Should patients with esophageal atresia be submitted to esophageal substitution before they start walking?

Esophageal replacement in children - 27 years of experience in a University Hospital

INTRODUCTION

esophageal replacement in children is indicated when it is impossible to maintain the native esophagus, which in the pediatric population includes patients with esophageal atresia and esophageal caustic stenosis. The objective of this communication is to report the experience of a university service with two techniques of esophageal replacement.

METHODS

this is a retrospective study based on the revision of hospital files. The study population consisted of patients who underwent esophageal replacement from 1995 to 2022, at the Hospital de Clínicas of the State University of Campinas. The analyzed data were age, sex, underlying disease, technical aspects, complications, and long-term results.

RESULTS

during the study period, 30 patients underwent esophageal replacement. The most common underlying diseases were esophageal atresia (73.33%) and caustic stenosis (26.67%). Twenty-one patients underwent gastric transposition (70%), and nine underwent esophagocoloplasty (30%). The most frequent postoperative complication was fistula of the proximal anastomosis, which occurred in 14 patients. Most of the patients with fistulas had a spontaneous recovery. There were three deaths. Of the 27 survivors, 24 can feed exclusively by mouth.

CONCLUSION

esophageal replacement in children is a procedure with high morbidity and mortality. Esophagocoloplasty and gastric transposition have similar results and complications, with the exception of proximal anastomotic fistulas, which are generally self-resolving and are more common in esophagocoloplasty. The choice of the best surgical technique must be individualized according to the patients characteristics and the surgeons experience, as both techniques offer the ability to feed orally in the short or medium term.

Esophageal substitution or esophageal elongation procedures in patients with complicated esophageal atresia? Results of a comparative study

BACKGROUND

In newborns with complex esophageal atresia, there are situations in which a primary anastomosis cannot be safely performed. The alternative is performing a late anastomosis after the esophageal ends have gone through a period of spontaneous growth or after elongations of the distant ends of the esophagus and create an anastomosis under tension which causes risks of morbidity. An alternative to the elongation procedures is to perform a cervical esophagostomy with a gastrostomy for nutritional support and later on an esophageal replacement. The purposes of this retrospective chart review study are to report on our experience with esophageal substitution procedures in such cases, address the quality of life of a group of patients, and compare our results with those of patients who underwent esophageal elongation procedures as reported in the literature.

METHODS

Patients with esophageal atresia underwent esophageal replacement procedures and quality of life was assessed in a group of esophagocoloplasty patients.

RESULTS

From February 1978 to July 2019, 276 children (232 colonic interpositions and 44 total gastric transpositions) were studied; the most frequent complication was cervical anastomosis leakage [70 (30.2%) esophagocoloplasty patients and 7 (15.9%) gastric transposition patients], which sealed spontaneously in all but 4 patients. The quality of life was considered excellent or good in approximately 90% of the studied 70 out of the 276 patients; the comparison with the esophageal elongation procedures showed that esophageal substitution procedures promoted excellent long-term results with normal deglutition function (98.2% of patients, versus 33.3%, 36.5%, and 62.5%, respectively from the elongation series, P <0.0001 for all comparisons).

CONCLUSION

Esophagocoloplasty or total gastric transposition is a good alternative to treat patients with complex esophageal atresia.

TYPE OF STUDY

Retrospective study.

LEVEL OF EVIDENCE

Level III.

Transhiatal isoperistaltic colon interposition without cervical oesophagostomy in long-gap oesophageal atresia

BACKGROUND

Oesophageal colonic interposition in oesophageal atresia (OA) patients is almost exclusively done as a staged operation with an initial oesophagostomy and gastrostomy followed by the definitive surgery months later. This study presents a series of patients in whom a cervical oesophagostomy was not performed before the substitution surgery.

PATIENTS AND METHODS

Records of EA patients were evaluated for those who underwent colon interposition without cervical oesophagostomy.

RESULTS

There were five patients: three with pure EA and two with proximal tracheo-oesophageal fistula. A delayed primary repair could not be performed because of intra-abdominally located distal pouch. The mean age at the time of definitive operation was 5.54 (±2.7) months and the mean weight was 6.24 (±1.3) kg. A right or a left colonic segment was used for interposition keeping the proximal anastomosis within the thorax. The post-operative results were quite satisfactory within a median follow-up period of 33.2 months.

CONCLUSION

Avoiding cervical oesophagostomy and its inherent complications and drawbacks is possible in a subset of patients with long-gap EA who underwent colonic substitution surgery. This approach may be seen as an extension of the consensus that the native oesophagus should be preserved whenever possible, because it uses the native oesophagus in its entirety.

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.

Mechanical bowel preparation for esophagocoloplasty in children: is it really necessary?

Esophagocoloplasty is a commonly performed procedure for esophageal replacement in children. Traditionally, mechanical bowel preparation (MBP) is performed before this operation. However, this practice has been questioned, initially in adults and now in children. The aim of this study was to evaluate the influence of MBP on esophagocoloplasty in a series of children. Data collected from 164 patients who underwent esophagocoloplasty in the Pediatric Surgery Division, University of São Paulo Medical School, from February 1978 to July 2011 were reviewed for postoperative complications. In 134 patients, at least one kind of MBP was performed before the surgery (PREP group). MBP was omitted in 30 patients (NO-PREP group). There was no statistical difference between the groups in the rates of evisceration, colocolic, or cologastric anastomotic dehiscence and death. However, in the NO-PREP group, the incidence of cervical leakage (6.6%) was significantly decreased in comparison with the classical PREP group (25.3%) (P= 0.03). The results of this study suggest that the omission of MBP has a positive impact on the incidence of postoperative complications in esophagocoloplasty.