheal injury occurred whereas in other patient there were dense adhesions between tracheal membrane and esophagus. Gastric tube was used for esophageal substitution in 40 (78.4%) patients whereas colon was transplanted in 11 (21.6%) patients. Colon was used only when stomach was not available. One patient (1.9%) had tracheal membrane injury whereas 4 patients (7.8%) had recurrent laryngeal nerve palsy. One patient each had thoracic duct injury and intrathoracic gastric tube leak. There was no operative mortality. Anastomotic complications like leak were present in 19.6% and stricture in 58.8% patients. All the patients were able to resume their normal duties and swallow normal food within 6 months of the surgery. CONCLUSION One-stage transhiatal esophageal resection and reconstruction could be safely used for the extirpation of scarred esophagus. Use of gastric conduit was technically simple, quicker, and offered good functional outcome. Postoperative anastomotic stricture amenable to dilatations was the commonest complication.
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Affiliation(s)
- Narendar Mohan Gupta
- Department of Surgery, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh, India
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McCollum MO, Rangel SJ, Blair GK, Moss RL, Smith BM, Skarsgard ED. Primary reversed gastric tube reconstruction in long gap esophageal atresia. J Pediatr Surg 2003; 38:957-62. [PMID: 12778402 DOI: 10.1016/s0022-3468(03)00133-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
BACKGROUND/PURPOSE Esophageal reconstruction in long-gap esophageal atresia (EA) poses a technical challenge with several surgical options. The purpose of this study was to review the authors' experience with the reversed gastric tube (RGT) in esophageal reconstruction. METHODS This series describes 7 babies with pure EA treated at 2 centers between 1989 and 2001. Data, gathered by retrospective chart review, included clinical details of the esophageal and associated malformations, technique and timing of repair, early and late complications, and long-term follow-up. Institutional review board (IRB) approval of this study has been obtained. RESULTS Seven babies were included. Associated malformations were present in 4: trisomy 21 in 2 and imperforate anus in 2. After gastrostomy tube placement, patients were treated with gastrostomy tube feedings and continuous upper pouch suction. Median gap length was 5.5 vertebral segments (range, 3 to 9). RGT with a posterior mediastinal esophagogastric anastomosis was performed at median age of 62 days (range, 38 to 131). There were no anastomotic leaks. Three patients had strictures, one required resection. Exclusive oral nourishment was achieved in 5 patients by 6 months of age. At last follow-up (mean, 4.5 years), 6 patients were receiving oral nutrition exclusively, and all were maintaining growth curves. CONCLUSIONS In long gap EA, early esophageal reconstruction using an RGT can be performed with minimal morbidity and promising short-term results.
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Affiliation(s)
- M O McCollum
- Division of Pediatric Surgery, British Columbia's Children's Hospital, Vancouver, BC, Canada
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Abstract
Reoperative esophageal surgery can be a very challenging endeavor. Preoperative evaluation, planning and preparation are essential to optimize results. A general reoperative approach and the range of reconstructive options are outlined. Management of specific problems is discussed including stricture, recurrent gastroesophageal reflux, recurrent tracheoesophageal fistula, esophageal interposition, and recurrent achalasia.
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Affiliation(s)
- Craig W Lillehei
- Department of Surgery, Children's Hospital Boston, 300 Longwood Avenue, Boston, MA 02115, USA
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46
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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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Chang VC, Chen HC, Hao SP, Liao CT. An adjunct to substernal dissection in esophageal reconstruction. Plast Reconstr Surg 2001; 108:260-1. [PMID: 11420537 DOI: 10.1097/00006534-200107000-00050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Affiliation(s)
- R P Scott
- Department of Surgery, Charles R. Drew University of Medicine and Science, Los Angeles, California, USA.
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50
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Abstract
BACKGROUND Use and techniques of oesophageal replacement for long gap oesophageal atresia are still evolving. Gastric tube graft interposition as an oesophageal substitute was evaluated on an animal model. METHODS Twenty-three postweaned, 28-day-old-piglets were used as the experimental animals. Isoperistaltic gastric tube interposition based on the right gastroepiploic vessels was performed at 28 days of life. Postoperative evaluation included weekly measurement of weight, clinical assessment for gastrointestinal and respiratory complications and deglutition difficulties. Haemoglobin, serum ferritin, albumin, globulins, total proteins and red cell folate were assayed. Pigs were killed and analysed histopathologically following a maximum observation period of 149 days. RESULTS Growth of the pigs was normal. Deglutition was not impaired in 16 pigs (89%). Minor leak was diagnosed in three pigs (17%), which was successfully managed conservatively. Anastomotic stricture was seen in two pigs (11%). Graft necrosis was not seen. Gross histology showed the absence of hypertrophy, redundancy and kinking of the interposed gastric tube graft. Microscopically non-erosive oesophagitis was seen in three pigs (17%), ulcerative oesophagitis was seen in two pigs (11%) and submucosal fibrosis was seen in seven pigs (39%). Dysplasia or Barrett's oesophagitis was not observed at the end of animal growth. CONCLUSIONS Gastric tube graft interposition is an immediate ideal oesophageal substitute due to fewer complications, probable absence of gastro-oesophageal reflux in the majority by histology, and absence of dilatation and redundancy of the interpose tube. The oesophageal substitute adequately met the nutritional needs for growth and development in the animal model.
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Affiliation(s)
- M Samuel
- Department of Paediatric Surgery, St George's Hospital, London, UK
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