- Email: [email protected]
Minimally invasive esophagectomy for caustic esophageal stricture in children
Minimally Invasive Esophagectomy for Caustic Esophageal Stricture in Children By Benedict C. Nwomeh, James D. Luketich, and Timothy D. Kane Pittsburgh, Pennsylvania
Esophageal stricture after lye ingestion in children is the most frequent indication for esophagectomy in children, but this operation entails significant risks for complications. With continuing advances in minimally invasive technology, complex procedures such as esophagectomy can be performed using small incisions, with the aim of reducing morbidity and mortality. Experience with minimally invasive esophagectomy is limited and has involved thoracoscopic dissection with the addition of laparotomy for gastric mobilization. The authors report a case of intractable caustic esophageal stricture in a child treated by a totally minimally invasive esophagectomy through a combined thoracoscopic and laparoscopic approach. In adult patients, this procedure has been associated with decreased hospital stay and more rapid
return to normal activities, and we believe similar benefits will be obtained in children. Until further studies are done to show the advantage over the standard open technique, this procedure should be performed only in centers with experience in open esophageal surgery in children as well as by surgeons with advanced thoracoscopic and laparoscopic skills. J Pediatr Surg 39:E20. © 2004 Elsevier Inc. All rights reserved.
A
we describe our technique for a combined thoracoscopic and laparoscopic approach for performing esophagectomy and replacement using a tubularized stomach conduit with a cervical esophagogastric anastomosis in a child with severe caustic esophageal stricture.
CQUIRED ESOPHAGEAL stricture in children is most commonly caused by ingestion of corrosive agents. The offending agents most frequently associated with progression to severe stricture formation are potassium and sodium hydroxide (lye), found in household cleaners.1,2 Historically, the initial treatment of the child with corrosive ingestion has included the use of systemic antibiotics and corticosteroids. However, the progression to stricture appears to be related more to the severity of the initial injury, rather than the effect of initial treatment measures, and the use of steroids in particular is quite controversial.3-5 When strictures develop, the mainstay of treatment has been repeated esophageal dilatation. The presence of tight strictures, lengthy strictures, failure of esophageal dilatations, and potential for malignant degeneration are some of the factors that generate the need for esophageal replacement. However, the timing of esophageal replacement and the choice of technique are also controversial aspects of the management of this problem. There is evidence showing that early esophageal replacement with reestablishment of oral feedings has several advantages over repeated dilatations and tube feedings.6 Despite this, the fear of serious postoperative complications including anastomotic leaks, tracheal injury, conduit necrosis, empyema, chylothorax, delayed gastric emptying, vocal cord palsy, or death, may delay or prevent referral for esophagectomy and esophageal replacement. The application of minimally invasive surgical techniques has made it possible to perform esophageal replacement with the potential for reduced morbidity and mortality in adult cancer patients.7 In this report, Journal of Pediatric Surgery, Vol 39, No 7 (July), 2004: E20
INDEX WORDS: Minimally invasive esophagectomy, thorascopic esophagectomy, laparoscopic esophagectomy, caustic stricture, esophageal replacement.
CASE REPORT A 17-year old girl with a history of mental retardation presented to our institution after the accidental ingestion of 3 ounces of industrial oven cleaner containing potassium hydroxide. Her initial complaints were of abdominal and back pain. There was no airway compromise. The buccal cavity and oropharynx showed signs of superficial caustic burn injury. Her chest x-ray was normal. Abdominal examination found marked tenderness in the epigastric area but no evidence of peritonitis. The initial management included withholding oral intake, intensive care observation, intravenous fluids, antibiotics, steroids, and acid suppression with omeprazole. The next day, a direct laryngoscopy showed mild injury to the epiglottis, but bronchoscopy findings showed a normal tracheobronchial tree. Esophagoscopy showed diffuse circumferential mucosal corrosive injury of the entire length of the esophagus and proximal stomach. However, there was no sign of esophageal or gastric perforation. A nasogastric tube was passed after the esophagoscopy, and tube feeding commenced the following day. However, because of severe gastritis, this attempt at early enteral feeding was unsuccessful. An open gastrostomy tube was placed on the sixth
From the Children’s Hospital of Pittsburgh and the Mark Ravitch/ Leon C. Hirsch Center for Minimally Invasive Surgery, University of Pittsburgh, Pittsburgh, PA. Address reprint requests to Timothy D. Kane, MD, Children’s Hospital of Pittsburgh, University of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA, 15213. © 2004 Elsevier Inc. All rights reserved. 1531-5037/04/3907-0041$30.00/0 doi:10.1016/j.jpedsurg.2004.03.082 e1
e2
NWOMEH, LUKETICH, AND KANE
stomach and cervical esophagogastric anastomosis utilizing a combined thoracoscopic and laparoscopic approach. In addition, a needle catheter jejunostomy was performed at the time of her esophagectomy for postoperative feeding purposes. Postoperatively, her recovery was uncomplicated; an esophagram on the fourth postoperative day showed an adequate anastomotic lumen with no leak. She was given a liquid diet, which was advanced rapidly to a pureed diet. She was discharged from the hospital on the eighth postoperative day. Her needle jejunostomy was used for tube feedings only for the first few days after her operation; the catheter was removed on her first outpatient visit 2 weeks after discharge. At 8 months’ follow-up, she was tolerating a regular diet, eating frequent small meals, and had regained her normal weight. She has not required any postgastric pull-up dilatations.
OPERATIVE TECHNIQUE
The procedure begins with flexible esophagoscopy, which confirms the presence of a tight stricture in the proximal esophagus. With a double-lumen tube in place for single lung ventilation, the patient is positioned in the left lateral decubitus position. The right lung is collapsed, and 4 thoracoscopic ports are inserted (Fig 3). The camera port (10 mm) is placed at the seventh intercostal space, midaxillary line. A second 10-mm port is placed at the fifth intercostal space anteriorly for
Fig 1. Esophagram 1 month after caustic ingestion with proximal stricture and diffuse distal narrowing of the esophagus.
hospital day with parenteral nutrition being administered until full enteral feeding was established on the seventh hospital day. At the time of gastrostomy tube insertion, a heavy silk string was passed into the stomach and brought out transnasally. This string was placed to facilitate subsequent retrograde and antegrade esophageal dilatations. She was discharged home after 16 days in the hospital. A month later, an esophagram was performed, which showed an esophageal stricture at the fourth thoracic vertebrae and diffuse narrowing distally (Fig 1). Over the next several months, she underwent multiple sessions of retrograde and then antegrade esophageal dilatations, up to a 40F bougie. Despite this, she continued to experience severe dysphagia owing to the proximal stricture and esophageal aperistalsis. She developed progression of the long-strictured segment, resulting in her inability to tolerate even oral liquids (Fig 2). A decision was then made to proceed with total esophagectomy and replacement with tubularized
Fig 2. Esophagram after several months of both retrograde and antegrade dilatations.
MINIMALLY INVASIVE ESOPHAGECTOMY
Fig 3.
e3
Right VATS port position for esophageal mobilization.
retraction of the lung and esophageal countertraction during dissection. Two 5-mm ports are placed, 1 at the ninth intercostal space posteriorly for the ultrasonic coagulating shears (US Surgical, Norwalk, CT), and another posterior to the tip of the scapula. The dissection begins in the mediastinal pleura overlying the esophagus, which is divided to expose the entire thoracic esophagus. Care is taken to avoid injury to the thoracic duct posteriorly and the airway medially throughout the dissection. A penrose drain is placed around the esophagus to facilitate traction and exposure (Fig 4). The azygos vein is divided, using a 2.5-mm endoscopic vascular stapler (Endo-GIA II; US Surgical). In this case, because of the presence of subcarinal lymphadenopathy with significant scarring, the esophagus was densely adherent to the posterior membranous trachea and left main bronchus. With meticulous dissection, however, circumferential mobilization of the esophagus, with surrounding lymph nodes, periesophageal tissue, and fat, the mediastinal pleura is performed from the diaphragmatic reflection to the thoracic inlet. The penrose drain around the dissected esophagus is positioned high up in the thoracic inlet to facilitate subsequent retrieval during the cervical approach. Finally, a 4-cm ⫻ 5-cm piece of Surgisis (Cook Surgical, Bloomington, IN) is attached with surgical
Fig 4.
Thoracoscopic esophageal mobilization.
Fig 5.
Port sites for laparoscopy.
clips to the opening of the thoracic inlet to decrease the size of the opening above the azygos vein and to avoid mediastinal contamination in the event of an anastomotic leak. A single 28F chest tube is inserted through the camera port, the lung is reinflated, and the other port sites are closed. The patient then is turned to the supine position, and 6 abdominal ports are placed similar to our approach for laparoscopic Nissen fundoplication (Fig 5). The gastrostomy is taken down with the Endo-GIA stapler (3.5 mm; US Surgical), and the site is utilized for port placement. The left lobe of the liver is retracted upward to expose the esophageal hiatus using a diamond flex retractor (Genzyme, Tucker, GA) and held in place with a selfretaining system (Mediflex; Velmed Inc, Wexford, PA). The dissection begins with division of the gastrohepatic ligament and exposure of the right crus of the diaphragm. Short gastric vessels are divided using the ultrasonic shears (US Surgical). The dissection continues along the greater curvature of the stomach, preserving the right gastroepiploic arcade. The stomach is retracted superiorly, to expose the left gastric artery and vein, which are divided using the Endo-GIA vascular stapler (2.5 mm; US Surgical). Next, a pyloroplasty is performed using ultrasonic shears and closed transversely using a 2-0 Endo-stitch device (US Surgical). A limited Kocher maneuver with mobilization of the duodenum and gastric antrum is then performed. The gastric tube, approximately 4 to 5 cm in diameter, is constructed by dividing the stomach from the direction of the lesser curvature using the 3.5-mm stapler (Endo-GIA) toward the greater curvature, preserving the right gastroepiploic vessels (Fig 6). The gastric tube is attached to the esophageal and gastric
e4
NWOMEH, LUKETICH, AND KANE
Fig 8. Resected specimen with proximal esophagus3stricture3 stomach.
Fig 6.
Laparoscopic gastric conduit creation.
specimen using 2 sutures (2-0 Endostitch; US Surgical), in preparation for pull-up into the neck. The ligament of Treitz is identified, and a laparoscopic needle jejunostomy catheter is placed by first attaching a limb of proximal jejunum to the anterior abdominal wall using the Endostitch. A needle catheter kit (Compact Biosystems, Minneapolis, MN) is inserted percutaneously into the peritoneal cavity, and, under direct laparoscopic vision, it is directed into the proximal loop of jejunum. The guide wire and catheter are threaded into the jejunum. The jejunal entry site is sutured to the anterior abdominal wall for a distance of several centimeters. The last step in the abdominal operation is the final dissection of the phrenoesophageal ligament, which opens the plane into the thoracic cavity. This step is completed last to minimize loss of pneumo-peritoneum into the mediastinum. Partial division of the right and left
Fig 7.
Completed laparoscopic and thoracoscopic operation.
crura at the apex is performed to widen the hiatus to prevent gastric tube outlet obstruction. Attention is turned to the neck where a 4-cm horizontal neck incision is made just above the suprasternal notch, and the cervical esophagus is mobilized and exposed. Finger dissection is continued distally until the thoracic dissection plane is encountered, and the penrose drain around the esophagus is easily retrieved. The cervical esophagus is divided, and the esophagogastric specimen is pulled up through the neck wound. As traction is applied to the specimen in this manner, the esophagus and attached gastric tube are guided laparoscopically in proper alignment into the mediastinum. The specimen is removed from the field through the neck. An anastomosis is performed between the esophagus and the gastric tube using standard techniques, and the gastric tube is sutured laparoscopically to the hiatus to prevent subsequent thoracic herniation (Fig 7). Total operating time was 7 hours. Pathologic examination of the surgical specimen found no evidence of malignant degeneration (Fig 8) but found a long significant stricture (Fig 9). DISCUSSION
The first line of treatment for esophageal stricture in children after ingestion of corrosive agents is dilatation.8 Dilatation is useful in the early management esophageal strictures and can be initiated within a few weeks of injury. Injection of steroids into localized segment of stricture is an adjunct that may improve results of dilatation.3 However, caustic strictures are typically irregular
Fig 9.
Resected specimen and cross section through stricture.
MINIMALLY INVASIVE ESOPHAGECTOMY
e5
and may involve a long segment of the esophagus. Although esophageal dilatation can be safe and effective in experienced hands, several problems could arise in patients with severe strictures who require repeated procedures over a long duration. The cumulative incidence of esophageal perforations following repeated dilations can be as high as 26%.6,9,10 Esophageal perforation after dilatation for caustic strictures results in mediastinitis with mortality rate in excess of 20%.6,11 Malignant degeneration after caustic injury occurs when the native esophagus is retained, although the latent period from exposure to lye in childhood to diagnosis of malignancy is typically 30 to 50 years.12-14 Operative management is indicated in caustic strictures that are resistant to dilatation. Dilatation may not be feasible when there are multiple extensive strictures, and marked irregularity or pocketing of the esophagus and surgical treatment becomes the only option. Other indications for surgical treatment include esophageal perforation, acquired tracheoesophageal fistula, Barrett’s metaplasia, and malignant transformation.2,8 The optimal timing for surgical intervention in patients with intractable strictures is controversial. Although surgical treatment has been reserved traditionally for such strictures, some have advocated early elective resection and replacement of the esophagus, with the goal of improving function and reducing the risk of malignancy.2,13 Controversial aspects of the operative strategy in children with caustic esophageal include the choice of conduit for esophageal substitution, the intrathoracic location of the conduit, and whether to resect the defunctioned esophagus. Short strictures may be amenable to resection with end-to-end esophageal anastomosis or the recently described esophageal stricturotomy.15 However, total esophagectomy is usually required, with substitution using an isoperistaltic gastric tube, reversed gastric tube, colonic interposition, or jejunal interposition. These conduits may be placed substernally or in the posterior mediastinum. Substitution without resection of the defunctioned esophagus may lead to the development of mucocele, although the risk of malignancy appears to be significantly reduced by esophageal exclusion.2 Our pre-
ferred approach for the management of intractable corrosive strictures in children has been the standard IvorLewis total esophagectomy, with replacement using a gastric tube placed in the posterior mediastinum and pulled up for a cervical esophagogastric anastomosis. With advances in minimally invasive technology, complex procedures such as esophagectomy have been performed through smaller incisions with the aim of reducing morbidity and mortality.16 Although there are several reports of minimally invasive esophagectomy in the literature, the experience with children is limited. In a recent report from Brazil, Cury et al17 describe thoracoscopic esophagectomy performed in 2 children for benign strictures. However, in both cases, a laparotomy was necessary to mobilize the stomach, which detracts from the benefits of the minimally invasive technique. We have performed a totally minimally invasive esophagectomy through a combined thoracoscopic and laparoscopic approach. Our institutional experience with this procedure has been extensive, and we have shown its feasibility and safety in adult patients with benign and malignant diseases of the esophagus.18-21 We have also shown that the totally minimally invasive approach to esophagectomy is associated with a decreased hospital stay and more rapid return to normal activities.19 Although this is our first pediatric case, we believe that similar benefits will be obtained in children with caustic esophageal strictures and other end-stage esophageal disorders. We must caution, however, that dense periesophageal fibrosis and adherence to the trachea may create significant hazards during the thoracoscopic mobilization of the esophagus. There is evidence that highvolume hospitals experience lower mortality rates after esophagectomy compared with low-volume institutions (8% v 23%).22 We agree with Nguyen et al23 that this procedure should only be performed in centers with vast experience in esophageal surgery and by surgeons with appropriate training in advanced minimally invasive techniques. Without doubt, this is a procedure that requires experience in open esophageal surgery in children as well as advanced thoracoscopic and laparoscopic skills.
REFERENCES 1. Rowe MI, O’Neill JA, Grosfeld JL, et al: Essentials of Pediatric Surgery. St Louis, MO, Mosby Year-Book, 1995 2. Ashcraft KW: The Esophagus, in Ashcraft KW, Murphy JP, Sharp RJ (eds): Pediatric Surgery. Philadelphia, PA, Saunders, 2000, pp 325-347 3. Anderson KD, Rouse TM, Randolph JG: A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 6(323):637-640, 1990 4. Moazam F, Talbert JL, Miller D, et al: Caustic ingestion and its sequelae in children. South Med J 80:187-190, 1987 5. Mamede RC, De Mello Filho FV: Treatment of caustic ingestion: An analysis of 239 cases. Dis Esophagus 15:210-213, 2002
6. Panieri E, Rode H, Millar AJ, et al: Oesophageal replacement in the management of corrosive strictures: When is surgery indicated? Pediatr Surg Int 5-6:336-340, 1998 7. Nguyen NT, Schauer PR, Luketich JD: Combined laparoscopic and thoracoscopic approach to esophagectomy. J Am Coll Surg 188: 328-332, 1999 8. Hamza AF, Abdelhay S, Sherif H, et al: Caustic esophageal strictures in children: 30 years’ experience. J Pediatr Surg 38:828-833, 2003 9. Gundogdu HZ, Tanyel FC, Buyukpamukcu N, et al: Colonic replacement for the treatment of caustic esophageal strictures in children. J Pediatr Surg 27:771-774, 1992
e6
10. Rao KS, Ananthakrishnan N, Banerjee A: Corrosive oesophagitis: An analysis of 50 cases. Aust N Z J Surg 58:723-726, 1988 11. Panieri E, Rode H, Millar AJ, et al: Iatrogenic esophageal perforation in children: Patterns of injury, presentation, management, and outcome. J Pediatr Surg 31:890-895, 1996 12. Csikos M, Horvath O, Petri A, et al: Late malignant transformation of chronic corrosive oesophageal strictures. Langenbecks Arch Chir 365:231-238, 1985 13. Kim YT, Sung SW, Kim JH: Is it necessary to resect the diseased esophagus in performing reconstruction for corrosive esophageal stricture? Eur J Cardiothorac Surg 20:1-6, 2001 14. Appelqvist P, Salmo M: Lye corrosion carcinoma of the esophagus: A review of 63 cases. Cancer 15:2655-265845, 1980 15. Anderson KD, Acosta JM, Meyer MS, et al: Application of the principles of myotomy and strictureplasty for treatment of esophageal strictures. J Pediatr Surg 37:403-406, 2002 16. Luketich JD, Alvelo-Rivera M, Schauer PR, et al: Minimally invasive esophagectomy (MIE): Outcomes in 222 patients. Ann Surg 238:486-494; discussion 494-495, 2003
NWOMEH, LUKETICH, AND KANE
17. Cury EK, Schraibman V, De Vasconcelos Macedo AL, et al: Thoracoscopic esophagectomy in children. J Pediatr Surg 36:E17, 2001 18. Nguyen NT, Schauer PR, Luketich JD: Combined laparoscopic and thoracoscopic approach to esophagectomy. J Am Coll Surg 188: 328-332, 1999 19. Luketich JD, Schauer PR, Christie NA, et al: Minimally invasive esophagectomy. Ann Thorac Surg 70:906-911, 2000 20. Litle VR, Buenaventura PO, Luketich JD: Minimally invasive resection for esophageal cancer. Surg Clin North Am 82:711-728, 2002 21. Perry Y, Fernando HC, Buenaventura PO, et al: Minimally invasive esophagectomy in the elderly. JSLS 6:299-304, 2002 22. Birkmeyer JD, Siewers AE, Finlayson EVA, et al: Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128-1137, 2002 23. Nguyen NT, Follette DM, Wolfe BM, et al: Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy. Arch Surg 135:920-925, 2000
Esophageal stricture after lye ingestion in children is the most frequent indication for esophagectomy in children, but this operation entails significant risks for complications. With continuing advances in minimally invasive technology, complex procedures such as esophagectomy can be performed using small incisions, with the aim of reducing morbidity and mortality. Experience with minimally invasive esophagectomy is limited and has involved thoracoscopic dissection with the addition of laparotomy for gastric mobilization. The authors report a case of intractable caustic esophageal stricture in a child treated by a totally minimally invasive esophagectomy through a combined thoracoscopic and laparoscopic approach. In adult patients, this procedure has been associated with decreased hospital stay and more rapid
return to normal activities, and we believe similar benefits will be obtained in children. Until further studies are done to show the advantage over the standard open technique, this procedure should be performed only in centers with experience in open esophageal surgery in children as well as by surgeons with advanced thoracoscopic and laparoscopic skills. J Pediatr Surg 39:E20. © 2004 Elsevier Inc. All rights reserved.
A
we describe our technique for a combined thoracoscopic and laparoscopic approach for performing esophagectomy and replacement using a tubularized stomach conduit with a cervical esophagogastric anastomosis in a child with severe caustic esophageal stricture.
CQUIRED ESOPHAGEAL stricture in children is most commonly caused by ingestion of corrosive agents. The offending agents most frequently associated with progression to severe stricture formation are potassium and sodium hydroxide (lye), found in household cleaners.1,2 Historically, the initial treatment of the child with corrosive ingestion has included the use of systemic antibiotics and corticosteroids. However, the progression to stricture appears to be related more to the severity of the initial injury, rather than the effect of initial treatment measures, and the use of steroids in particular is quite controversial.3-5 When strictures develop, the mainstay of treatment has been repeated esophageal dilatation. The presence of tight strictures, lengthy strictures, failure of esophageal dilatations, and potential for malignant degeneration are some of the factors that generate the need for esophageal replacement. However, the timing of esophageal replacement and the choice of technique are also controversial aspects of the management of this problem. There is evidence showing that early esophageal replacement with reestablishment of oral feedings has several advantages over repeated dilatations and tube feedings.6 Despite this, the fear of serious postoperative complications including anastomotic leaks, tracheal injury, conduit necrosis, empyema, chylothorax, delayed gastric emptying, vocal cord palsy, or death, may delay or prevent referral for esophagectomy and esophageal replacement. The application of minimally invasive surgical techniques has made it possible to perform esophageal replacement with the potential for reduced morbidity and mortality in adult cancer patients.7 In this report, Journal of Pediatric Surgery, Vol 39, No 7 (July), 2004: E20
INDEX WORDS: Minimally invasive esophagectomy, thorascopic esophagectomy, laparoscopic esophagectomy, caustic stricture, esophageal replacement.
CASE REPORT A 17-year old girl with a history of mental retardation presented to our institution after the accidental ingestion of 3 ounces of industrial oven cleaner containing potassium hydroxide. Her initial complaints were of abdominal and back pain. There was no airway compromise. The buccal cavity and oropharynx showed signs of superficial caustic burn injury. Her chest x-ray was normal. Abdominal examination found marked tenderness in the epigastric area but no evidence of peritonitis. The initial management included withholding oral intake, intensive care observation, intravenous fluids, antibiotics, steroids, and acid suppression with omeprazole. The next day, a direct laryngoscopy showed mild injury to the epiglottis, but bronchoscopy findings showed a normal tracheobronchial tree. Esophagoscopy showed diffuse circumferential mucosal corrosive injury of the entire length of the esophagus and proximal stomach. However, there was no sign of esophageal or gastric perforation. A nasogastric tube was passed after the esophagoscopy, and tube feeding commenced the following day. However, because of severe gastritis, this attempt at early enteral feeding was unsuccessful. An open gastrostomy tube was placed on the sixth
From the Children’s Hospital of Pittsburgh and the Mark Ravitch/ Leon C. Hirsch Center for Minimally Invasive Surgery, University of Pittsburgh, Pittsburgh, PA. Address reprint requests to Timothy D. Kane, MD, Children’s Hospital of Pittsburgh, University of Pittsburgh, 3705 Fifth Ave, Pittsburgh, PA, 15213. © 2004 Elsevier Inc. All rights reserved. 1531-5037/04/3907-0041$30.00/0 doi:10.1016/j.jpedsurg.2004.03.082 e1
e2
NWOMEH, LUKETICH, AND KANE
stomach and cervical esophagogastric anastomosis utilizing a combined thoracoscopic and laparoscopic approach. In addition, a needle catheter jejunostomy was performed at the time of her esophagectomy for postoperative feeding purposes. Postoperatively, her recovery was uncomplicated; an esophagram on the fourth postoperative day showed an adequate anastomotic lumen with no leak. She was given a liquid diet, which was advanced rapidly to a pureed diet. She was discharged from the hospital on the eighth postoperative day. Her needle jejunostomy was used for tube feedings only for the first few days after her operation; the catheter was removed on her first outpatient visit 2 weeks after discharge. At 8 months’ follow-up, she was tolerating a regular diet, eating frequent small meals, and had regained her normal weight. She has not required any postgastric pull-up dilatations.
OPERATIVE TECHNIQUE
The procedure begins with flexible esophagoscopy, which confirms the presence of a tight stricture in the proximal esophagus. With a double-lumen tube in place for single lung ventilation, the patient is positioned in the left lateral decubitus position. The right lung is collapsed, and 4 thoracoscopic ports are inserted (Fig 3). The camera port (10 mm) is placed at the seventh intercostal space, midaxillary line. A second 10-mm port is placed at the fifth intercostal space anteriorly for
Fig 1. Esophagram 1 month after caustic ingestion with proximal stricture and diffuse distal narrowing of the esophagus.
hospital day with parenteral nutrition being administered until full enteral feeding was established on the seventh hospital day. At the time of gastrostomy tube insertion, a heavy silk string was passed into the stomach and brought out transnasally. This string was placed to facilitate subsequent retrograde and antegrade esophageal dilatations. She was discharged home after 16 days in the hospital. A month later, an esophagram was performed, which showed an esophageal stricture at the fourth thoracic vertebrae and diffuse narrowing distally (Fig 1). Over the next several months, she underwent multiple sessions of retrograde and then antegrade esophageal dilatations, up to a 40F bougie. Despite this, she continued to experience severe dysphagia owing to the proximal stricture and esophageal aperistalsis. She developed progression of the long-strictured segment, resulting in her inability to tolerate even oral liquids (Fig 2). A decision was then made to proceed with total esophagectomy and replacement with tubularized
Fig 2. Esophagram after several months of both retrograde and antegrade dilatations.
MINIMALLY INVASIVE ESOPHAGECTOMY
Fig 3.
e3
Right VATS port position for esophageal mobilization.
retraction of the lung and esophageal countertraction during dissection. Two 5-mm ports are placed, 1 at the ninth intercostal space posteriorly for the ultrasonic coagulating shears (US Surgical, Norwalk, CT), and another posterior to the tip of the scapula. The dissection begins in the mediastinal pleura overlying the esophagus, which is divided to expose the entire thoracic esophagus. Care is taken to avoid injury to the thoracic duct posteriorly and the airway medially throughout the dissection. A penrose drain is placed around the esophagus to facilitate traction and exposure (Fig 4). The azygos vein is divided, using a 2.5-mm endoscopic vascular stapler (Endo-GIA II; US Surgical). In this case, because of the presence of subcarinal lymphadenopathy with significant scarring, the esophagus was densely adherent to the posterior membranous trachea and left main bronchus. With meticulous dissection, however, circumferential mobilization of the esophagus, with surrounding lymph nodes, periesophageal tissue, and fat, the mediastinal pleura is performed from the diaphragmatic reflection to the thoracic inlet. The penrose drain around the dissected esophagus is positioned high up in the thoracic inlet to facilitate subsequent retrieval during the cervical approach. Finally, a 4-cm ⫻ 5-cm piece of Surgisis (Cook Surgical, Bloomington, IN) is attached with surgical
Fig 4.
Thoracoscopic esophageal mobilization.
Fig 5.
Port sites for laparoscopy.
clips to the opening of the thoracic inlet to decrease the size of the opening above the azygos vein and to avoid mediastinal contamination in the event of an anastomotic leak. A single 28F chest tube is inserted through the camera port, the lung is reinflated, and the other port sites are closed. The patient then is turned to the supine position, and 6 abdominal ports are placed similar to our approach for laparoscopic Nissen fundoplication (Fig 5). The gastrostomy is taken down with the Endo-GIA stapler (3.5 mm; US Surgical), and the site is utilized for port placement. The left lobe of the liver is retracted upward to expose the esophageal hiatus using a diamond flex retractor (Genzyme, Tucker, GA) and held in place with a selfretaining system (Mediflex; Velmed Inc, Wexford, PA). The dissection begins with division of the gastrohepatic ligament and exposure of the right crus of the diaphragm. Short gastric vessels are divided using the ultrasonic shears (US Surgical). The dissection continues along the greater curvature of the stomach, preserving the right gastroepiploic arcade. The stomach is retracted superiorly, to expose the left gastric artery and vein, which are divided using the Endo-GIA vascular stapler (2.5 mm; US Surgical). Next, a pyloroplasty is performed using ultrasonic shears and closed transversely using a 2-0 Endo-stitch device (US Surgical). A limited Kocher maneuver with mobilization of the duodenum and gastric antrum is then performed. The gastric tube, approximately 4 to 5 cm in diameter, is constructed by dividing the stomach from the direction of the lesser curvature using the 3.5-mm stapler (Endo-GIA) toward the greater curvature, preserving the right gastroepiploic vessels (Fig 6). The gastric tube is attached to the esophageal and gastric
e4
NWOMEH, LUKETICH, AND KANE
Fig 8. Resected specimen with proximal esophagus3stricture3 stomach.
Fig 6.
Laparoscopic gastric conduit creation.
specimen using 2 sutures (2-0 Endostitch; US Surgical), in preparation for pull-up into the neck. The ligament of Treitz is identified, and a laparoscopic needle jejunostomy catheter is placed by first attaching a limb of proximal jejunum to the anterior abdominal wall using the Endostitch. A needle catheter kit (Compact Biosystems, Minneapolis, MN) is inserted percutaneously into the peritoneal cavity, and, under direct laparoscopic vision, it is directed into the proximal loop of jejunum. The guide wire and catheter are threaded into the jejunum. The jejunal entry site is sutured to the anterior abdominal wall for a distance of several centimeters. The last step in the abdominal operation is the final dissection of the phrenoesophageal ligament, which opens the plane into the thoracic cavity. This step is completed last to minimize loss of pneumo-peritoneum into the mediastinum. Partial division of the right and left
Fig 7.
Completed laparoscopic and thoracoscopic operation.
crura at the apex is performed to widen the hiatus to prevent gastric tube outlet obstruction. Attention is turned to the neck where a 4-cm horizontal neck incision is made just above the suprasternal notch, and the cervical esophagus is mobilized and exposed. Finger dissection is continued distally until the thoracic dissection plane is encountered, and the penrose drain around the esophagus is easily retrieved. The cervical esophagus is divided, and the esophagogastric specimen is pulled up through the neck wound. As traction is applied to the specimen in this manner, the esophagus and attached gastric tube are guided laparoscopically in proper alignment into the mediastinum. The specimen is removed from the field through the neck. An anastomosis is performed between the esophagus and the gastric tube using standard techniques, and the gastric tube is sutured laparoscopically to the hiatus to prevent subsequent thoracic herniation (Fig 7). Total operating time was 7 hours. Pathologic examination of the surgical specimen found no evidence of malignant degeneration (Fig 8) but found a long significant stricture (Fig 9). DISCUSSION
The first line of treatment for esophageal stricture in children after ingestion of corrosive agents is dilatation.8 Dilatation is useful in the early management esophageal strictures and can be initiated within a few weeks of injury. Injection of steroids into localized segment of stricture is an adjunct that may improve results of dilatation.3 However, caustic strictures are typically irregular
Fig 9.
Resected specimen and cross section through stricture.
MINIMALLY INVASIVE ESOPHAGECTOMY
e5
and may involve a long segment of the esophagus. Although esophageal dilatation can be safe and effective in experienced hands, several problems could arise in patients with severe strictures who require repeated procedures over a long duration. The cumulative incidence of esophageal perforations following repeated dilations can be as high as 26%.6,9,10 Esophageal perforation after dilatation for caustic strictures results in mediastinitis with mortality rate in excess of 20%.6,11 Malignant degeneration after caustic injury occurs when the native esophagus is retained, although the latent period from exposure to lye in childhood to diagnosis of malignancy is typically 30 to 50 years.12-14 Operative management is indicated in caustic strictures that are resistant to dilatation. Dilatation may not be feasible when there are multiple extensive strictures, and marked irregularity or pocketing of the esophagus and surgical treatment becomes the only option. Other indications for surgical treatment include esophageal perforation, acquired tracheoesophageal fistula, Barrett’s metaplasia, and malignant transformation.2,8 The optimal timing for surgical intervention in patients with intractable strictures is controversial. Although surgical treatment has been reserved traditionally for such strictures, some have advocated early elective resection and replacement of the esophagus, with the goal of improving function and reducing the risk of malignancy.2,13 Controversial aspects of the operative strategy in children with caustic esophageal include the choice of conduit for esophageal substitution, the intrathoracic location of the conduit, and whether to resect the defunctioned esophagus. Short strictures may be amenable to resection with end-to-end esophageal anastomosis or the recently described esophageal stricturotomy.15 However, total esophagectomy is usually required, with substitution using an isoperistaltic gastric tube, reversed gastric tube, colonic interposition, or jejunal interposition. These conduits may be placed substernally or in the posterior mediastinum. Substitution without resection of the defunctioned esophagus may lead to the development of mucocele, although the risk of malignancy appears to be significantly reduced by esophageal exclusion.2 Our pre-
ferred approach for the management of intractable corrosive strictures in children has been the standard IvorLewis total esophagectomy, with replacement using a gastric tube placed in the posterior mediastinum and pulled up for a cervical esophagogastric anastomosis. With advances in minimally invasive technology, complex procedures such as esophagectomy have been performed through smaller incisions with the aim of reducing morbidity and mortality.16 Although there are several reports of minimally invasive esophagectomy in the literature, the experience with children is limited. In a recent report from Brazil, Cury et al17 describe thoracoscopic esophagectomy performed in 2 children for benign strictures. However, in both cases, a laparotomy was necessary to mobilize the stomach, which detracts from the benefits of the minimally invasive technique. We have performed a totally minimally invasive esophagectomy through a combined thoracoscopic and laparoscopic approach. Our institutional experience with this procedure has been extensive, and we have shown its feasibility and safety in adult patients with benign and malignant diseases of the esophagus.18-21 We have also shown that the totally minimally invasive approach to esophagectomy is associated with a decreased hospital stay and more rapid return to normal activities.19 Although this is our first pediatric case, we believe that similar benefits will be obtained in children with caustic esophageal strictures and other end-stage esophageal disorders. We must caution, however, that dense periesophageal fibrosis and adherence to the trachea may create significant hazards during the thoracoscopic mobilization of the esophagus. There is evidence that highvolume hospitals experience lower mortality rates after esophagectomy compared with low-volume institutions (8% v 23%).22 We agree with Nguyen et al23 that this procedure should only be performed in centers with vast experience in esophageal surgery and by surgeons with appropriate training in advanced minimally invasive techniques. Without doubt, this is a procedure that requires experience in open esophageal surgery in children as well as advanced thoracoscopic and laparoscopic skills.
REFERENCES 1. Rowe MI, O’Neill JA, Grosfeld JL, et al: Essentials of Pediatric Surgery. St Louis, MO, Mosby Year-Book, 1995 2. Ashcraft KW: The Esophagus, in Ashcraft KW, Murphy JP, Sharp RJ (eds): Pediatric Surgery. Philadelphia, PA, Saunders, 2000, pp 325-347 3. Anderson KD, Rouse TM, Randolph JG: A controlled trial of corticosteroids in children with corrosive injury of the esophagus. N Engl J Med 6(323):637-640, 1990 4. Moazam F, Talbert JL, Miller D, et al: Caustic ingestion and its sequelae in children. South Med J 80:187-190, 1987 5. Mamede RC, De Mello Filho FV: Treatment of caustic ingestion: An analysis of 239 cases. Dis Esophagus 15:210-213, 2002
6. Panieri E, Rode H, Millar AJ, et al: Oesophageal replacement in the management of corrosive strictures: When is surgery indicated? Pediatr Surg Int 5-6:336-340, 1998 7. Nguyen NT, Schauer PR, Luketich JD: Combined laparoscopic and thoracoscopic approach to esophagectomy. J Am Coll Surg 188: 328-332, 1999 8. Hamza AF, Abdelhay S, Sherif H, et al: Caustic esophageal strictures in children: 30 years’ experience. J Pediatr Surg 38:828-833, 2003 9. Gundogdu HZ, Tanyel FC, Buyukpamukcu N, et al: Colonic replacement for the treatment of caustic esophageal strictures in children. J Pediatr Surg 27:771-774, 1992
e6
10. Rao KS, Ananthakrishnan N, Banerjee A: Corrosive oesophagitis: An analysis of 50 cases. Aust N Z J Surg 58:723-726, 1988 11. Panieri E, Rode H, Millar AJ, et al: Iatrogenic esophageal perforation in children: Patterns of injury, presentation, management, and outcome. J Pediatr Surg 31:890-895, 1996 12. Csikos M, Horvath O, Petri A, et al: Late malignant transformation of chronic corrosive oesophageal strictures. Langenbecks Arch Chir 365:231-238, 1985 13. Kim YT, Sung SW, Kim JH: Is it necessary to resect the diseased esophagus in performing reconstruction for corrosive esophageal stricture? Eur J Cardiothorac Surg 20:1-6, 2001 14. Appelqvist P, Salmo M: Lye corrosion carcinoma of the esophagus: A review of 63 cases. Cancer 15:2655-265845, 1980 15. Anderson KD, Acosta JM, Meyer MS, et al: Application of the principles of myotomy and strictureplasty for treatment of esophageal strictures. J Pediatr Surg 37:403-406, 2002 16. Luketich JD, Alvelo-Rivera M, Schauer PR, et al: Minimally invasive esophagectomy (MIE): Outcomes in 222 patients. Ann Surg 238:486-494; discussion 494-495, 2003
NWOMEH, LUKETICH, AND KANE
17. Cury EK, Schraibman V, De Vasconcelos Macedo AL, et al: Thoracoscopic esophagectomy in children. J Pediatr Surg 36:E17, 2001 18. Nguyen NT, Schauer PR, Luketich JD: Combined laparoscopic and thoracoscopic approach to esophagectomy. J Am Coll Surg 188: 328-332, 1999 19. Luketich JD, Schauer PR, Christie NA, et al: Minimally invasive esophagectomy. Ann Thorac Surg 70:906-911, 2000 20. Litle VR, Buenaventura PO, Luketich JD: Minimally invasive resection for esophageal cancer. Surg Clin North Am 82:711-728, 2002 21. Perry Y, Fernando HC, Buenaventura PO, et al: Minimally invasive esophagectomy in the elderly. JSLS 6:299-304, 2002 22. Birkmeyer JD, Siewers AE, Finlayson EVA, et al: Hospital volume and surgical mortality in the United States. N Engl J Med 346:1128-1137, 2002 23. Nguyen NT, Follette DM, Wolfe BM, et al: Comparison of minimally invasive esophagectomy with transthoracic and transhiatal esophagectomy. Arch Surg 135:920-925, 2000