Laparoscopic Gastric Transposition with Cervical Esophagogastric Anastomosis for Long Gap Pure Esophageal Atresia

Functional outcome after laparoscopic assisted gastric transposition including pyloric dilatation in long-gap esophageal atresia

BACKGROUND/PURPOSE

Among the options for esophageal replacement in long-gap esophageal atresia (LGEA), gastric transposition (GT) is accessible for an endoscopic approach. Here we report a novel technique and functional results after laparoscopic-assisted gastric transposition (LAGT), including pyloric dilatation in patients with LGEA.

METHODS

Retrospective analysis of 14 children undergoing LAGT. Surgical steps included the release of the gastrostomy, transumbilical ante-situ section of the stomach including pyloric balloon-dilation, and laparoscopically controlled transhiatal retromediastinal blunt dissection followed by LAGT for cervical anastomosis to the proximal esophagus.

RESULTS

The median age at LAGT was 110 days (33-327 days), bodyweight 5.3 kg (3.1-8.3 kg). Operation time was 255 min (180-436 min); one conversion was necessary. The duration of ventilation was 4 days (1-14 days). Postpyloric feeding was started after 2 days, and oral feeding after 13 days. Complications were recurrent pleural effusion or pneumothorax and transient Horner syndrome or transient incomplete paresis of the recurrence nerve. After a median follow-up of 60 months (13-240 months), all children have a patent upper GI tract, show weight gain, and are fed without delayed gastric emptying, dumping, or reflux. Severe (n = 1) or mild (n = 2) anastomotic or pyloric (n = 5) stenosis was resolved with endoscopic dilatations.

CONCLUSIONS

Functional outcome after LAGT in patients with LGEA is good. The laparoscopic retromediastinal dissection preserves thoracal structures and increases patients' safety. The technique of pyloric dilatation might also prevent dumping syndrome.

TYPE OF STUDY

Case Series with no Comparison Group.

LEVEL OF EVIDENCE

Level IV.

Surgical treatment and major complications Within the first year of life in newborns with long-gap esophageal atresia gross type A and B - a systematic review

BACKGROUND

The surgical repair of long-gap esophageal atresia (LGEA) is still a challenge and there is no consensus on the preferred method of reconstruction. We performed a systematic review of the surgical treatment of LGEA Gross type A and B with the primary aim to compare the postoperative complications related to the different methods within the first postoperative year.

METHODS

Systematic literature review on the surgical repair of LGEA Gross type A and B within the first year of life published from January 01, 1996 to November 01, 2016.

RESULTS

We included 57 articles involving a total of 326 patients of whom 289 had a Gross type A LGEA. Delayed primary anastomosis (DPA) was the most applied surgical method (68.4%) in both types, followed by gastric pull-up (GPU) (8.3%). Anastomotic stricture (53.7%), gastro-esophageal reflux (GER) (32.2%) and anastomotic leakage (22.7%) were the most common postoperative complications, with stricture and GER occurring more often after DPA (61.9% and 40.8% respectively) compared to other methods (p < 0.001).

CONCLUSION

The majority of patients in this review were managed by DPA and postoperative complications were common despite the surgical method, with anastomotic stricture and GER being most common after DPA.

LEVEL OF EVIDENCE

Systematic review of case series and case reports with no comparison group (level IV).

Single-incision laparoscopy-assisted gastric transposition combined with thoracoscopic esophagectomy for esophageal replacement

INTRODUCTION

We present a novel approach to single-incision laparoscopy-assisted gastric transposition combined with thoracoscopic esophagectomy in a child with long-segment corrosive esophageal stricture (CES).

MATERIALS AND SURGICAL TECHNIQUE

A 2.5-year-old boy with a history of caustic ingestion underwent periodic esophageal dilatations at 3-week intervals, four sessions of topical mitomycin C application, and a strict antacid/H₂ antagonist therapy for 8 months. The esophageal replacement was indicated because of persistent corrosive esophageal stricture. First, thoracoscopic native esophagus dissection was performed. After gastric mobilization with single-incision laparoscopy, esophagectomy and esophagogastric anastomosis were performed through the cervical incision. There was no complication, and the patient had gained weight by the end of the 12-month follow-up.

DISCUSSION

Single-incision laparoscopy-assisted gastric transposition combined with thoracoscopic esophagectomy is feasible, safe, and effective in patients with corrosive esophageal stricture.

Management of long gap esophageal atresia: A systematic review and evidence-based guidelines from the APSA Outcomes and Evidence Based Practice Committee

BACKGROUND

Treatment of the neonate with long gap esophageal atresia (LGEA) is one of the most challenging scenarios facing pediatric surgeons today. Contributing to this challenge is the variability in case definition, multiple approaches to management, and heterogeneity of the reported outcomes. This necessitates a clear summary of existing evidence and delineation of treatment controversies.

METHODS

The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee drafted four consensus-based questions regarding LGEA. These questions concerned the definition and determination of LGEA, the optimal method of surgical management, expected long-term outcomes, and novel therapeutic techniques. A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to identify, review and report salient articles.

RESULTS

More than 3000 publications were reviewed, with 178 influencing final recommendations. In total, 18 recommendations are provided, primarily based on level 4-5 evidence. These recommendations provide detailed descriptions of the definition of LGEA, treatment techniques, outcomes and future directions of research.

CONCLUSIONS

Evidence supporting best practices for LGEA is currently low quality. This review provides best recommendations based on a critical evaluation of the available literature. Based on the lack of strong evidence, prospective and comparative research is clearly needed.

TYPE OF STUDY

Treatment study, prognosis study and study of diagnostic test.

LEVEL OF EVIDENCE

Level II-V.

Oesophageal replacement with stomach: A personal series and review of published experience

AIM

To describe the outcomes of oesophageal replacement using stomach in children.

METHODS

All children undergoing oesophageal replacement in a regional centre were prospectively recorded in a customised database and subjected to continual follow up. Complications within 30 days were classified as early, and all other complications were classified as late. Outcomes were related to a comprehensive analysis of published experience where studies were classified as having long-term follow up if the median duration exceeded 5 years.

RESULTS

Ten children underwent oesophageal replacement using the stomach between 1998 and 2016. Indications were oesophageal atresia (6), caustic ingestion (2), foreign body ingestion (1) and oesophageal hamartoma (1). Two children died at 2 and 7 months after gastric transposition. All survivors are under review, with a median follow up of 8.5 years (range 3-14 years). Complications occurred in every case. Among survivors, three had early complications and eight had late complications. Early complications included anastomotic leak (2) and lung compression by stomach (1). Late complications were anaemia (8), anastomotic stricture (7), oesophagitis (5), dumping syndrome (2), perforation of a jejunostomy (1), para-gastric hiatal hernia (1), gastric outlet obstruction (1), Barrett's oesophagus (1), prolonged inability to swallow (1) and recurrent lower respiratory tract infections (1). Among 57 publications, only three achieved complete long-term follow up. The incidence of reported complications was higher when follow up was complete.

CONCLUSIONS

Oesophageal replacement by gastric transposition in children leads to serious chronic morbidity. Published experience masks this because of incomplete and short follow up.

Outcomes of primary gastric transposition for long-gap esophageal atresia in neonates

BACKGROUND

Gastric transposition is a relatively novel method of esophageal replacement. The purpose of this retrospective study was to assess the outcomes of long-gap esophageal atresia (LGEA) treated with esophageal replacement using primary gastric transposition in neonates.

METHODS

Between March 2008 and May 2015, 14 newborns with LGEA were treated in our hospital. They were all found to have gaps of over 3 cm at the time of the surgery and were diagnosed with LGEA. Primary gastric transposition was performed. They also underwent a gastric drainage procedure by pyloromyotomy. The nasogastric tube was removed if no anastomotic fistula was present and oral feeding was initiated. After initial recovery and discharge, the patients were evaluated with outpatient follow-ups or telephone follow-ups from 1 month after the surgery.

RESULTS

The mean age of the neonates at the time of the surgery was 32 hours (range, 4-96 h). The mean birth weight was 2550 g (range, 2100-3500 g). There were 2 deaths in this series of patients due to respiratory failure or withdrawal of treatment by the parents, with a mortality rate of 14.3%. Seven of the neonates developed unilateral or bilateral severe pneumonia. Early anastomotic leak occurred in 3 cases and anastomotic strictures occurred in 4 cases. These 4 neonates were able to eat a fairly normal diet after esophageal balloon dilation. Gastroesophageal reflux occurred in 7 of 12 cases. Feeding multiple small meals and postural support for positioning and feeding were instructed for these 7 cases. Subsequently, the symptoms alleviated and they had no additional surgical therapy. None of the neonates had delayed gastric emptying or gastric retention.

CONCLUSION

Primary gastric transposition may be a rewarding reconstructive option in the treatment of LGEA.

Long-gap esophageal atresia

The management of long-gap esophageal atresia remains challenging with limited consensus on the definition, evaluation, and surgical approach to treatment. Efforts to preserve the native esophagus have been successful with delayed primary anastomosis and tension-based esophageal growth induction processes. Esophageal replacement is necessary in a minority of cases, with the conduit of choice and patient outcomes largely dependent on institutional expertise. Given the complexity of this patient population with significant morbidity, treatment and long-term follow-up are best done in multidisciplinary esophageal and airway treatment centers.

Esophageal replacement

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.

Endoscopic esophageal substitution for pure esophageal atresia and wide gap esophageal atresia: A report of five cases with minimum follow-up of twelve months

AIM

The aim of the study is to report feasibility and safety of endoscopic esophageal substitution in infants with pure esophageal atresia and wide gap tracheoesophageal fistula with a minimum one year follow-up.

MATERIALS AND METHODS

This prospective study was conducted from January 2012 for twenty four consecutive months at Apollo Hospital, New Delhi. All babies either followed up or referred for esophageal substitution without any history of mediastinitis or associated major congenital anomaly and weighing greater than 6kg were to be included in the study. The indication, intraoperative details, operative approach, conversion to open, esophageal substitute, postoperative ventilation, ICU and hospital stay, time to solid foods, morbidity and mortality were recorded. Informed consent was obtained from all the parents and ethical clearance was obtained for the study from the hospital ethical committee. Postoperatively babies were followed up monthly for first six months, 3 monthly for next six months and annually thereafter.

RESULTS

Between January 2012 and December 2013, in the two year period six infants were admitted for laparoscopic gastric transposition. In five patients the procedure was completed by the laparoscopic approach and one required conversion to open surgery owing to dense adhesions. The age range at the time of surgery was from 8months to 12months with a mean age of 10months. Four patients had pure esophageal atresia (type A) and two had wide gap esophageal atresia with distal tracheoesophageal atresia (type C). Five had primary esophagostomy and gastrostomy as a newborn, the sixth had postoperative anastomotic leak and required subsequent diversion. The mean operating time was 194minutes (range 170-210minutes). The mean stay in ICU was 7days with a range of 4-12days. All patients were ventilated in the postoperative period for an average of 5days with a range of 4-7days. One patient had prolonged gastric ileus which delayed the oral feeds by 14days. The mean time to start the oral feeds was 8days with a range of 6-14days. The mean hospital stay was 19.6days (range 16-23days). Early complications were pneumonia and pleural effusion in one patient. One patient developed anastomotic stricture which was amenable to dilatation. One patient had leak from esophagogastric anastomosis which healed spontaneously. All children are now orally fed, swallow without difficulty, and parents report an excellent cosmetic outcome. The follow-up ranges from 12 to 36months.

CONCLUSION

The initial results of endoscopic esophageal substitution are encouraging and easily comparable to the outcome of open surgery with all the attendant benefits of minimally invasive approach.

Comparison of minimally invasive and open gastric transposition in children

BACKGROUND

Gastric transposition is an established method of esophageal replacement in children, and the use of minimally invasive techniques avoids the trauma of open access. The objective of this study was to compare outcomes of minimally invasive versus open gastric transposition in children.

MATERIALS AND METHODS

All cases of attempted laparoscopic-assisted gastric transposition at Great Ormond Street Hospital (GOSH), London, United Kingdom, between 2003 and 2012 were retrospectively reviewed. A comprehensive literature search was completed on MEDLINE for minimally invasive gastric transposition in children, and postoperative outcomes were collated. The outcomes from the retrospective review (single-center, GOSH) and the literature search (multicenter) were compared with those of the largest study on open gastric transposition consisting of 192 cases performed at GOSH.

RESULTS

In this retrospective review of 19 patients (mean age, 3.5 years; range, 0.4-15 years), the indications were long-gap esophageal atresia, postoperative, caustic, and idiopathic esophageal stricture, and esophageal dysmotility. Three cases were converted to laparotomy and excluded from subsequent analysis. There were one anastomotic leak, two strictures, and no deaths in this series. The literature search yielded a further 50 cases for comparison. Single-center (n=16) and multicenter (n=66) comparison of minimally invasive versus open technique (n=192) showed no difference in leak (6.3% and 16.7%, respectively, versus 12.0%; P=.701 and P=.398), stricture (12.5% and 15.2% versus 20.8%; P=.535 and P=.370), and mortality rates (0% and 1.5% versus 4.7%; P=1.000 and P=.461).

CONCLUSION

Minimally invasive gastric transposition is a safe and acceptable alternative to open surgery in children.

Development of new devices for translumenal endoscopic esophageal anastomosis

AIM

This study aimed to develop new devices for translumenal endoscopic esophageal anastomosis-a stent and a ligating device-and to confirm the feasibility of our novel procedure using those devices.

MATERIALS AND METHODS

We designed a ligating device as an overtube whose tip worked like the EVL device (Sumitomo Bakelite Co. Ltd., Tokyo, Japan). The newly developed procedure for anastomosis is as follows: a silicone elastic band, which was released from the device located at the upper esophagus, and a custom-made expandable stent, which was expanded by the balloon catheter in the lower esophagus, tightened the upper and lower esophageal walls. After producing the devices, we performed the anastomosis procedure in porcine models.

RESULTS

A ligating device and an expandable stent were developed for this study. An ex vivo feasibility study was performed in three porcine models. Endoscopic visualization revealed that all steps in this procedure were technically successful. The median time needed to perform this procedure was 24 (range, 19-25) minutes. Patency of the anastomosis was confirmed in all specimens.

CONCLUSIONS

Translumenal esophagoesophageal anastomosis using the new devices was feasible. The procedure time was sufficiently short for clinical use. An in vivo survival study is needed to confirm the safety and reliability of this procedure.

Laparoscopic and thoracoscopic gastric pull-up for pure esophageal atresia in early infancy

In the developing countries, the babies with pure esophageal atresia undergo an esophagostomy and feeding gastrostomy at birth. It assists in early discharge from hospital. Esophageal substitution in these babies around six months is recommended. We report the first laparoscopic and thoracoscopic gastric pull up in early infancy from India.

Surgical advances in the fetus and neonate: esophageal atresia

This article focuses on selected topics in the diagnosis and management of patients with esophageal atresia (EA) with or without tracheoesophageal fistula. The current status of prenatal diagnosis and recent advances in surgical techniques, including thoracoscopic repair for short-gap EA and tension-induced esophageal growth for long-gap EA, are reviewed. Although no consensus exists among pediatric surgeons regarding the role of these procedures in the treatment of EA, one can reasonably expect that, as they evolve, their application will become more widespread in this challenging patient population.

Laparoscopic-assisted transhiatal gastric transposition for long gap esophageal atresia in an infant

Previous reports describing laparoscopic-assisted transhiatal gastric transposition for long gap esophageal atresia (LGEA) have focused on older infants (median age of 11 months). By performing this operation at an earlier age, patients may avoid esophagostomies or prolonged hospitalizations with nasoesophageal tubes. An additional benefit is the earlier introduction of oral feeds, which is likely to decrease the incidence of oral aversion and feeding difficulties. In this report, we describe our surgical technique for performing a laparoscopic-assisted gastric transposition in a 56-day-old former 36-week premature infant with LGEA.