Laparoscopic Transhiatal Esophagectomy and Gastric Pull-Up in Long-Gap Esophageal Atresia: Description of the Technique in Our First 10 Cases

Long-gap esophageal atresia: gastric transposition or esophageal lengthening with delayed primary anastomosis? A systematic review

PURPOSE

This study aims to evaluate different surgical approaches to long-gap esophageal atresia (LGEA) with or without tracheoesophageal fistula (TEF) is unclear.

METHODS

A systematic literature review was done comparing gastric transposition versus esophageal lengthening with delayed primary anastomosis in infants with LGEA+/-TEF. The primary outcome was time to full oral feeds. Secondary outcomes were time to full enteric feeds, need for further surgery, growth, mortality, and postoperative adverse events.

RESULTS

No comparative studies were found. However, the literature was re-interrogated for non-comparative studies. Four hundred thirty-eight articles were identified and screened, and 18 met the inclusion criteria. All were case series. Forty-three infants underwent gastric transposition, and 106 had esophageal lengthening with delayed primary anastomosis. One study on gastric transposition reported time to full oral feeds, and one study in each group reported growth. Time to full enteric feeds was reported in one study in each group. 30% of infants had further surgery following gastric transposition, including hiatus hernia repair (5/43, 12%) and esophageal dilation (7/43, 16%). Following esophageal lengthening, 62/106 (58%) had anti-reflux surgery, 58/106 (55%) esophageal dilatation and 11/106 (10%) esophageal stricture resection. Anastomotic complications occurred in 13/43 (30%), gastrointestinal in 16/43 (37%), respiratory in 17/43 (40%), and nerve injury in 2/43 (5%) of the gastric transposition group. In the esophageal lengthening group, anastomotic complications occurred in 68/106 (64%), gastrointestinal in 62/106 (58%), respiratory in 6/106 (6%), and none sustained nerve injury. Each group had one death due to a cause not directly related to the surgical procedure.

CONCLUSIONS

This systematic review highlights the morbidity associated with both surgical procedures and the variety in reporting outcomes.

ERNICA Consensus Conference on the Management of Patients with Long-Gap Esophageal Atresia: Perioperative, Surgical, and Long-Term Management

INTRODUCTION

 Evidence supporting best practice for long-gap esophageal atresia is limited. The European Reference Network for Rare Inherited Congenital Anomalies (ERNICA) organized a consensus conference on the management of patients with long-gap esophageal atresia based on expert opinion referring to the latest literature aiming to provide clear and uniform statements in this respect.

MATERIALS AND METHODS

 Twenty-four ERNICA representatives from nine European countries participated. The conference was prepared by item generation, item prioritization by online survey, formulation of a final list containing items on perioperative, surgical, and long-term management, and literature review. The 2-day conference was held in Berlin in November 2019. Anonymous voting was conducted via an internet-based system using a 1 to 9 scale. Consensus was defined as ≥75% of those voting scoring 6 to 9.

RESULTS

 Ninety-seven items were generated. Complete consensus (100%) was achieved on 56 items (58%), e.g., avoidance of a cervical esophagostomy, promotion of sham feeding, details of delayed anastomosis, thoracoscopic pouch mobilization and placement of traction sutures as novel technique, replacement techniques, and follow-up. Consensus ≥75% was achieved on 90 items (93%), e.g., definition of long gap, routine pyloroplasty in gastric transposition, and avoidance of preoperative bougienage to enable delayed anastomosis. Nineteen items (20%), e.g., methods of gap measurement were discussed controversially (range 1-9).

CONCLUSION

 This is the first consensus conference on the perioperative, surgical, and long-term management of patients with long-gap esophageal atresia. Substantial statements regarding esophageal reconstruction or replacement and follow-up were formulated which may contribute to improve patient care.

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.

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.

Esophageal replacements in children

Replacement of the esophagus in children can be performed in cases of malformations, injuries, or acquired conditions. The new esophagus should allow normal oral feeding, with little or no gastroesophageal reflux, and be able to work well for the lifetime of the patient. For over a century, many substitutes have been used, such as segments of colon, the entire stomach, gastric tubes, or parts of the small bowel, but none are perfect or function like a normal esophagus. Esophageal replacements are demanding challenges for pediatric surgeons. Here, I review the different techniques and the pitfalls related to these procedures on the basis of our experience of more than 300 esophageal replacements in children performed since 1989.

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.