- Email: [email protected]
Esophageal replacement: Overcoming the need
Esophageal Replacement: Overcoming the Need Lewis Spitz PII: DOI: Reference:
S0022-3468(14)00020-7 doi: 10.1016/j.jpedsurg.2014.01.011 YJPSU 56642
To appear in:
Journal of Pediatric Surgery
Received date: Accepted date:
10 January 2014 27 January 2014
Please cite this article as: Spitz Lewis, Esophageal Replacement: Overcoming the Need, Journal of Pediatric Surgery (2014), doi: 10.1016/j.jpedsurg.2014.01.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
SC
RI P
T
Stephen L Gans Distinguished Overseas Lecture 2013
Esophageal Replacement: Overcoming the Need
NU
Lewis Spitz
ED
MA
Emeritus Nuffield Professor of Paediatric Surgery Institute of Child Health, University College, London Great Ormond Street Hospital for Children NHS Trust London WC1N 3JH U.K.
AC
CE
PT
E-Mail: [email protected]
ACCEPTED MANUSCRIPT Abstract
MA
NU
SC
RI P
T
Three developments which have contributed to the declining necessity for esophageal replacement are improvement in the management of esophageal atresia, prevention of caustic injuries to the esophagus, and early antireflux surgery for intractable gastro-esophageal reflux. Despite these advances, replacement of the esophagus may still be necessary. The two most commonly used procedures for replacing the esophagus are colonic interposition and gastric transposition. Experience with 236 gastric transposition operations reveal a mortality of 2.5%, leak rate of 12%, and stricture of 20%. The followup shows a satisfaction of over 90%. New methods of overcoming the need for esophageal replacement are in progress with tissue engineering with a scaffold to produce a tubular graft to bridge the gap in the continuity of the esophagus.
AC
CE
PT
ED
Keywords: esophageal replacement; gastric transposition; colon interposition; gastroesophageal reflux
ACCEPTED MANUSCRIPT
RI P
T
The necessity to replace the esophagus has receded significantly in recent years as a result of three main developments: 1. improvements in the management of esophageal atresia particularly with reference to “long gap” atresia, 2. avoidance of caustic injuries, and 3. early treatment of severe gastro-esophageal reflux to prevent intractable strictures. Improvements in the management of esophageal atresia.
NU
SC
In all cases in the management of esophageal atresia, complications such as anastomotic leaks and strictures can be avoided by employing a gentle, meticulous, and accurate technique. Willis Potts in 1959 1. wrote
MA
“To anastomose the ends of an infant’s esophagus, the surgeon must be as delicate and precise as a skilled watchmaker. No other operation offers a greater opportunity for pure technical artistry”.
CE
PT
ED
It is almost always possible to achieve a primary anastomosis in “wide” esophageal atresia where there is a distal tracheo-esophageal fistula, but where the distance between the proximal and distal segments appears too far apart. By constructing an anastomosis even under extreme tension and electively paralyzing and mechanically ventilating the infant for an arbitrary period of around 5 days, it is possible to effect a satisfactory primary repair with a low leak rate but a high incidence of strictures and the need for surgery for gastroesophageal reflux.2..
AC
Numerous methods have been described to reduce the gap between the proximal and distal pouches in “pure or isolated” atresia. Of primary importance is to exclude the presence of a proximal fistula which is present up to 15% of cases 3, which severely limits the mobility of the upper esophagus. Methods include delayed primary anastomosis, stretching of the esophagus, Lividitis esophagomyotomy, and the Foker technique of inducing esophageal growth by applying internal and external traction. With the delayed approach, it is generally unproductive to wait longer than 12 weeks in the expectation that the gap will narrow sufficiently to permit a primary anastomosis. While it is generally accepted that the child’s own esophagus is best, there are instances where replacement is a better option, particularly in cases where persisting with futile attempts to retain the native esophagus are detrimental to the well-being of the child and the family. Examples are repeated failed procedures to achieve esophageal continuity, the development of
ACCEPTED MANUSCRIPT complications such as empyema from anastomotic leaks, refractory or extensive stricturing, or multiple recurrences of fistulas.
RI P
T
There is a clear need to centralize the management of the “difficult esophagus” to a limited number of special centers. The concentration of a large volume of cases will serve to enhance expertise, improve outcome, and generate research into new methods of treatment.
SC
Caustic esophageal damage.
AC
CE
PT
ED
MA
NU
Injury to the mucosal surface occurs within seconds of the ingestion of the strong alkali. The liquifaction necrosis rapidly extends through the epithelial layer and submucosa and may extend into and through the muscle layer. The ultimate outcome in severe cases is extensive stricture formation. The provision of child proof containers of caustic soda has had a major preventative effect in developed countries, whereas in the developing world, particularly in rural areas where caustic agents are used extensively for soap making and drying fruit, and where cleaning material is stored in unsuitable containers, caustic injuries continue to be a major health hazard4.. The prevalence of caustic injuries among children in the United States is estimated to be 1.08 per 100,000 population. The number of hospitalizations is down from 5,000 – 15,000 per year in the 1980’s to 807 in 20095.. Early esophagoscopy is important to confirm the ingestion and to assess the severity of the damage. The continuing need for regular dilatation 6 – 12 months following the injury constitutes an indication for esophageal resection and replacement. Reflux strictures. Early antireflux surgery of severe pathological gastro-esophageal reflux will prevent intractable strictures from developing. It is particularly in the severely neurologically disabled child that symptoms of reflux are ascribed to the developmental delay while irreversible strictures occur. Most cases of severely strictured and inflamed esophaguses will resolve following fundoplication and regular postoperative dilatations. A small minority will eventually require esophageal replacement 6...
RI P
Other indications for esophageal replacement.
T
ACCEPTED MANUSCRIPT
Esophageal replacement.
MA
NU
SC
Other indications for esophageal replacement include tumors of the esophagus, such as diffuse leiomyoma or inflammatory pseudotumor or rarely carcinoma, prolonged impaction of foreign bodies, such as aluminum ring can tops7, which are radiolucent and may escape detection for prolonged periods, and button batteries causing wide tracheoesophageal fistula, intractable achalasia, epidermolysis, and human immunodeficiency (HIV) strictures 8..
PT
ED
The four most commonly used methods of esophageal replacement are 1. colonic interposition 2. reversed gastric tube 3. jejunal interposition 4. gastric transposition
AC
CE
Each method has its own problems and complications, but in our experience the gastric transposition is associated with the lowest complication rate and is the least complicated procedure. Colon interposition has a precarious blood supply, usually arising from the ascending branch of the left colic artery. It is complicated by a high incidence of anastomotic leaks and strictures and in the long-term by redundancy of the interposition with stasis, which may require surgical revision. Gastric tube esophagoplasty involves a very extensive suture line with a high incidence of leaks and strictures. There is also the problem of Barrett’s esophagitis developing from acid reflux into the cervical stump. Jejunal interposition is favored by some, but the blood supply is precarious, although the interposed jejunal segment is of appropriate calibre and is reputed to retain peristaltic activity.
ACCEPTED MANUSCRIPT
SC
RI P
T
Gastric transposition involves transposing the whole stomach into the cervical region. The blood supply of the stomach is excellent, length is not a problem, and the procedure is relatively straight forward. The anastomotic leak rate is low and most close spontaneously, but strictures occur in 20% of cases with the highest incidence in replacement for caustic injury (58%). Reflux, dumping, and poor gastric emptying are problems mainly in the shortterm, and Barrett’s esophagitis may develop long-term.
NU
Surgical technique for gastric transposition (Fig.1). 9,10
AC
Results. 12
CE
PT
ED
MA
The preferred route for gastric transposition is a transhiatal retromediastinal approach without thoracotomy. The procedure has been performed laparoscopically with good results 11. The stomach is fully mobilized, dividing the left gastric and left gastro-epiploic vessels, and a pyloroplasty or myotomy is performed. The highest point on the mobilized stomach is the top of the fundus, which is marked with two different sutures to prevent rotation during transfer through the mediastinum. The stomach is passed via the hiatus through the retromediastinum into the neck, where it is anastomosed to the cervical esophageal stump. A trans-gastric or jejunal feeding tube is placed for temporary enteral feeding in children who have never taken nutrition orally. Postoperatively, elective paralysis and ventilation are used for a few days.
The surgical team at Great Ormond Street Hospital (GOS), London, has performed a total of 236 gastric transposition procedures since 1980. There were 147 male and 89 female patients. The primary condition affecting the infants were esophageal atresia in 177 cases, of which 95 were atresia with distal tracheoesophageal fistula, 65 isolated atresia, 15 atresia with proximal fistula, and two H-fistula. In addition, 32 had extensive stricture following caustic ingestion, and 9 suffered intractable gastroesophageal reflux strictures. The remaining 16 patients included congenital stricture (4), amotile esophagus (3), achalasia, diffuse leiomyomatosis, and prolonged foreign body impaction (2 each, respectively). Eighty-one percent of cases were referred to us from abroad (110) or from other centers in the United Kingdom (81), leaving 41 patients undergoing all their treatment at GOS, less than 1% of the case load.
ACCEPTED MANUSCRIPT
RI P
T
A prior attempt at replacement had been carried out in 33 patients (14%) of which 19 involved colon, 5 partial gastric replacement, 3 each Scharli procedures and gastric tube esophagoplasty, and one attempt at the Foker procedure.
NU
SC
The route for the replacement was via the posterior mediastinum without thoracotomy in 109 cases, transthoracic in 95 cases due to extensive scarring from previous surgery, retrosternal in 7, and recently laparoscopically in 25 cases, of which 8 needed to be converted to open approach due to dense adhesions. A pyloroplasty or myotomy was performed according to surgeon preference. All patients were electively ventilated postoperatively except for the first 4 cases.
AC
CE
PT
ED
MA
Eleven patients died, 5 from conditions unrelated to the gastric transposition, giving a procedure related mortality of 2.5%. Anastomotic leaks occurred in 28 patients (12%) and strictures in 48 cases (20%), of which 17 were secondary to caustic scarring. Swallowing problems postoperatively were almost universal, but in 55 (29%) patients it was significant, moderate in 26, and severe in 29 cases. Delayed gastric emptying was a problem in 21 (8.8%) cases in some patients necessitating conversion of pyloromyotomy to plasty or more radically to gastrojujenostomy. Eight patients developed problematic dumping syndrome which eventually resolved and 4 others a Horner’s syndrome which also eventually resolved. A late complication encountered in 6 patients was herniation of small intestine into the chest via the esophageal hiatus. This complication was eliminated by narrowing the hiatus and suturing the edge of the hiatus to the antrum of the stomach. Follow-up showed that weight generally was in the lower centiles for age, while height was normally distributed. Overall, more than 90% of patients were highly satisfied with the procedure, and there did not appear to be any deterioration in functioning of the transposed stomach in the long-term.
Conclusion. Significant progress has been made in recent years to reduce the need for esophageal replacement. These include improved management of esophageal atresia, prevention of caustic injury by child proof containers, and earlier
ACCEPTED MANUSCRIPT surgery for intractable gastro-esophageal reflux, particularly in the neurologically impaired child.
SC
RI P
T
Despite these advances, there are occasions when the esophagus needs to be replaced. Of the two most commonly used methods of replacement, gastric transposition is favored because of the excellent blood supply of the stomach, the ease of the procedure, and lower leak and stricture rates. There is a clear need to centralize the management of the “difficult” esophageal atresia cases as well as for replacing the esophagus to few specialist centers to improve outcomes, enhance expertise, and carry out research.
PT
Acknowledgements:
ED
MA
NU
Progress is being made with tissue engineering in the creation of a tubularized graft of the esophagus which may supercede current methods of replacement.13. The new esophagus will be comprised of a scaffold of synthetic or natural origin and cells which could be derived from fetal tissue if the diagnosis of pure atresia is suspected prenatally or from bone marrow and mucosa if replacement is required after birth.
AC
CE
Thanks are due to Edward Kiely, Agostino Pierro, David Drake, and Joe Curry for allowing inclusion of their patients, to Paolo De Coppi for information on tissue engineering, and to Marcia Matias for collecting the data.
ACCEPTED MANUSCRIPT References. 1. Potts W.J. In The Surgeon and the Child; Philadelphia. Saunders 1959
RI P
T
2. Spitz L. Esophageal Atresia: Past , Present and Future. J. Pediatr Surg 1996; 31: 19-25.
SC
3. Spitz, L. Esophageal atresia – Lessons I have learned in a 40 year experience. J. Pediatr. Surg. 2006 ; 41 ; 1635-1640.
MA
NU
4. Millar A.J.W. and Numanoglu A. Caustic Strictures of the Esophagus. In Pediatric Surgery 7th Ed. Edit Coran AG, Adzick NS, Krummel TM, Laberge J-M, Shamberger RC and Caldamone AA. Elsevier Saunders 2012, 919 – 926.
ED
5. Johnson CM, Brigger MT. The public health impact of pediatric caustic ingestion injuries. Arch Otolaryngol Head Neck Surg.2012,138:11111115.
CE
PT
6. Spitz L, Roth K, Kiely EM, Drake DP, Milla PJ. Operation for gastrooesophageal reflux associated with severe mental retardation. Arch Dis Child 1993; 68: 347-351
AC
7. Spitz L, Hirsig J. Prolonged foreign body impaction in the oesophagus. Arch Dis Child 1982; 57: 551-553 8. Loveland JA, Mitchell CE, van Wyk P, Beale P. Esophageal replacement in children with AIDS. J Pediatr. Surg. 2010, 45, 2068-70 9. Spitz L. Gastric transposition via the mediastinal route for infants with long-gap esophageal atresia. J Pediatr Surg 1984; 19: 149-154. 10. Spitz L,Pierro A. Gastric replacement of the esophagus in Operative Pediatric Surgery 7th Ed. Edited Spitz L and Coran AG, CRC Press Taylor and Francis Group. Boca Raton FL 2013, 163-173.
ACCEPTED MANUSCRIPT 11. Stanwell J, Drake D, Pierro A, Kiely E, Curry J. Pediatric laparoscopicassisted gastric transposition: early experience and outcomes. J Laparoendosc. Adv. Surg. Tech A 2010, 20, 177-81
RI P
T
12. Spitz L, Kiely E, Pierro A. Gastric transposition in children – a 21-year experience. J.Pediatr. Surg. 2004; 39: 276-281
AC
CE
PT
ED
MA
NU
SC
13. Totonelli G, Maghsoudlou P, Fishman JM, Orlando G, Ansari T, Sibbons P, Birchall MA, Pierro A, Eaton S, De Coppi P. Esophageal tissue engineering: a new approach for esophageal replacement. World J Gastroenterol. 2012 ,47: 6900-7.
ACCEPTED MANUSCRIPT Figure 1.
SC
RI P
T
Illustration of the technique of gastric transposition.
MA
b
CE
PT
ED
a
h
AC
c
e
NU
d
a – closure of gastrostomy b – closure of gastro-esophageal junction c – pyloroplasty / myotomy d – sutures of top of fundus of stomach
e – esophago-gastric anastomosis f – transposed stomach g – pyloroplasty below hiatus h – jejunal feeding tube
f – py lo gro –pl py as lo ty ro be pl lo as w ty hi be at lo us f w hi at us f
AC
CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT
S0022-3468(14)00020-7 doi: 10.1016/j.jpedsurg.2014.01.011 YJPSU 56642
To appear in:
Journal of Pediatric Surgery
Received date: Accepted date:
10 January 2014 27 January 2014
Please cite this article as: Spitz Lewis, Esophageal Replacement: Overcoming the Need, Journal of Pediatric Surgery (2014), doi: 10.1016/j.jpedsurg.2014.01.011
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service to our customers we are providing this early version of the manuscript. The manuscript will undergo copyediting, typesetting, and review of the resulting proof before it is published in its final form. Please note that during the production process errors may be discovered which could affect the content, and all legal disclaimers that apply to the journal pertain.
ACCEPTED MANUSCRIPT
SC
RI P
T
Stephen L Gans Distinguished Overseas Lecture 2013
Esophageal Replacement: Overcoming the Need
NU
Lewis Spitz
ED
MA
Emeritus Nuffield Professor of Paediatric Surgery Institute of Child Health, University College, London Great Ormond Street Hospital for Children NHS Trust London WC1N 3JH U.K.
AC
CE
PT
E-Mail: [email protected]
ACCEPTED MANUSCRIPT Abstract
MA
NU
SC
RI P
T
Three developments which have contributed to the declining necessity for esophageal replacement are improvement in the management of esophageal atresia, prevention of caustic injuries to the esophagus, and early antireflux surgery for intractable gastro-esophageal reflux. Despite these advances, replacement of the esophagus may still be necessary. The two most commonly used procedures for replacing the esophagus are colonic interposition and gastric transposition. Experience with 236 gastric transposition operations reveal a mortality of 2.5%, leak rate of 12%, and stricture of 20%. The followup shows a satisfaction of over 90%. New methods of overcoming the need for esophageal replacement are in progress with tissue engineering with a scaffold to produce a tubular graft to bridge the gap in the continuity of the esophagus.
AC
CE
PT
ED
Keywords: esophageal replacement; gastric transposition; colon interposition; gastroesophageal reflux
ACCEPTED MANUSCRIPT
RI P
T
The necessity to replace the esophagus has receded significantly in recent years as a result of three main developments: 1. improvements in the management of esophageal atresia particularly with reference to “long gap” atresia, 2. avoidance of caustic injuries, and 3. early treatment of severe gastro-esophageal reflux to prevent intractable strictures. Improvements in the management of esophageal atresia.
NU
SC
In all cases in the management of esophageal atresia, complications such as anastomotic leaks and strictures can be avoided by employing a gentle, meticulous, and accurate technique. Willis Potts in 1959 1. wrote
MA
“To anastomose the ends of an infant’s esophagus, the surgeon must be as delicate and precise as a skilled watchmaker. No other operation offers a greater opportunity for pure technical artistry”.
CE
PT
ED
It is almost always possible to achieve a primary anastomosis in “wide” esophageal atresia where there is a distal tracheo-esophageal fistula, but where the distance between the proximal and distal segments appears too far apart. By constructing an anastomosis even under extreme tension and electively paralyzing and mechanically ventilating the infant for an arbitrary period of around 5 days, it is possible to effect a satisfactory primary repair with a low leak rate but a high incidence of strictures and the need for surgery for gastroesophageal reflux.2..
AC
Numerous methods have been described to reduce the gap between the proximal and distal pouches in “pure or isolated” atresia. Of primary importance is to exclude the presence of a proximal fistula which is present up to 15% of cases 3, which severely limits the mobility of the upper esophagus. Methods include delayed primary anastomosis, stretching of the esophagus, Lividitis esophagomyotomy, and the Foker technique of inducing esophageal growth by applying internal and external traction. With the delayed approach, it is generally unproductive to wait longer than 12 weeks in the expectation that the gap will narrow sufficiently to permit a primary anastomosis. While it is generally accepted that the child’s own esophagus is best, there are instances where replacement is a better option, particularly in cases where persisting with futile attempts to retain the native esophagus are detrimental to the well-being of the child and the family. Examples are repeated failed procedures to achieve esophageal continuity, the development of
ACCEPTED MANUSCRIPT complications such as empyema from anastomotic leaks, refractory or extensive stricturing, or multiple recurrences of fistulas.
RI P
T
There is a clear need to centralize the management of the “difficult esophagus” to a limited number of special centers. The concentration of a large volume of cases will serve to enhance expertise, improve outcome, and generate research into new methods of treatment.
SC
Caustic esophageal damage.
AC
CE
PT
ED
MA
NU
Injury to the mucosal surface occurs within seconds of the ingestion of the strong alkali. The liquifaction necrosis rapidly extends through the epithelial layer and submucosa and may extend into and through the muscle layer. The ultimate outcome in severe cases is extensive stricture formation. The provision of child proof containers of caustic soda has had a major preventative effect in developed countries, whereas in the developing world, particularly in rural areas where caustic agents are used extensively for soap making and drying fruit, and where cleaning material is stored in unsuitable containers, caustic injuries continue to be a major health hazard4.. The prevalence of caustic injuries among children in the United States is estimated to be 1.08 per 100,000 population. The number of hospitalizations is down from 5,000 – 15,000 per year in the 1980’s to 807 in 20095.. Early esophagoscopy is important to confirm the ingestion and to assess the severity of the damage. The continuing need for regular dilatation 6 – 12 months following the injury constitutes an indication for esophageal resection and replacement. Reflux strictures. Early antireflux surgery of severe pathological gastro-esophageal reflux will prevent intractable strictures from developing. It is particularly in the severely neurologically disabled child that symptoms of reflux are ascribed to the developmental delay while irreversible strictures occur. Most cases of severely strictured and inflamed esophaguses will resolve following fundoplication and regular postoperative dilatations. A small minority will eventually require esophageal replacement 6...
RI P
Other indications for esophageal replacement.
T
ACCEPTED MANUSCRIPT
Esophageal replacement.
MA
NU
SC
Other indications for esophageal replacement include tumors of the esophagus, such as diffuse leiomyoma or inflammatory pseudotumor or rarely carcinoma, prolonged impaction of foreign bodies, such as aluminum ring can tops7, which are radiolucent and may escape detection for prolonged periods, and button batteries causing wide tracheoesophageal fistula, intractable achalasia, epidermolysis, and human immunodeficiency (HIV) strictures 8..
PT
ED
The four most commonly used methods of esophageal replacement are 1. colonic interposition 2. reversed gastric tube 3. jejunal interposition 4. gastric transposition
AC
CE
Each method has its own problems and complications, but in our experience the gastric transposition is associated with the lowest complication rate and is the least complicated procedure. Colon interposition has a precarious blood supply, usually arising from the ascending branch of the left colic artery. It is complicated by a high incidence of anastomotic leaks and strictures and in the long-term by redundancy of the interposition with stasis, which may require surgical revision. Gastric tube esophagoplasty involves a very extensive suture line with a high incidence of leaks and strictures. There is also the problem of Barrett’s esophagitis developing from acid reflux into the cervical stump. Jejunal interposition is favored by some, but the blood supply is precarious, although the interposed jejunal segment is of appropriate calibre and is reputed to retain peristaltic activity.
ACCEPTED MANUSCRIPT
SC
RI P
T
Gastric transposition involves transposing the whole stomach into the cervical region. The blood supply of the stomach is excellent, length is not a problem, and the procedure is relatively straight forward. The anastomotic leak rate is low and most close spontaneously, but strictures occur in 20% of cases with the highest incidence in replacement for caustic injury (58%). Reflux, dumping, and poor gastric emptying are problems mainly in the shortterm, and Barrett’s esophagitis may develop long-term.
NU
Surgical technique for gastric transposition (Fig.1). 9,10
AC
Results. 12
CE
PT
ED
MA
The preferred route for gastric transposition is a transhiatal retromediastinal approach without thoracotomy. The procedure has been performed laparoscopically with good results 11. The stomach is fully mobilized, dividing the left gastric and left gastro-epiploic vessels, and a pyloroplasty or myotomy is performed. The highest point on the mobilized stomach is the top of the fundus, which is marked with two different sutures to prevent rotation during transfer through the mediastinum. The stomach is passed via the hiatus through the retromediastinum into the neck, where it is anastomosed to the cervical esophageal stump. A trans-gastric or jejunal feeding tube is placed for temporary enteral feeding in children who have never taken nutrition orally. Postoperatively, elective paralysis and ventilation are used for a few days.
The surgical team at Great Ormond Street Hospital (GOS), London, has performed a total of 236 gastric transposition procedures since 1980. There were 147 male and 89 female patients. The primary condition affecting the infants were esophageal atresia in 177 cases, of which 95 were atresia with distal tracheoesophageal fistula, 65 isolated atresia, 15 atresia with proximal fistula, and two H-fistula. In addition, 32 had extensive stricture following caustic ingestion, and 9 suffered intractable gastroesophageal reflux strictures. The remaining 16 patients included congenital stricture (4), amotile esophagus (3), achalasia, diffuse leiomyomatosis, and prolonged foreign body impaction (2 each, respectively). Eighty-one percent of cases were referred to us from abroad (110) or from other centers in the United Kingdom (81), leaving 41 patients undergoing all their treatment at GOS, less than 1% of the case load.
ACCEPTED MANUSCRIPT
RI P
T
A prior attempt at replacement had been carried out in 33 patients (14%) of which 19 involved colon, 5 partial gastric replacement, 3 each Scharli procedures and gastric tube esophagoplasty, and one attempt at the Foker procedure.
NU
SC
The route for the replacement was via the posterior mediastinum without thoracotomy in 109 cases, transthoracic in 95 cases due to extensive scarring from previous surgery, retrosternal in 7, and recently laparoscopically in 25 cases, of which 8 needed to be converted to open approach due to dense adhesions. A pyloroplasty or myotomy was performed according to surgeon preference. All patients were electively ventilated postoperatively except for the first 4 cases.
AC
CE
PT
ED
MA
Eleven patients died, 5 from conditions unrelated to the gastric transposition, giving a procedure related mortality of 2.5%. Anastomotic leaks occurred in 28 patients (12%) and strictures in 48 cases (20%), of which 17 were secondary to caustic scarring. Swallowing problems postoperatively were almost universal, but in 55 (29%) patients it was significant, moderate in 26, and severe in 29 cases. Delayed gastric emptying was a problem in 21 (8.8%) cases in some patients necessitating conversion of pyloromyotomy to plasty or more radically to gastrojujenostomy. Eight patients developed problematic dumping syndrome which eventually resolved and 4 others a Horner’s syndrome which also eventually resolved. A late complication encountered in 6 patients was herniation of small intestine into the chest via the esophageal hiatus. This complication was eliminated by narrowing the hiatus and suturing the edge of the hiatus to the antrum of the stomach. Follow-up showed that weight generally was in the lower centiles for age, while height was normally distributed. Overall, more than 90% of patients were highly satisfied with the procedure, and there did not appear to be any deterioration in functioning of the transposed stomach in the long-term.
Conclusion. Significant progress has been made in recent years to reduce the need for esophageal replacement. These include improved management of esophageal atresia, prevention of caustic injury by child proof containers, and earlier
ACCEPTED MANUSCRIPT surgery for intractable gastro-esophageal reflux, particularly in the neurologically impaired child.
SC
RI P
T
Despite these advances, there are occasions when the esophagus needs to be replaced. Of the two most commonly used methods of replacement, gastric transposition is favored because of the excellent blood supply of the stomach, the ease of the procedure, and lower leak and stricture rates. There is a clear need to centralize the management of the “difficult” esophageal atresia cases as well as for replacing the esophagus to few specialist centers to improve outcomes, enhance expertise, and carry out research.
PT
Acknowledgements:
ED
MA
NU
Progress is being made with tissue engineering in the creation of a tubularized graft of the esophagus which may supercede current methods of replacement.13. The new esophagus will be comprised of a scaffold of synthetic or natural origin and cells which could be derived from fetal tissue if the diagnosis of pure atresia is suspected prenatally or from bone marrow and mucosa if replacement is required after birth.
AC
CE
Thanks are due to Edward Kiely, Agostino Pierro, David Drake, and Joe Curry for allowing inclusion of their patients, to Paolo De Coppi for information on tissue engineering, and to Marcia Matias for collecting the data.
ACCEPTED MANUSCRIPT References. 1. Potts W.J. In The Surgeon and the Child; Philadelphia. Saunders 1959
RI P
T
2. Spitz L. Esophageal Atresia: Past , Present and Future. J. Pediatr Surg 1996; 31: 19-25.
SC
3. Spitz, L. Esophageal atresia – Lessons I have learned in a 40 year experience. J. Pediatr. Surg. 2006 ; 41 ; 1635-1640.
MA
NU
4. Millar A.J.W. and Numanoglu A. Caustic Strictures of the Esophagus. In Pediatric Surgery 7th Ed. Edit Coran AG, Adzick NS, Krummel TM, Laberge J-M, Shamberger RC and Caldamone AA. Elsevier Saunders 2012, 919 – 926.
ED
5. Johnson CM, Brigger MT. The public health impact of pediatric caustic ingestion injuries. Arch Otolaryngol Head Neck Surg.2012,138:11111115.
CE
PT
6. Spitz L, Roth K, Kiely EM, Drake DP, Milla PJ. Operation for gastrooesophageal reflux associated with severe mental retardation. Arch Dis Child 1993; 68: 347-351
AC
7. Spitz L, Hirsig J. Prolonged foreign body impaction in the oesophagus. Arch Dis Child 1982; 57: 551-553 8. Loveland JA, Mitchell CE, van Wyk P, Beale P. Esophageal replacement in children with AIDS. J Pediatr. Surg. 2010, 45, 2068-70 9. Spitz L. Gastric transposition via the mediastinal route for infants with long-gap esophageal atresia. J Pediatr Surg 1984; 19: 149-154. 10. Spitz L,Pierro A. Gastric replacement of the esophagus in Operative Pediatric Surgery 7th Ed. Edited Spitz L and Coran AG, CRC Press Taylor and Francis Group. Boca Raton FL 2013, 163-173.
ACCEPTED MANUSCRIPT 11. Stanwell J, Drake D, Pierro A, Kiely E, Curry J. Pediatric laparoscopicassisted gastric transposition: early experience and outcomes. J Laparoendosc. Adv. Surg. Tech A 2010, 20, 177-81
RI P
T
12. Spitz L, Kiely E, Pierro A. Gastric transposition in children – a 21-year experience. J.Pediatr. Surg. 2004; 39: 276-281
AC
CE
PT
ED
MA
NU
SC
13. Totonelli G, Maghsoudlou P, Fishman JM, Orlando G, Ansari T, Sibbons P, Birchall MA, Pierro A, Eaton S, De Coppi P. Esophageal tissue engineering: a new approach for esophageal replacement. World J Gastroenterol. 2012 ,47: 6900-7.
ACCEPTED MANUSCRIPT Figure 1.
SC
RI P
T
Illustration of the technique of gastric transposition.
MA
b
CE
PT
ED
a
h
AC
c
e
NU
d
a – closure of gastrostomy b – closure of gastro-esophageal junction c – pyloroplasty / myotomy d – sutures of top of fundus of stomach
e – esophago-gastric anastomosis f – transposed stomach g – pyloroplasty below hiatus h – jejunal feeding tube
f – py lo gro –pl py as lo ty ro be pl lo as w ty hi be at lo us f w hi at us f
AC
CE
PT
ED
MA
NU
SC
RI P
T
ACCEPTED MANUSCRIPT