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Transcervical myotomy for wide-gap esophageal atresia
Transcervicai Myotomy for Wide-Gap Esophageal Atresia By David G. Hoffman and Farhat Moazam Gainesville, Florida
O A primary end-to-end anastomosis of t h e esophagus can be accomplished in the wide-gap esophageal atresia by obtaining extra esophageal length through circular myotomy of the proximal esophageal pouch. However, a very short proximal esophageal pouch may not be accessible through the standard thoracic incision, precluding this procedure. An infant is reported in whom the inaccessible proximal pouch was exteriorized into the neck through a concomitant cervical incision, allowing three circular myotomies to be performed with ease. The proximal esophagus was then reintroduced into the chest cavity and a primary esophagoesophagostomy performed without difficulty. INDEX WORDS: Esophageal atresia; esophageal circular myotomy.
HE TREATMENT of congenital wide-gap esophageal atresia is a difficult problem that has taxed the ingenuity of pediatric surgeons for years. In 1973, Livaditis1 introduced the concept of circular myotomy of the proximal esophageal pouch as a means of obtaining increased length to allow an end-to-end esophageal anastomosis without tension. Since then, multiple clinical reports 2m have attested to the effectiveness of this procedure. However, an extremely short proximal esophageal pouch may not be accessible via the standard thoracic incision, precluding the performance of the circular myotomies. An infant is reported in whom a short proximal esophageal pouch was exteriorized through a separate and concomitant cervical incision, allowing the performance of three circular myotomies to provide adequate length for a primary anastomosis.
T
CASE REPORT M.H., a white female infant, was the product of a 35-week gestation and weighed 1,940 g at birth. Due to the presence of
From the Department of Surgery, University of Florida College of Medicine, Gainesville, Fla. Presented before the 15th Annual Meeting of the American Pediatric Surgical Association, Marco Beach, Florida, May 9-12, 1984. Address reprint requests to Farhat Moazam, MD, Associate Professor, Division of Pediatric Surgery, Box J286, J. Hillis Miller Health Center, University of Florida, Gainesville, FL 32610. 9 1984 by Grune & Stratton, Inc. 0022-3468/84/1906~011 $03.00/0 680
copious oral secretions, an esophageal atresia was suspected soon after birth. A Replogle nasogastric tube was found to stop at the level of the thoracic inlet (Fig 1). Normal gas pattern was evident on roentgenographic examination of the abdomen. A barium pouchogram confirmed an extremely high, blind proximal pouch, and the possibility of a wide-gap atresia was entertained. The infant underwent the placement of a central venous catheter and a Stamm gastrostomy soon after birth. At 4 days of age, the patient was returned to the operating room for an extrapleural thoracotomy through the fifth intercostal space, She was placed in a standard left lateral position and the right side of the neck was prepped and encompassed within the operative field. At thoracotomy, the tip of the proximal pouch was barely visible at the level of the thoracic inlet, despite pressure via an indwelling tube. The distal tracheoesophageal fistula found entering the trachea at the level of the carina was ligated and divided. Despite mobilization of the proximal and distal esophagus, it became evident that the wide gap between the two esophageal ends would not allow a primary anastomosis. At this point, a concomitant, transverse incision was made in the right neck and the proximal esophagus was mobilized from this approach. With the carotid sheath and the internal jugular veins retracted laterally, the entire proximal esophagus was exteriorized into the cervical incision (Fig 2). A bougie was introduced into the proximal pouch and three circular myotomies were performed. The myotomized esophagus was then replaced into the thoracic cage and the cervical incision closed in layers without drainage. With the additional length obtained via the three myotomies, an end-to-end esophageal anastomosis was achieved without difficulty. Fifteen months following surgery, the patient is tolerating a normal diet for age and has a satisfactory weight gain. An esophagogram at 14 months of age reveals minimal narrowing at the site of the anastomosis with a relatively normal esophageal contour (Fig 3).
DISCUSSION
Ten to 20 percent of infants presenting with esophageal atresia have a significantly long distance between the proximal and distal esophageal ends, making attempts at primary endto-end anastomosis very difficult) In these patients, primary reconstruction of the esophagus is postponed for several months, after which esophageal continuity is usually established via esophogeal substitutes, consisting of segments of colons'6 or gastric tubes. 7 These procedures, however, represent major operative intervention with often significant morbidity as well as long-term functional disorders. 8 In 1973, LivaditisI introduced the concept of circular esophageal myotomy to obtain additional esophageal length to enable an end-to-end esophageal anastomosis in Journal of Pediatric Surgery, Vo119, No 6 (December), 1984
TRANSCERVICAL MYOTOMY
681
Fig 1. The tip of the Replogle tube visible at the thoracic inlet, suggests the presence of a wide gap esophageal atresia.
wide-gap atresia. This procedure is possible due to the excellent submucosal esophageal blood supply of the proximal esophageal pouch. The use of circular esophageal myotomies has subsequently been reported by various authors2'3 as an effective aid in accomplishing primary esophageal anastomosis without tension. A problem arises, however, when the proximal
Fig 3. An esophagogram at 14 months of age reveals a relatively normal esophageal contour.
pouch is inaccessible through the standard thoracic incision. In 1981, when faced with a similar problem, Janeck and his associates9 repositioned the infant in a supine position to deliver the esophagus through a separate cervical incision. Following transcervical esophageal myotomies, the patient was repositioned and the thoracic incision reopened to accomplish the anastomosis. The present report, however, demonstrates that positioning the infant in the standard left lateral position and encompassing the neck in the operative field can allow simultaneous exposure of the proximal esophagus through concomitant thoracic and cervical incisions. This prevents the necessity of frequent repositioning of the patient in order to establish the circular myotomies. We believe transcervical esophageal myotomy provides another advance in accomplishing a safe, primary end-to-end esophagoesophagostomy in the wide gap esophageal atresia. REFERENCES
nn Preparation for Circular Myotomies x :5 Fig 2. Exteriorization of the proximal esophagus through a concomitant cervical incision allowed circular myotomies without difficulty.
1. LivaditisA, Radberg L, Odensjo G: Esophagealendto-endanastomosis.ScandJ ThoracCardiovascSurg 6:206214, 1972 2. de LorimierAA, Harrison MR: Longgap esophageal atresia. Primaryanastomosisafter esophagealelongationby
682
HOFFMAN AND MOAZAM
bougienage and esophagomyotomy. J Thorac Cardiovasc Surg 79:138-141, 1980 3. Ricketts RR, Luck SR, Raffensperger JG: Circular esophagomyotomyfor primary repair of long-gapesophageal atresia. J Pediatr Surg 16:365-369, 1981 4. Santos AD, Thompson TR, Johnson DE, et al: Correction of esophageal atresia with distal tracheoesophageal fistula. J Thorac Cardiovasc Surg 85:229-236, 1983 5. Hormoz A, Azar H, Chrispin AR, et al: Esophageal replacement with transverse colon in infants and children. J Pediatr Surg 6:1-3, 1971
6. Waterston DJ: Colonic replacement of esophagus (intrathoracic). Surg Clin North Am 44:1441-1447, 1964 7. Burrington JD, Stephens CA: Esophageal replacement with a gastric tube in infants and children. J Pediatr Surg 3:246-252, 1968 8. Louhimo I, Pasila M, Visakorpi JK: Late gastrointestinal complicationsin patients with colonicreplacement of the esophagus. J Pediatr Surg 4:663-673, 1969 9. Janik JS, SimpsonJS, Filler RM: Wide gap esophageal atresia with inaccessible upper pouch. J Thorac Cardiovasc Surg 82:198-202, 1981
Discussion Franco Soave (Genoa, Italy): I have had two similar cases in the past, and this operation has helped me in m a k i n g an anastomosis between the proximal and distal pouch in case of tracheoesophageal atresia. But, in all of these cases, I
have had a very big diverticulum, and when the child was 4 months of age, it could not swallow well. I was compelled to make a resection of the diverticulum and a new anastomosis. After that, the patients were very well.
O A primary end-to-end anastomosis of t h e esophagus can be accomplished in the wide-gap esophageal atresia by obtaining extra esophageal length through circular myotomy of the proximal esophageal pouch. However, a very short proximal esophageal pouch may not be accessible through the standard thoracic incision, precluding this procedure. An infant is reported in whom the inaccessible proximal pouch was exteriorized into the neck through a concomitant cervical incision, allowing three circular myotomies to be performed with ease. The proximal esophagus was then reintroduced into the chest cavity and a primary esophagoesophagostomy performed without difficulty. INDEX WORDS: Esophageal atresia; esophageal circular myotomy.
HE TREATMENT of congenital wide-gap esophageal atresia is a difficult problem that has taxed the ingenuity of pediatric surgeons for years. In 1973, Livaditis1 introduced the concept of circular myotomy of the proximal esophageal pouch as a means of obtaining increased length to allow an end-to-end esophageal anastomosis without tension. Since then, multiple clinical reports 2m have attested to the effectiveness of this procedure. However, an extremely short proximal esophageal pouch may not be accessible via the standard thoracic incision, precluding the performance of the circular myotomies. An infant is reported in whom a short proximal esophageal pouch was exteriorized through a separate and concomitant cervical incision, allowing the performance of three circular myotomies to provide adequate length for a primary anastomosis.
T
CASE REPORT M.H., a white female infant, was the product of a 35-week gestation and weighed 1,940 g at birth. Due to the presence of
From the Department of Surgery, University of Florida College of Medicine, Gainesville, Fla. Presented before the 15th Annual Meeting of the American Pediatric Surgical Association, Marco Beach, Florida, May 9-12, 1984. Address reprint requests to Farhat Moazam, MD, Associate Professor, Division of Pediatric Surgery, Box J286, J. Hillis Miller Health Center, University of Florida, Gainesville, FL 32610. 9 1984 by Grune & Stratton, Inc. 0022-3468/84/1906~011 $03.00/0 680
copious oral secretions, an esophageal atresia was suspected soon after birth. A Replogle nasogastric tube was found to stop at the level of the thoracic inlet (Fig 1). Normal gas pattern was evident on roentgenographic examination of the abdomen. A barium pouchogram confirmed an extremely high, blind proximal pouch, and the possibility of a wide-gap atresia was entertained. The infant underwent the placement of a central venous catheter and a Stamm gastrostomy soon after birth. At 4 days of age, the patient was returned to the operating room for an extrapleural thoracotomy through the fifth intercostal space, She was placed in a standard left lateral position and the right side of the neck was prepped and encompassed within the operative field. At thoracotomy, the tip of the proximal pouch was barely visible at the level of the thoracic inlet, despite pressure via an indwelling tube. The distal tracheoesophageal fistula found entering the trachea at the level of the carina was ligated and divided. Despite mobilization of the proximal and distal esophagus, it became evident that the wide gap between the two esophageal ends would not allow a primary anastomosis. At this point, a concomitant, transverse incision was made in the right neck and the proximal esophagus was mobilized from this approach. With the carotid sheath and the internal jugular veins retracted laterally, the entire proximal esophagus was exteriorized into the cervical incision (Fig 2). A bougie was introduced into the proximal pouch and three circular myotomies were performed. The myotomized esophagus was then replaced into the thoracic cage and the cervical incision closed in layers without drainage. With the additional length obtained via the three myotomies, an end-to-end esophageal anastomosis was achieved without difficulty. Fifteen months following surgery, the patient is tolerating a normal diet for age and has a satisfactory weight gain. An esophagogram at 14 months of age reveals minimal narrowing at the site of the anastomosis with a relatively normal esophageal contour (Fig 3).
DISCUSSION
Ten to 20 percent of infants presenting with esophageal atresia have a significantly long distance between the proximal and distal esophageal ends, making attempts at primary endto-end anastomosis very difficult) In these patients, primary reconstruction of the esophagus is postponed for several months, after which esophageal continuity is usually established via esophogeal substitutes, consisting of segments of colons'6 or gastric tubes. 7 These procedures, however, represent major operative intervention with often significant morbidity as well as long-term functional disorders. 8 In 1973, LivaditisI introduced the concept of circular esophageal myotomy to obtain additional esophageal length to enable an end-to-end esophageal anastomosis in Journal of Pediatric Surgery, Vo119, No 6 (December), 1984
TRANSCERVICAL MYOTOMY
681
Fig 1. The tip of the Replogle tube visible at the thoracic inlet, suggests the presence of a wide gap esophageal atresia.
wide-gap atresia. This procedure is possible due to the excellent submucosal esophageal blood supply of the proximal esophageal pouch. The use of circular esophageal myotomies has subsequently been reported by various authors2'3 as an effective aid in accomplishing primary esophageal anastomosis without tension. A problem arises, however, when the proximal
Fig 3. An esophagogram at 14 months of age reveals a relatively normal esophageal contour.
pouch is inaccessible through the standard thoracic incision. In 1981, when faced with a similar problem, Janeck and his associates9 repositioned the infant in a supine position to deliver the esophagus through a separate cervical incision. Following transcervical esophageal myotomies, the patient was repositioned and the thoracic incision reopened to accomplish the anastomosis. The present report, however, demonstrates that positioning the infant in the standard left lateral position and encompassing the neck in the operative field can allow simultaneous exposure of the proximal esophagus through concomitant thoracic and cervical incisions. This prevents the necessity of frequent repositioning of the patient in order to establish the circular myotomies. We believe transcervical esophageal myotomy provides another advance in accomplishing a safe, primary end-to-end esophagoesophagostomy in the wide gap esophageal atresia. REFERENCES
nn Preparation for Circular Myotomies x :5 Fig 2. Exteriorization of the proximal esophagus through a concomitant cervical incision allowed circular myotomies without difficulty.
1. LivaditisA, Radberg L, Odensjo G: Esophagealendto-endanastomosis.ScandJ ThoracCardiovascSurg 6:206214, 1972 2. de LorimierAA, Harrison MR: Longgap esophageal atresia. Primaryanastomosisafter esophagealelongationby
682
HOFFMAN AND MOAZAM
bougienage and esophagomyotomy. J Thorac Cardiovasc Surg 79:138-141, 1980 3. Ricketts RR, Luck SR, Raffensperger JG: Circular esophagomyotomyfor primary repair of long-gapesophageal atresia. J Pediatr Surg 16:365-369, 1981 4. Santos AD, Thompson TR, Johnson DE, et al: Correction of esophageal atresia with distal tracheoesophageal fistula. J Thorac Cardiovasc Surg 85:229-236, 1983 5. Hormoz A, Azar H, Chrispin AR, et al: Esophageal replacement with transverse colon in infants and children. J Pediatr Surg 6:1-3, 1971
6. Waterston DJ: Colonic replacement of esophagus (intrathoracic). Surg Clin North Am 44:1441-1447, 1964 7. Burrington JD, Stephens CA: Esophageal replacement with a gastric tube in infants and children. J Pediatr Surg 3:246-252, 1968 8. Louhimo I, Pasila M, Visakorpi JK: Late gastrointestinal complicationsin patients with colonicreplacement of the esophagus. J Pediatr Surg 4:663-673, 1969 9. Janik JS, SimpsonJS, Filler RM: Wide gap esophageal atresia with inaccessible upper pouch. J Thorac Cardiovasc Surg 82:198-202, 1981
Discussion Franco Soave (Genoa, Italy): I have had two similar cases in the past, and this operation has helped me in m a k i n g an anastomosis between the proximal and distal pouch in case of tracheoesophageal atresia. But, in all of these cases, I
have had a very big diverticulum, and when the child was 4 months of age, it could not swallow well. I was compelled to make a resection of the diverticulum and a new anastomosis. After that, the patients were very well.