Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia

The timing of oesophageal dilatations in anastomotic stenosis after one-stage anastomosis for congenital oesophageal atresia

BACKGROUND

In infants with congenital oesophageal atresia, anastomotic stenosis easily occurs after one-stage oesophageal anastomosis, leading to dysphagia. In severe cases, oesophageal dilatation is required. In this paper, the timing of oesophageal dilatation in infants with anastomotic stenosis was investigated through retrospective data analysis.

METHODS

The clinical data of 107 infants with oesophageal atresia who underwent one-stage anastomosis in our hospital from January 2015 to December 2018 were retrospectively analysed. Data such as the timing and frequency of oesophageal dilatation under gastroscopy after surgery were collected to analyse the timing of oesophageal dilatation in infants with different risk factors.

RESULTS

For infants with refractory stenosis, the average number of dilatations in the early dilatation group (the first dilatation was performed within 6 months after the surgery) was 5.75 ± 0.5, which was higher than the average of 7.40 ± 1.35 times in the normal dilatation group (the first dilatation was performed 6 months after the surgery), P = 0.038. For the infants with anastomotic fistula and anastomotic stenosis, the number of oesophageal dilatations in the early dilatation group was 2.58 ± 2.02 times, which was less than the 6.38 ± 2.06 times in the normal dilatation group, P = 0.001. For infants with non-anastomotic fistula stenosis, early oesophageal dilatation could not reduce the total number of oesophageal dilatations.

CONCLUSION

Starting to perform oesophageal dilatation within 6 months after one-stage anastomosis for congenital oesophageal atresia can reduce the required number of dilatations in infants with postoperative anastomotic fistula and refractory anastomotic stenosis.

Post-esophageal atresia repair double acquired tracheoesophageal fistulas treated successfully by gastric transposition: a case report

Background

Postoperative recurrence of tracheoesophageal fistula (TEF) is a frequent complication in the repair of esophageal atresia (EA). Based on the recent etiologic classification, a TEF that develops in a different new pathway from the original one is categorized as an acquired TEF. The TEFs that fall into this category have been reported to be refractory and their mechanisms have not been fully understood. Here, we report the complicated case of an acquired TEF derived from mediastinitis after the original TEF repair developed an anastomotic stricture. The TEF contained double fistulas, both towards the right lobe bronchi, and was repaired by gastric transposition through a retrosternal route.

Case presentation

The patient was diagnosed with Gross C esophageal atresia after birth and underwent tracheoesophageal fistula banding during the neonatal period. He experienced an intractable anastomotic stenosis after surgery which was treated with repeated balloon dilation therapy. By the age of 11 months, he developed a mediastinal abscess that improved with conservative treatment. At 18 months old, a fistula from the esophagus to the right superior lobe bronchus was identified. The patient underwent a right upper lobectomy to resect the fistula. However, at 21 months old, another fistula to the right lower lobe was revealed. An esophageal banding was done to relieve the respiratory symptoms. This was followed by esophagectomy and gastric transposition through the retrosternal route at 26 months old. The patient started rehabilitation and oral intake gradually after surgery. By 3 years after gastric transposition, he could already take blended food orally with the support of small amounts of enteral feeding.

Conclusion

Cases of TEF derived from severe inflammation have the potential to form a complicated network and lead to recurrence. Surgeons should consider the possibility of multiple tiny fistulas in cases of severe acquired TEF. These may be repaired successfully by gastric transposition through the retrosternal route.

14 Years’ experience of esophageal replacement surgeries

BACKGROUND

Esophageal replacement is a challenge to the therapeutic skills of surgeons and a technically demanding operation in the pediatric age group. Various conduits and routes have been described in the literature, each with their specific advantages and disadvantages. We carried out this retrospective study to share our experience of esophageal replacement.

METHODOLOGY

This study was conducted at the department of pediatric surgery The Children's Hospital and The Institute of Child Health, Lahore. The records of patients treated for esophageal replacement were reviewed. The patients under follow-up were called for clinical evaluation and assessed of long terms complications if any.

RESULTS

A total of 93 patients with esophageal replacement were included in the study. Esophageal replacement was done with gastric transposition in 84 cases (90%), colon interposition in 7 cases (7.5%) including one case of redo colonic interposition, and jejunal interposition in 2 cases (2%). Routes of esophageal replacement were trans-hiatal in 71 (76%), retrosternal in 13 (14%), and trans-hiatal with thoracotomy in 9 (10%) patients. Postoperatively, all of the conduits maintained viability. Wound infection was seen in 10 (11%), wound dehiscence in 5 (5%), anastomotic leak in 9 (10%), anastomotic stenosis in 12 (13%), fistula formation in 4 (4%), aortic injury 1 (1%), dumping syndrome 8 (9%), reflux 18 (19%), dysphagia 15 (16%) and death occurred in 12 patients (13%).

CONCLUSION

There are problems with esophageal replacement in developing countries. In this context, gastric conduit appeared as the best conduit for esophageal replacement, using the trans-hiatal route for replacement, in the authors' experience.

Twenty-Four Hour pH Study and Manometry in Gastric Esophageal Substitutes in Children

PURPOSE

Studies on the physiology of the transposed stomach as an esophageal substitute in the form of a gastric pull-up or a gastric tube in children are limited. We conducted a study of motility and the pH of gastric esophageal substitutes using manometry and 24-hour pH measurements in 10 such patients.

METHODS

Manometry and 24 hour pH studies were performed on 10 children aged 24 to 55 months who had undergone gastric esophageal replacement.

RESULTS

Six gastric tubes (4, isoperistaltic; 2, reverse gastric tubes) and 4 gastric pull-ups were studied. Two gastric tubes and 4 gastric pull-ups were transhiatal. Four gastric tubes were retrosternal. The mean of the lowest pH at the midpoint of the substitute was 4.0 (range, 2.8-5.0) and in the stomach remaining below the diaphragm was 3.3 (range, 1.9-4.2). In both types of substitute, the difference between the peak and the nadir pH recorded in the intra-thoracic and the sub-diaphragmatic portion of the stomach was statistically significant (p<0.05), with the pH in the portion below the diaphragm being lower. The lowest pH values in the substitute and in the remnant stomach were noted mainly in the evening hours whereas the highest pH was noted mainly in the morning hours. All the cases showed a simultaneous rise in the intra-cavitatory pressure along the substitute while swallowing.

CONCLUSION

The study suggested a normal gastric circadian rhythm in the gastric esophageal substitute. Mass contractions occurred in response to swallowing. The substitute may be able to effectively clear contents.

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.

Pediatric airway surgery

The management of pediatric airway pathology can be challenging and requires a dedicated team, consisting of thoracic surgeons, phoniatricians, logopedics, pediatricians and anesthetists. It necessitates a tailored treatment approach for each individual patient in order to address the minor variances that exist between cases. The majority of pediatric airway problems are a sequela of prematurity and prolonged post-partal intubation/tracheostomy. Surgical repair is often complicated by additional malformation or severe comorbidities. This comprehensive review should give an overview on most common airway problems in neonates and children as well as available surgical techniques.

Surgical outcomes of different approaches to esophageal replacement in long-gap esophageal atresia: A systematic review

BACKGROUND

Esophageal replacement (ER) surgery has been widely used in long-gap esophageal atresia (LGEA) over the past few decades. The most commonly used surgical approaches in many pediatric surgical centers include colon interposition (CI), gastric pull-up (GPU), jejunal interposition (JI), and gastric tube reconstruction (GTR). However, there is no systematic evidence on which is the optimal conduit for the native esophagus. The aim of this systematic review was to evaluate the short- and long-term outcomes among these 4 replacement approaches in LGEA cases based on current evidence.

METHODS

PubMed, Web of Science, Cochrane Library, and EMBASE were searched for relevant literature on November 18 2016. Studies on ER in LGEA were reviewed and selected according to eligibility criteria. We focused on surgical outcomes regarding to different replacement approaches, including postoperative complications and long-term follow-up. Both detailed descriptions of single studies and pooled data analysis were conducted. Data were computed by Reviewer Manager 5.3.

RESULTS

Twenty-three studies were included (4 comparative retrospective, 3 prospective, and 16 retrospective) with a total of 593 patients (393 LGEA, 66.3%). The number of patients with available data for analysis was 534 (90.1%), including 127 patients (98 LGEA) of GPU, 335 (223 LGEA) of CI, 45 (all LGEA) of JI, and 27 (all LGEA) of GTR. Follow-up information was provided in 15 studies. Anastomotic leak and stricture, respiratory problems, and gastroesophageal reflux were analyzed as major postoperative complications. Long-term follow-ups were concentrated on growth and feeding conditions.

CONCLUSION

Current evidence on short- and long-term outcomes of ER in LGEA patients was limited, and proper prospective comparative studies were lacking. This present systematic review indicates CI and GPU as comparable and favorable approaches, especially CI in the long-term outcomes. Studies on JI and GTR were limited, which need larger sample size to assess their validity and outcomes.

Pediatric esophageal substitution by gastric pull-up and gastric tube

Aim:

The aim of this study was to report the results of pediatric esophageal substitution by gastric pull-up (GPU) and gastric tube (GT) from a tertiary care pediatric center.

Materials and Methods:

Retrospective analysis of the surgical techniques, results, complications, and final outcome of all pediatric patients who underwent esophageal substitution in a single institution was performed.

Results:

Twenty-four esophageal substitutions were performed over 15-year period. The indications were pure esophageal atresia (EA)-19, EA with distal trachea-esophageal fistula-2, EA with proximal pouch fistula-1, and esophageal stricture in two patients. Mean age and weight at operation were 17 months and 9.5 kg, respectively. GPU was the most common procedure (19) followed by reverse GT (4) and gastric fundal tube (1). Posterior mediastinal and retrosternal routes were used in 17 and 7 cases, respectively. Major complications included three deaths in GPU cases resulting from postoperative tachyarrhythmias leading to cardiac arrest, cervical anastomotic leak-17, and anastomotic stricture in six cases. Perioperative tachyarrhythmias (10/19) and transient hypertension (2/19) were observed in GPU patients, and they were managed with beta blocker drugs. Postoperative ventilation in Intensive Care Unit was performed for all GPU, but none of the GT patients. Follow-up ranged from 6 months to 15 years that showed short-term feeding difficulties and no major growth-related problems.

Conclusions:

Perioperative tachyarrhythmias are common following GPU which mandates close intensive care monitoring with ventilation and judicious use of beta blocking drugs. Retrosternal GT with a staged neck anastomosis can be performed without postoperative ventilation.

Partial gastric pull-up in the treatment of patients with long-gap esophageal atresia

BACKGROUND

This study was to analyze outcomes of long-gap esophageal atresia (LGEA) treated with partial gastric pull-up (PGP) into the thorax.

METHODS

The medical records of all children who had undergone PGP for LGEA from 1999 to 2012 were reviewed. Preoperative data, initial postoperative course, complications, time to full oral nutrition, follow-up diagnostics and nutritional status were assessed.

RESULTS

Nine children who had undergone PGP were followed up for a mean period of 6.2 ± 3.1 years. Their median gestational age was 37 ± 2 weeks, and mean birth weight 2462 ± 658 g. Eight children were primarily treated with a gastrostomy, their mean age at PGP was 11.4 ± 10.9 weeks and mean weight was 4484 ± 1966 g. Their mean operation time was 199 ± 51 minutes. Leakage was an early postoperative complication in three children, one of whom had a consecutive stricture resection. Late complications were stenosis (n=7) and gastro-esophageal reflux (n=5). The general status of the children was judged as "good" or "very good" on the last presentation. The median percentile of the body-mass-index was 25. Gastroscopy at 3.7 ± 3.2 years after the operation revealed a grade I esophagitis in two children. There was no death in this group of children.

CONCLUSIONS

Because of its high complication rate, partial gastric pull-up cannot be recommended as an alternative for the treatment of LGEA at present. A final judgment could be made on the basis of a comparative study.

Extensive preoperative workup in diffuse esophageal leiomyomatosis associated with Alport syndrome influences surgical treatment: A case report

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Diffuse esophageal leiomyomatosis is frequently associated with Alport syndrome.

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Only curative option is esophagectomy.

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Misdiagnosis is common and workup should include endoscopic ultrasonography and 3D-gastric computed tomography for better anatomical delineation.

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Extensive imaging workup can result in better operative planning.

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Total esophagectomy should include all diseased tissue and provide good long term quality of life.

Introduction

Diffuse esophageal leiomyomatosis is a rare disease. Misdiagnosis is frequent and previous surgeries can complicate surgical management. The only treatment described for severe symptomatic cases is esophagectomy.

Presentation of case

We describe a case of diffuse esophageal leiomyomatosis associated with Alport syndrome in a 21 year-old female where endoscopic ultrasonography (EUS) with concomitant fluoroscopy and 3D-gastric computed tomography (3D-GCT) modified surgical management.

Discussion

The diagnosis of diffuse esophageal leiomyomatosis is difficult but can be greatly facilitated by extensive endoscopic and radiologic workup. Esophagectomy should only be entertained after complete anatomic mapping of the lesions, especially after previous surgeries.

Conclusion

EUS and 3D-GCT should strongly be considered as part of routine preoperative workup in these patients.

Antesternal colonic interposition for corrosive esophageal stricture

Restoration of swallowing in a patient with dysphagia due to nondilatable corrosive stricture of esophagus remains a surgical challenge. Organs available for replacement are stomach, jejunum, or colon. Jejunum is useful to replace a small segment, whereas stomach and colon are required for a long-segment replacement. In cases where the stomach is also injured, colon remains the only option. The route of colonic interposition has also been a subject of debate over the years. Antesternal, retrosternal, or esophageal bed passage are the routes described. In the present series, the data of antesternal colonic interposition (ACI) performed for nondilatable benign esophageal strictures in 32 patients (1988-2011) have been retrospectively analyzed. The results indicate that ACI for corrosive strictures is a quick and simple procedure. Thoracotomy is avoided and anastomosis is easily performed in the neck, and mortality rate due to anastomotic failure or graft failure is diminished. This retrospective analysis discusses the ease, effectiveness, quality of life, morbidity, and mortality of ACI and compares the pros and cons of ACI with other procedures described in the literature.

Gastric transposition in infants and children

The loss of esophageal length in long-gap esophageal atresia or obliteration of the esophageal lumen due to stricture may require major operative reconstruction. A number of procedures have been developed to allow anatomic replacement of the esophagus. The gastric transposition requires a single cervical anastomosis and uses a gastric conduit with excellent blood supply. This review illustrates the procedure and discusses its indications, planning, and outcome.

Esophageal leiomyomatosis -- an unusual cause of pseudoachalasia

Esophageal leiomyomatosis is a rare hamartomatous disorder with varied presentation. In the literature, it is described mostly in children, and is associated with Alport's syndrome. A case of leiomyomatosis that presented as achalasia not associated with Alport's syndrome is described in a 35-year-old woman with a 16-year history of dysphagia. Barium swallow showed a smooth narrowing at the lower end of the esophagus with a longer than usual stricture length. Endoscopy showed a dilated esophagus with a submucosal nodule in the region of the cardia. A computed tomography scan revealed circumferential thickening of the esophagus involving the gastroesophageal junction, with fat planes maintained with the adjacent structure. Endoscopic ultrasound demonstrated a lesion arising from the muscularis propria. The manometry findings were suggestive of achalasia. She underwent transhiatal esophagectomy with gastric pull-up. Leiomyomatosis should be considered as a cause of psuedoachalasia in patients with symptoms suggestive of achalasia and atypical barium findings. Attempts should be made to confirm the diagnosis preoperatively using computed tomography and/or endoscopic ultrasound. Esophagectomy is the treatment of choice.

Ileal pedicle grafting for esophageal replacement in children

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.