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Modified Collis-Nissen procedure for long gap pure esophageal atresia
Journal of Pediatric Surgery (2012) 47, 462–466
www.elsevier.com/locate/jpedsurg
Modified Collis-Nissen procedure for long gap pure esophageal atresia Yasuo Nakahara ⁎, Koji Aoyama, Takafumi Goto, Yoshinobu Iwamura, Yusuke Takahashi, Takeshi Asai Department of Pediatric Surgery, National Hospital Okayama Medical Center, Okayama 701-1192, Japan Received 6 May 2011; revised 4 August 2011; accepted 5 August 2011
Key words: Long gap; Esophageal atresia; Collis-Nissen; Gastric tube
Abstract Background/Purpose: Esophageal reconstruction in long gap esophageal atresia (EA) is technically challenging, and several procedures have been described. The purpose of this study is to review our experience with the modified Collis-Nissen procedure in the repair of long gap pure EA. Methods: Six patients with pure EA were treated at our institution from 1985 to 2008. Patients' demographics, surgical technique, timing of repair, early and late complications, and long-term functional outcomes were retrospectively reviewed. Results: Five primary cases and 1 redo case were included. The mean gap length was 5.3 vertebral bodies (range, 4-6). Modified Collis-Nissen procedure was performed at a mean age of 11.6 months (range, 9-14 months) in primary cases. There was 1 anastomotic leak in the redo case, which healed spontaneously. Two patients had anastomotic strictures requiring balloon dilatations. Patients were weaned from tube feeding at a mean duration of 4 months (range, 1-6 months) postoperatively. All patients have normal oral intake at the last follow-up visit. Two adult patients had normal growth and development and no digestive symptoms. Endoscopic examination and pH monitoring showed no signs of significant gastroesophageal reflux. Conclusions: Modified Collis-Nissen procedure is a good option to consider in patients with long gap pure EA and is associated with an acceptable complication rate and promising short- and long-term results. © 2012 Elsevier Inc. All rights reserved.
Pure esophageal atresia (EA) accounts for approximately 8% to 10% of all cases of EA and tracheoesophageal fistula. In most cases of pure atresia, the gap between upper and lower esophageal pouches is long, and surgical repair is a major challenge. Several esophageal reconstruction procedures have been reported, including procedures that elongate the native esophagus as well as use of stomach, small intestine, or colon as esophageal replacement. The Collis-Nissen procedure was originally described as an antireflux procedure for short
esophagus and consisted of a Collis gastroplasty and Nissen fundoplication [1,2]. One of the authors (KA) modified the Collis-Nissen procedure and adapted it to long gap pure EA in 1985. We report the surgical outcomes of the modified CollisNissen (MCN) procedure from a single institution.
⁎ Corresponding author. Tel.: +81 86 294 9911; fax: +81 86 294 9255. E-mail address: [email protected] (Y. Nakahara).
With approval from the institutional review board, we performed a retrospective chart review of patients who were
0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.08.001
1. Patients and methods
MCN procedure for long gap pure esophageal atresia
463
treated for pure EA. We have treated 8 patients with EA without a fistula since 1985. The MCN procedure was the primary operation in 5 patients and used as a redo procedure in 1 patient. The remaining 2 patients were repaired by primary anastomosis because there was adequate esophageal length. In this study, we report the treatment and outcome of the 6 patients who underwent the MCN procedure.
1.1. Preoperative management At our institution in the newborn period, we initially placed a gastrostomy in patients with pure EA to provide enteral nutrition. We performed bronchoscopy at the same time to rule out a tracheoesophageal fistula. Patients were fed through the gastrostomy tube, and a continuous suction tube was placed through their nose to clear secretions from the proximal esophageal pouch. After patients were medically stable, the mothers stayed at the hospital and learned to care for the patients including gastrostomy tube care, management of nasal continuous suction tube and suction machine, and infant safety. Parents and patients went home with a continuous suction machine, a portable suction unit for travel, and an oxygen saturation monitor. Parents were able to safely provide care for the patients at home until the time for definitive repair. The gap between the upper and lower esophagus was measured under fluoroscopy by inserting a Nelaton tube into the upper esophagus and a flexible bronchoscope into the lower esophagus. When it was difficult to pass a bronchoscope, the end of the lower esophagus was confirmed by injecting contrast into stomach. Long gap was defined as the length between the 2 ends (which were under tension), of more than 4 vertebral bodies. The MCN procedure was performed when the patients reached the age of 9 months.
1.2. MCN procedure The patient was placed in a left lateral position. A posterior-lateral thoracotomy was performed, and the ribs bordering the fourth interspace were opened. We used an extrapleural approach to expose the esophagus. The parietal pleura was separated from the ribs, and dissection was carried in the extrapleural space toward the esophagus. The upper esophagus was fully mobilized to the thoracic inlet. The seventh interspace was then opened through the same skin incision to fully mobilize the lower esophagus down to the diaphragmatic hiatus. Several long traction sutures were placed on the tip of lower esophagus. These long sutures were fixed to the thoracic wall to mark the route of the neoesophagus. The chest incision was temporarily closed, and patient was placed in a supine position. A laparotomy was performed. The stomach was mobilized, and the gastrostomy was closed. The short gastric vessels were divided, and left gastric artery was ligated and divided close to the main trunk to preserve the blood supply from the right gastric artery. The lower esophagus, marked by attached long
Fig. 1 A, Schematic representation of the creation of the gastric tube. B, Schematic representation of the gastric tube and Nissen fundoplication.
traction sutures, was delivered into the abdominal cavity. The gastric tube was created by stapling the stomach starting on the left side of the cardia for a length of 6.0 to 8.0 cm (Fig. 1A). A 360° fundoplication was performed (Fig. 1B). The chest incision was reopened, and the gastric tube was pulled up through the hiatus by pulling on the traction sutures. A posterior mediastinal esophagoesophageal anastomosis was performed. Finally, a tube jejunostomy was inserted for postoperative enteral feeding.
2. Results Two girls and 4 boys with pure EA were repaired by the MCN procedure. Three children had associated anomalies including anorectal malformation, laryngomalacia, congenital heart disease, and tracheal stenosis. The mean birth weight was 2196 g (range, 1538-2520 g) with mean gestational age of 37 weeks (range, 31-39 weeks). Gastrostomy tubes were placed in all children within the first 24h of life. In the neonatal period, the mean hospital stay after gastrostomy tube placement was 43 days (range, 27-60 days) for 3 patients without associated anomalies. The remaining 3 patients with associated anomalies required longer hospitalization to repair their associated anomalies and stabilize their condition. Their mean hospital stay was 179 days (range, 156-201 days). During the period of home care, there were no instances of aspiration pneumonia nor other complications that necessitated hospital readmission. One patient with a gap of 4 vertebral bodies had primary esophageal anastomosis at the age of 10 months with a Livaditis myotomy, but the anastomosis was taken down because of a major anastomotic leakage. Modified CollisNissen procedure was performed for this patient at age 30 months.
464
Y. Nakahara et al.
Table 1
Case Case Case Case Case Case
1 2 3 4 5 6
Clinical characteristics of patients Age at operation (mo)
Weight at operation (kg)
Gap (vertebral body)
Associated malformation
Postoperative follow-up periods
9 9 13 14 13 30 (redo case)
7.5 8.2 9.0 9.5 8.7 11.2
6 6 6 5 5 4 at primarily
None Anorectal malformation None LBWB, bowel perforation, laryngomalasia Pulmonary sling, PS, PDA, VSD, tracheal stenosis none
26 22 31 23 18 30
y y mo mo mo mo
Abbreviations: LBWB, low birth weight baby; PS, pulmonary stenosis; PDA, patent ductus artriosus; VSD, ventricular septal defect.
The remaining 5 patients were primarily repaired by MCN procedure. The mean age at repair was 11 months (range, 9-14), and the gaps between the upper and lower pouches were 5 to 6 vertebral bodies (Table 1). Early postoperative complications occurred in 3 patients, including a minor anastomotic leak that healed spontaneously in the redo patient and anastomotic stricture that resolved with balloon dilatation in 2 patients. Two patients have been followed up for more than 20 years and could reply to a questionnaire about their digestive symptoms. They had no dysphagia, chest pain, or heart burn. They rarely had any vomiting. Except for mild dilatation of the upper esophagus on fluoroscopic examination, they have a good quality of life without digestive symptoms and do not require any medications. The remaining 4 patients have shorter follow-up periods (median, 27 months; range, 23-31 months). Oral nutrition was started with fluid, and baby foods and patients were weaned from tube feedings at a mean of 4 months postoperatively (range, 1-6 months). Total oral nutrition with normal foods was achieved in all the cases. Of the 4 patients with short-term follow-up, the mean z scores for height and weight for age were −2.0 and −1.3, respectively, at the latest measurement. All showed gradual
Fig. 2
catch up growth. The mean z scores of height and weight for the 2 adult patients was 0.4 and −0.1, respectively. pH monitoring was performed in 2 cases. Four sensors were placed: above the native Lower esophageal sphincter (LES), below the native LES, above the fundoplication, and within the stomach. No significant acid reflux was detected by the sensor above the native LES, although sensors at other locations showed pH below 4.0 for most of the time. Manometric examination was performed in 3 cases. There were high-pressure zones at the fundoplication and native esophageal sphincter (Fig. 2). Both of these high-pressure zones may have prevented the gastric acid from refluxing up into the native esophagus. Endoscopic evaluation was performed in 2 adult patients and did not show esophagitis in the native esophagus.
3. Discussion The surgical management of patients with pure EA remains challenging. Primary anastomosis of the native esophagus after elongation procedures [3] or replacement of the esophagus using the stomach, jejunum, or colon is widely
Result of manometric examination in case 1.
MCN procedure for long gap pure esophageal atresia performed throughout the world [4-9]. Theoretically, the native esophagus may yield the best result, but there are occasions when the gap between the upper and lower pouch is too long to perform an anastomosis. An anastomosis that is under significant tension is at great risk for serious postoperative complication. Stricture and significant gastroesophageal reflux (GER) are some of the main postoperative problems observed in the procedure of Foker et al [3]. Gastroesophageal reflux is also a major postoperative problem after gastric transposition [4] as well as the reversed gastric tube [6]. Anastomotic problems are common in the replacement procedures using the colon or jejunum [7-10]. There are a few reports of the Collis-Nissen procedure applied to pure EA. Evans [11] performed Collis gastroplasty at first and added a Nissen procedure afterward. Kawahara et al [12] reported 4 cases of Collis-Nissen procedure, and one of them was a pure EA. Both of their postoperative results were good with acceptable morbidity. The MCN procedure has several benefits. Postoperative GER is prevented or minimized because of the Nissen antireflux procedure as well as the high-pressure zone of the native LES. The gastric tube tends not to dilate when compared with other grafts. The gastric tube can be created to accommodate various gap lengths. Severe complications such as graft necrosis are rare because of the stomach's robust blood supply. Importantly, these advantages have contributed to excellent outcomes in all of the 6 patients after the MCN procedure. They are eating normally and have not required any additional open corrective procedures. We performed the MCN procedure as a delayed primary approach. All of our patients were cared for at home after their condition was stabilized in the neonatal period. They neither developed pneumonia nor other major problems during the preoperative home care period. A survey in North America shows that 25% of surgeons managed a total of 63 patients with long gap EA at home preoperatively. No major complications were noted among these 63 patients during the preoperative home care periods [13]. Aziz [14] reported 5 patients who were treated successfully at home while waiting for esophageal reconstruction. Only 1 patient required hospital readmission for pneumonia. Based on our experience, this approach can be safely applied when patients are medically stabilized and parents received adequate hands-on education to care for them. Another predictable problem of the delayed primary approach is oral aversion and feeding difficulty after surgery [15]. We allowed parents to give their child clear water with a continuous suction device in place after we had determined that it was safe to practice swallowing during the preoperative period. In addition, patients had nursing support after surgery. Consequently, our patients accomplished exclusive oral nourishment in an average of 4 months after the MCN procedure. All patients were able to eat normal food at the latest of 1 year after reconstruction. To lessen the risks of postoperative complications in long gap EA, it is important to perform a tension-free
465 anastomosis with good blood supply and minimize GER. In the MCN procedure, the blood supply to the tip of the native lower esophagus is preserved and is supplied by the right gastric artery. The native lower esophagus in long gap pure EA is usually short enough to live only on intralammellar blood supply. One of the reasons for waiting until the patient reaches 9 months of age is that the lower esophagus becomes more robust and the stomach grows larger to allow for fashioning of the lower esophageal tube from the stomach and still have adequate stomach tissue for the fundoplication. However, it may be possible to perform this procedure at a younger age without increased morbidity. In all 6 patients from this series, the right gastric artery was not under tension from pulling the lower esophagus cephalad. So theoretically, it is possible to construct a longer conduit if we staple down further toward the distal stomach. The remaining stomach is small, but it gradually grows larger. After this procedure, the esophageal motility may be compromised. However, the tension-free anastomosis, preservation of the native LES, and an adequate Nissen wrap at the abdominal part of gastric tube appear to adequately compensate for the loss of motility and effectively prevent clinically significant GER. Although the number of patients in this study is small, it represents one of the largest experiences in the use of the MCN procedure to repair long gap pure EA. Our experience with this procedure has shown that it is safe, technically simple, allows for a tension-free anastomosis with excellent blood supply, minimizes GER, and yields good functional outcomes.
References [1] Collis JL. An operation for hiatus hernia with short esophagus. Thorax 1957;12:181-8. [2] Nissen R. Gastropexy and fundoplication is surgical treatment of hiatal hernia. Am J Dig Dis 1961;6:954-61. [3] Foker JE, Linden B, Boyle EM, et al. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg 1997;226: 533-43. [4] Spitz L, Kiely E, Pierro A. Gastric transposition for esophageal substitution in children: a 21-year experience. J Pediatr Surg 2004;39: 276-81. [5] Scharli AF. Esophageal reconstruction by elongation of the lesser gastric curvature. Pediatr Surg Int 1996;11:214-7. [6] McCollum MO, Rangel SJ, Blair GK, et al. Primary reversed gastric tube reconstruction in long gap esophageal atresia. J Pediatr Surg 2003;38:957-62. [7] Bax KM. Jejunum for bridging long gap esophageal atresia. Semin Pediatr Surg 2009;18:34-9. [8] Saeki M, Tuchida Y, Ogata T, et al. Long-term results of jejunal replacement of the esophagus. J Pediatr Surg 1988;23:483-9. [9] Hamza AF. Colonic replacement in cases of esophageal atresia. Semin Pediatr Surg 2009;18:40-3. [10] Hunter JC, Petrosyan M, Connelly ME, et al. Repair of long-gap esophageal atresia: gastric conduit may improve outcome—a 20-year single center experience. Pediatr Surg Int 2009;25:1087-91. [11] Evans M. Application of Collis gastroplasty to the management of esophageal atresia. J Pediatr Surg 1995;30:1232-5.
466 [12] Kawahara H, Imura K, Yagi M, et al. Collis-Nissen procedure in patients with esophageal atresia: long term evaluation. World J Surg 2002;26:1222-7. [13] Hollands C, Lankau CA, Burnweit CA, et al. Preoperative home care for esophageal atresia—a survey. J Pediatr Surg 2000;35: 279-82.
Y. Nakahara et al. [14] Aziz D, Schiller D, Gerstle JT, et al. Can “long-gap” esophageal atresia be safely managed at home while awaiting anastomosis? J Pediatr Surg 2003;38:705-8. [15] Cavallaro S, Pineschi A, Freni G, et al. Feeding troubles following delayed primary repair of esophageal atresia. Eur J Pediatr Surg 1992; 2:73-7.
www.elsevier.com/locate/jpedsurg
Modified Collis-Nissen procedure for long gap pure esophageal atresia Yasuo Nakahara ⁎, Koji Aoyama, Takafumi Goto, Yoshinobu Iwamura, Yusuke Takahashi, Takeshi Asai Department of Pediatric Surgery, National Hospital Okayama Medical Center, Okayama 701-1192, Japan Received 6 May 2011; revised 4 August 2011; accepted 5 August 2011
Key words: Long gap; Esophageal atresia; Collis-Nissen; Gastric tube
Abstract Background/Purpose: Esophageal reconstruction in long gap esophageal atresia (EA) is technically challenging, and several procedures have been described. The purpose of this study is to review our experience with the modified Collis-Nissen procedure in the repair of long gap pure EA. Methods: Six patients with pure EA were treated at our institution from 1985 to 2008. Patients' demographics, surgical technique, timing of repair, early and late complications, and long-term functional outcomes were retrospectively reviewed. Results: Five primary cases and 1 redo case were included. The mean gap length was 5.3 vertebral bodies (range, 4-6). Modified Collis-Nissen procedure was performed at a mean age of 11.6 months (range, 9-14 months) in primary cases. There was 1 anastomotic leak in the redo case, which healed spontaneously. Two patients had anastomotic strictures requiring balloon dilatations. Patients were weaned from tube feeding at a mean duration of 4 months (range, 1-6 months) postoperatively. All patients have normal oral intake at the last follow-up visit. Two adult patients had normal growth and development and no digestive symptoms. Endoscopic examination and pH monitoring showed no signs of significant gastroesophageal reflux. Conclusions: Modified Collis-Nissen procedure is a good option to consider in patients with long gap pure EA and is associated with an acceptable complication rate and promising short- and long-term results. © 2012 Elsevier Inc. All rights reserved.
Pure esophageal atresia (EA) accounts for approximately 8% to 10% of all cases of EA and tracheoesophageal fistula. In most cases of pure atresia, the gap between upper and lower esophageal pouches is long, and surgical repair is a major challenge. Several esophageal reconstruction procedures have been reported, including procedures that elongate the native esophagus as well as use of stomach, small intestine, or colon as esophageal replacement. The Collis-Nissen procedure was originally described as an antireflux procedure for short
esophagus and consisted of a Collis gastroplasty and Nissen fundoplication [1,2]. One of the authors (KA) modified the Collis-Nissen procedure and adapted it to long gap pure EA in 1985. We report the surgical outcomes of the modified CollisNissen (MCN) procedure from a single institution.
⁎ Corresponding author. Tel.: +81 86 294 9911; fax: +81 86 294 9255. E-mail address: [email protected] (Y. Nakahara).
With approval from the institutional review board, we performed a retrospective chart review of patients who were
0022-3468/$ – see front matter © 2012 Elsevier Inc. All rights reserved. doi:10.1016/j.jpedsurg.2011.08.001
1. Patients and methods
MCN procedure for long gap pure esophageal atresia
463
treated for pure EA. We have treated 8 patients with EA without a fistula since 1985. The MCN procedure was the primary operation in 5 patients and used as a redo procedure in 1 patient. The remaining 2 patients were repaired by primary anastomosis because there was adequate esophageal length. In this study, we report the treatment and outcome of the 6 patients who underwent the MCN procedure.
1.1. Preoperative management At our institution in the newborn period, we initially placed a gastrostomy in patients with pure EA to provide enteral nutrition. We performed bronchoscopy at the same time to rule out a tracheoesophageal fistula. Patients were fed through the gastrostomy tube, and a continuous suction tube was placed through their nose to clear secretions from the proximal esophageal pouch. After patients were medically stable, the mothers stayed at the hospital and learned to care for the patients including gastrostomy tube care, management of nasal continuous suction tube and suction machine, and infant safety. Parents and patients went home with a continuous suction machine, a portable suction unit for travel, and an oxygen saturation monitor. Parents were able to safely provide care for the patients at home until the time for definitive repair. The gap between the upper and lower esophagus was measured under fluoroscopy by inserting a Nelaton tube into the upper esophagus and a flexible bronchoscope into the lower esophagus. When it was difficult to pass a bronchoscope, the end of the lower esophagus was confirmed by injecting contrast into stomach. Long gap was defined as the length between the 2 ends (which were under tension), of more than 4 vertebral bodies. The MCN procedure was performed when the patients reached the age of 9 months.
1.2. MCN procedure The patient was placed in a left lateral position. A posterior-lateral thoracotomy was performed, and the ribs bordering the fourth interspace were opened. We used an extrapleural approach to expose the esophagus. The parietal pleura was separated from the ribs, and dissection was carried in the extrapleural space toward the esophagus. The upper esophagus was fully mobilized to the thoracic inlet. The seventh interspace was then opened through the same skin incision to fully mobilize the lower esophagus down to the diaphragmatic hiatus. Several long traction sutures were placed on the tip of lower esophagus. These long sutures were fixed to the thoracic wall to mark the route of the neoesophagus. The chest incision was temporarily closed, and patient was placed in a supine position. A laparotomy was performed. The stomach was mobilized, and the gastrostomy was closed. The short gastric vessels were divided, and left gastric artery was ligated and divided close to the main trunk to preserve the blood supply from the right gastric artery. The lower esophagus, marked by attached long
Fig. 1 A, Schematic representation of the creation of the gastric tube. B, Schematic representation of the gastric tube and Nissen fundoplication.
traction sutures, was delivered into the abdominal cavity. The gastric tube was created by stapling the stomach starting on the left side of the cardia for a length of 6.0 to 8.0 cm (Fig. 1A). A 360° fundoplication was performed (Fig. 1B). The chest incision was reopened, and the gastric tube was pulled up through the hiatus by pulling on the traction sutures. A posterior mediastinal esophagoesophageal anastomosis was performed. Finally, a tube jejunostomy was inserted for postoperative enteral feeding.
2. Results Two girls and 4 boys with pure EA were repaired by the MCN procedure. Three children had associated anomalies including anorectal malformation, laryngomalacia, congenital heart disease, and tracheal stenosis. The mean birth weight was 2196 g (range, 1538-2520 g) with mean gestational age of 37 weeks (range, 31-39 weeks). Gastrostomy tubes were placed in all children within the first 24h of life. In the neonatal period, the mean hospital stay after gastrostomy tube placement was 43 days (range, 27-60 days) for 3 patients without associated anomalies. The remaining 3 patients with associated anomalies required longer hospitalization to repair their associated anomalies and stabilize their condition. Their mean hospital stay was 179 days (range, 156-201 days). During the period of home care, there were no instances of aspiration pneumonia nor other complications that necessitated hospital readmission. One patient with a gap of 4 vertebral bodies had primary esophageal anastomosis at the age of 10 months with a Livaditis myotomy, but the anastomosis was taken down because of a major anastomotic leakage. Modified CollisNissen procedure was performed for this patient at age 30 months.
464
Y. Nakahara et al.
Table 1
Case Case Case Case Case Case
1 2 3 4 5 6
Clinical characteristics of patients Age at operation (mo)
Weight at operation (kg)
Gap (vertebral body)
Associated malformation
Postoperative follow-up periods
9 9 13 14 13 30 (redo case)
7.5 8.2 9.0 9.5 8.7 11.2
6 6 6 5 5 4 at primarily
None Anorectal malformation None LBWB, bowel perforation, laryngomalasia Pulmonary sling, PS, PDA, VSD, tracheal stenosis none
26 22 31 23 18 30
y y mo mo mo mo
Abbreviations: LBWB, low birth weight baby; PS, pulmonary stenosis; PDA, patent ductus artriosus; VSD, ventricular septal defect.
The remaining 5 patients were primarily repaired by MCN procedure. The mean age at repair was 11 months (range, 9-14), and the gaps between the upper and lower pouches were 5 to 6 vertebral bodies (Table 1). Early postoperative complications occurred in 3 patients, including a minor anastomotic leak that healed spontaneously in the redo patient and anastomotic stricture that resolved with balloon dilatation in 2 patients. Two patients have been followed up for more than 20 years and could reply to a questionnaire about their digestive symptoms. They had no dysphagia, chest pain, or heart burn. They rarely had any vomiting. Except for mild dilatation of the upper esophagus on fluoroscopic examination, they have a good quality of life without digestive symptoms and do not require any medications. The remaining 4 patients have shorter follow-up periods (median, 27 months; range, 23-31 months). Oral nutrition was started with fluid, and baby foods and patients were weaned from tube feedings at a mean of 4 months postoperatively (range, 1-6 months). Total oral nutrition with normal foods was achieved in all the cases. Of the 4 patients with short-term follow-up, the mean z scores for height and weight for age were −2.0 and −1.3, respectively, at the latest measurement. All showed gradual
Fig. 2
catch up growth. The mean z scores of height and weight for the 2 adult patients was 0.4 and −0.1, respectively. pH monitoring was performed in 2 cases. Four sensors were placed: above the native Lower esophageal sphincter (LES), below the native LES, above the fundoplication, and within the stomach. No significant acid reflux was detected by the sensor above the native LES, although sensors at other locations showed pH below 4.0 for most of the time. Manometric examination was performed in 3 cases. There were high-pressure zones at the fundoplication and native esophageal sphincter (Fig. 2). Both of these high-pressure zones may have prevented the gastric acid from refluxing up into the native esophagus. Endoscopic evaluation was performed in 2 adult patients and did not show esophagitis in the native esophagus.
3. Discussion The surgical management of patients with pure EA remains challenging. Primary anastomosis of the native esophagus after elongation procedures [3] or replacement of the esophagus using the stomach, jejunum, or colon is widely
Result of manometric examination in case 1.
MCN procedure for long gap pure esophageal atresia performed throughout the world [4-9]. Theoretically, the native esophagus may yield the best result, but there are occasions when the gap between the upper and lower pouch is too long to perform an anastomosis. An anastomosis that is under significant tension is at great risk for serious postoperative complication. Stricture and significant gastroesophageal reflux (GER) are some of the main postoperative problems observed in the procedure of Foker et al [3]. Gastroesophageal reflux is also a major postoperative problem after gastric transposition [4] as well as the reversed gastric tube [6]. Anastomotic problems are common in the replacement procedures using the colon or jejunum [7-10]. There are a few reports of the Collis-Nissen procedure applied to pure EA. Evans [11] performed Collis gastroplasty at first and added a Nissen procedure afterward. Kawahara et al [12] reported 4 cases of Collis-Nissen procedure, and one of them was a pure EA. Both of their postoperative results were good with acceptable morbidity. The MCN procedure has several benefits. Postoperative GER is prevented or minimized because of the Nissen antireflux procedure as well as the high-pressure zone of the native LES. The gastric tube tends not to dilate when compared with other grafts. The gastric tube can be created to accommodate various gap lengths. Severe complications such as graft necrosis are rare because of the stomach's robust blood supply. Importantly, these advantages have contributed to excellent outcomes in all of the 6 patients after the MCN procedure. They are eating normally and have not required any additional open corrective procedures. We performed the MCN procedure as a delayed primary approach. All of our patients were cared for at home after their condition was stabilized in the neonatal period. They neither developed pneumonia nor other major problems during the preoperative home care period. A survey in North America shows that 25% of surgeons managed a total of 63 patients with long gap EA at home preoperatively. No major complications were noted among these 63 patients during the preoperative home care periods [13]. Aziz [14] reported 5 patients who were treated successfully at home while waiting for esophageal reconstruction. Only 1 patient required hospital readmission for pneumonia. Based on our experience, this approach can be safely applied when patients are medically stabilized and parents received adequate hands-on education to care for them. Another predictable problem of the delayed primary approach is oral aversion and feeding difficulty after surgery [15]. We allowed parents to give their child clear water with a continuous suction device in place after we had determined that it was safe to practice swallowing during the preoperative period. In addition, patients had nursing support after surgery. Consequently, our patients accomplished exclusive oral nourishment in an average of 4 months after the MCN procedure. All patients were able to eat normal food at the latest of 1 year after reconstruction. To lessen the risks of postoperative complications in long gap EA, it is important to perform a tension-free
465 anastomosis with good blood supply and minimize GER. In the MCN procedure, the blood supply to the tip of the native lower esophagus is preserved and is supplied by the right gastric artery. The native lower esophagus in long gap pure EA is usually short enough to live only on intralammellar blood supply. One of the reasons for waiting until the patient reaches 9 months of age is that the lower esophagus becomes more robust and the stomach grows larger to allow for fashioning of the lower esophageal tube from the stomach and still have adequate stomach tissue for the fundoplication. However, it may be possible to perform this procedure at a younger age without increased morbidity. In all 6 patients from this series, the right gastric artery was not under tension from pulling the lower esophagus cephalad. So theoretically, it is possible to construct a longer conduit if we staple down further toward the distal stomach. The remaining stomach is small, but it gradually grows larger. After this procedure, the esophageal motility may be compromised. However, the tension-free anastomosis, preservation of the native LES, and an adequate Nissen wrap at the abdominal part of gastric tube appear to adequately compensate for the loss of motility and effectively prevent clinically significant GER. Although the number of patients in this study is small, it represents one of the largest experiences in the use of the MCN procedure to repair long gap pure EA. Our experience with this procedure has shown that it is safe, technically simple, allows for a tension-free anastomosis with excellent blood supply, minimizes GER, and yields good functional outcomes.
References [1] Collis JL. An operation for hiatus hernia with short esophagus. Thorax 1957;12:181-8. [2] Nissen R. Gastropexy and fundoplication is surgical treatment of hiatal hernia. Am J Dig Dis 1961;6:954-61. [3] Foker JE, Linden B, Boyle EM, et al. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg 1997;226: 533-43. [4] Spitz L, Kiely E, Pierro A. Gastric transposition for esophageal substitution in children: a 21-year experience. J Pediatr Surg 2004;39: 276-81. [5] Scharli AF. Esophageal reconstruction by elongation of the lesser gastric curvature. Pediatr Surg Int 1996;11:214-7. [6] McCollum MO, Rangel SJ, Blair GK, et al. Primary reversed gastric tube reconstruction in long gap esophageal atresia. J Pediatr Surg 2003;38:957-62. [7] Bax KM. Jejunum for bridging long gap esophageal atresia. Semin Pediatr Surg 2009;18:34-9. [8] Saeki M, Tuchida Y, Ogata T, et al. Long-term results of jejunal replacement of the esophagus. J Pediatr Surg 1988;23:483-9. [9] Hamza AF. Colonic replacement in cases of esophageal atresia. Semin Pediatr Surg 2009;18:40-3. [10] Hunter JC, Petrosyan M, Connelly ME, et al. Repair of long-gap esophageal atresia: gastric conduit may improve outcome—a 20-year single center experience. Pediatr Surg Int 2009;25:1087-91. [11] Evans M. Application of Collis gastroplasty to the management of esophageal atresia. J Pediatr Surg 1995;30:1232-5.
466 [12] Kawahara H, Imura K, Yagi M, et al. Collis-Nissen procedure in patients with esophageal atresia: long term evaluation. World J Surg 2002;26:1222-7. [13] Hollands C, Lankau CA, Burnweit CA, et al. Preoperative home care for esophageal atresia—a survey. J Pediatr Surg 2000;35: 279-82.
Y. Nakahara et al. [14] Aziz D, Schiller D, Gerstle JT, et al. Can “long-gap” esophageal atresia be safely managed at home while awaiting anastomosis? J Pediatr Surg 2003;38:705-8. [15] Cavallaro S, Pineschi A, Freni G, et al. Feeding troubles following delayed primary repair of esophageal atresia. Eur J Pediatr Surg 1992; 2:73-7.