Endoscopic esophageal anastomosis

Endoscopic Esophageal Anastomosis By Dieter Booss, Michael H/511warth, and Hugo Sauer Bremen, West Germany and Graz, Austria 9 This paper describes four cases of esophageal atresia w i t h o u t a l o w e r fistula in which a perlon t h r e a d w a s inserted through the t w o esophageal s e g m e n t s by an endoscopic method. W i t h the aid of the t h r e a d and t w o metal olives the segments w e r e d r a w n closer t o g e t h e r and finally a c o m m u n i c a t i o n w a s established w i t h o u t an operation. T h e m e t h o d of introducing the t h r e a d and the olive technique are d e m o n s t r a t e d in a series of drawings, and the results achieved in the case of four children are also presented. INDEX WORDS: geal atresia.

Endoscopic anastomosis; esopha-

N E OF T H E M O S T D I F F I C U L T problems in the treatment of esophageal atresia arises in those cases in which a large gap between the blind pouches does not permit a primary anastomosis, in particular, where it forms without a lower tracheo-esophageal fistula with or without an upper tistula. In these cases the lower blind pouch is usually so short that direct anastomosis is not possible. There are several therapeutic methods to cope with this problem: One is by bridging the defect with segments of the intestine, mainly the colon interposition of Waterston ~or the stomach interposition of Cohen and Middleton; 2 another is by shortening the distance between the two esophageal segments (with the goal of a delayed primary esophageal anastomosis) by means of bougienage of the upper segment as described by Howard and Myers. 3 The hypoplastic lower segment can be stretched through the gastrostomy in the same manner. Livaditis 4 has recommended

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This paper was submitted to mark the occasion of the 70th birthday of Professor Fritz Rehbein, April 8, 1981.

From the Children's Surgical Clinic o f the Central Hospital St. Jiirgenstrasse, Bremen, West Germany (Directors: Dr. D. Booss and Dr. G. v.d. Oelsnitz, Lecturer) and the Children ) Surgical Clinic o f the Karl Franzens-University in Graz, Austria (Board o f Management: Prof. Dr. H. Sauer). Presented before the X X V l l Annual International Congress o f the British Association o f Pediatric Surgeons, Oxford, England, September 10-12, 1980. Address reprint requests to Dr. Dieter Booss, Kinderchirurgische Klinik, Friedrich-Karl-Strasse, D-2800 Bremen 1, West Germany. 9 1982 by Grune & Stratton, Inc. 0022-3468/82/1702q9005501.00/0 138

circular myotomy of the proximal segment in order to elongate the upper blind pouch. MATERIALS AND METHODS The "Olive-Method'" In 1971 and 1972 Rehbein and Schweder 5'6 published a new method. When the primary operation showed that an end to end anastomosis during the thoracotomy is not possible, after closure of the fistula, a perlon thread is inserted from the proximal into the distal esophageal segment and led out orally or nasally and through the gastrostomy. Around that part of the thread which bridges the mediastinum there develops an epithelialized tistulous canal, which is surrounded by granulation tissue. This canal is the starting point of a continuity between the two esophageal segments and can, if the distance is relatively small, be dilated by bougienage. In cases without fistulae and with a long distance, the thread serves to assist the mutual approach of the two esophageal segments with the aid of introduced metal olives (Figs. I and 2). In suitable cases it is possible to induce necrosis of the tissue between the olives in order to establish an anastomosis (Figs. 3 and 4). The main clement used in the procedure is the perlon thread. In order to bring the thread into the desired position in the segments and in the intervening mediastinum, the method used hitherto has always been a thoracotomy.

Endoscopic Procedure In 1975 the first successful introduction of the thread using the endoscopical technique was carried out, thus avoiding the necessity of a thoracotomy. This was achieved in cooperation between Okmian in Lund (Sweden) and our group in Bremen. 7 Under general anesthesia we introduced the thread with a long thin sterile steel needle through the instrumental channel of an ordinary I I Fr cystoscope ( S T O R Z R) from the gastrostomy and the lower segment. From the mouth we had inserted a rigid esophagoscope. In the moment of close contact and straight direction of both the instruments the needle was pressed in the distal opening of the esophagoscope and finally pulled out of the mouth (Figs. 5-8). The exact position of the endoscopes was continuously controlled by fluoroscopy in two planes. Between two plastic balls kept under tension by means of the introduced thread a communication was established. Kato et al. 8 using specially designed equipment, reported four cases in which the thread was inserted in a similar manner and an esophageal passage established. However, two of these children died from other causes, the other two have complete esophagi.

CASE REPORTS Since 1976 in the Children's Surgical Clinic, Bremen (West Germany) and in the Children's Surgical Hospital of the University of Graz (Austria) we have inserted the thread

Journal of Pediatric Surgery, Vol. 17, No. 2 (April), 1982

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Fig. 1. Metal olives are inserted into the lower and upper segment.

Fig. 3. Repeatedly drawing the olives together results in the esophageal segments coming closer together.

Fig. 2. The upper olive is drawn downwards by pulling the thread (right hand) and the lower olive is moved upwards by Pressing against the metal catheter (left hand).

Fig. 4. It is possible to squeeze the bridge of tissue between the esophageal segments and a communication can be established.

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1' Fig. S. Positioning of the patient and location of the endoscopes before the thread is introduced.

endoscopically in a total of four children and subsequently applied the method according to Rehbein. Case 1. Esophageal atresia was diagnosed in a male newborn (J.t 1.) with a birth weight of 2900 g (Fig. 9). On the day after birth, tracheoseopy was carried out and an upper trache~esophageal fistula was found. Perinatat sepsis developed which required antibiotic therapy and parenteral feeding. On the 8th day of life, a gastrostomy was made and enteral feeding started. At the age of 7 wk, while being monitored by two image converters in anteroposterior and by lateral fluoroscopy, an esophagoscope was inserted into the upper esophageal pouch and an infant cystoscope was passed through the gastrostomy up to the lower pouch (Fig. 10). When both the endoscopes were exactly aligned to each other, a thread was passed through both endoscopes with a low flexible needle. In the same anesthesia, the upper tracheoesophageal fistula was closed from the neck. During the nexl 10 days, longitudinal bougienage was carried out with the olive technique. The picture, which represents a

Fig. 7. A flexible needle is inserted through the lower endoscope. The point of the needle has pierced the ends of the two esophageal segments and is visible in the upper endoscope.

!l Fig. 6. Location of the two endoscopes in the upper and lower esophageal segments,

Fig. 8. The thread now passes both segments and olive treatment can commence.

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Fig, 11, Double exposed x - r a y of the thorax a - p with the olives in situ, not subjected to tension (wide gap), subjected to tension (narrow gap). (Patient J.H.)

Fig. 9. X - r a y a - p of the thorax and abdomen (patient J.H.) immediately after birth. There was no air in the abdomen.

Fig. 10. Radiological check with the t w o endoscopes prior to introducing the thread.

double exposure of the radiological situation without and with tension exerted on the olives, shows clearly how the esophageal blind pouches can be pulled together (Fig. 1 l). After l0 days, the olives perforated the thin bridge of tissue between the pouches. During the following weeks, bougienage with the thread, as guide was carried out. At the same time we started oral feeding. Ten wk after birth the child was discharged from the hospital with the thread still in position. At first bougienage was performed once a week, later on at longer intervals. After 6 mo it was possible to remove the thread. One year after the primary procedure an x - r a y checkup showed normal passage of the contrast medium. Esophageal manometry showed good propulsive peristalsis, passing the anastomosis area (Fig. 12). The child is completely symptom free and is developing like a normal child of its age. Caxe 2. In a male child (B.P.), with an upper fistula and with similar course of symptoms, a cicatricial stenosis in the anastomotic area which proved to be resistant to therapy had to be resected 2 yr after the thread had been inserted by endoscopy. W e think that in this case at the beginning the bougienage was not carried out thoroughly enough. Case 3. In another male child (D.St.), after successful insertion of the thread and application of the olives a fistula between the esophagus and the right main bronchus that had not been disclosed before required a thoracotomy at the age of 10 mo. On this occasion, the short anastomotic canal was resected and direct end to end anastomosis applied. It was possible to establish this anastomosis without technical problems since the segments of the esophagus had already approached each other. Patients 2 and 3 had been prepared by a blunt elongation of the segments after Howard and Myers' suggestion for some weeks. Case 4. In the fourth child of this series (R.G.), female, there existed a Vater association with esophageal atresia and upper fistula, anorectal atresia, atresia of uterus and vagina, a double left kidney with double ureters, ureterovesical reflux, a patent Botallo's duct and valvular aortic stenosis. Three wk after birth, the duct was closed. Seven wk after

142

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birth a thread was inserted endoseopically through the segments and the upper fistula was closed. Unfortunately the thread was soon found to have passcd the right main bronchus. It was removed and we performed intermittent longitudinal bougienagc according to ltoward and Myers, One mo later it was possible to insert a new thread by endoscopy, this time without difficulties. This was followed by treatment with the olive technique. The further course of events was uncomplicated and 6 wk later we were able to discharge the child in good condition with full oral feeding. However, 3 mo later the child died from acute toxicosis, whereby the endocardial fibrosis, which was revealed by autopsy and confirmed histologically,was also partly responsible for the fatal outcome. The postmortem examination showed a wide anastomosis with a circumference of 24 mm.

DISCUSSION Based on our experience with endoscopic insertion of the thread, we think that this method can be applied in esophageal atresia without lower fistula and with a wide gap. It is advisable to insert the thread as soon as possible but preferable at that point when, as a result of p r e l i m i n a r y elongation, the two segments have achieved m a x i m u m proximity. In this way it is possible to avoid a thoracotomy; in addition an

upper tistula that may coexist can be closed from the neck in the same stage. Thorough bougienage starting in the form of longitudinal bougienage with the olive technique and subsequently with dilatation of the c o m m u n i c a t i o n leads to a sufficiently wide anastomosis. All four children tolerated this procedure without severe complications. There is a possibility of a p u n c t u r e of the pleura or injury to the main bronchus. But this is only a slight risk, especially if very careful attention is paid to close contact and exact a l i g n m e n t of the two endoscopes at the m o m e n t of penetration of the needle. No child of our small group of patients died from complications of the endoscopic insertion of the thread. W e think that thorough and longtime dilatation t r e a t m e n t can in most cases prevent the development of later stenoses and the necessity of a reoperation. Endoscopic insertion of the thread and olive t r e a t m e n t according to Rehbein's principle is therefore a valuable alternative to other methods dealing with the long gap problem with the aim to preserve the continuity of the child's own esophagus.

REFERENCES 1. Waterston D: Colonic replacement ofesophagus (intrathoracic). SurgClin N Am 44:1441-I447, 1964

2. Cohen DH, Middleton A, Fletcher J: Gastric tube esophagoplasty. J Pediatr Surg 9:451-460, 1974

ENDOSCOPIC ESOPHAGEAL ANASTOMOSIS

3. Howard R, Myers NA: Esophageal atresia: A technique for elongating the upper pouch. Surgery 58:725-727, 1965 4. Livaditis A, Radberg L, Odensjo G: Esophageal endto-end anastomosis. Scand J Thor Cardiovasc Surg 6:206214, 1972 5. Rehbein F, Schweder N: Reconstruction of the esophagus without colon transplantation in cases of atresia. J Pediatr Surg 6:746-752, 1971 6. Rehbein F: Kinderchirurgische Operationen. Stuttgart, Hippokrates Verlag, 1976 pp 94-125

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7. Okmian L, Booss D, Ekelund I: An endoscopic technique for Rehbein's silver olive method. Z Kinderchir 16:212-215, 1975 8. Kato T, Hollmann G, H6pner F, et al: Ein neues Instrument zur Fadenlegung ohne Thorakotomie in ausgew~ihlten Fallen von 13sophagusatresie. Z Kinderchir 29:2023, 1980 9. Hendren WH, Hale JR: Electromagnetic bougienage to lengthen esophageal segments in congenital esophageal atresia. N Engl J Med 293:428 432, 1975