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Esophageal Replacement: Overcoming the Need

Lewis Spitz

PII: S0022-3468(14)00020-7DOI: doi: 10.1016/j.jpedsurg.2014.01.011Reference: YJPSU 56642

To appear in: Journal of Pediatric Surgery

Received date: 10 January 2014Accepted date: 27 January 2014

Please cite this article as: Spitz Lewis, Esophageal Replacement: Overcoming the Need,Journal of Pediatric Surgery (2014), doi: 10.1016/j.jpedsurg.2014.01.011

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Stephen L Gans Distinguished Overseas Lecture 2013

Esophageal Replacement: Overcoming the Need

Lewis Spitz

Emeritus Nuffield Professor of Paediatric Surgery

Institute of Child Health, University College, London

Great Ormond Street Hospital for Children NHS Trust

London WC1N 3JH U.K.

E-Mail: l.spitz@ucl.ac.uk

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Abstract

Three developments which have contributed to the declining necessity for

esophageal replacement are improvement in the management of esophageal

atresia, prevention of caustic injuries to the esophagus, and early antireflux

surgery for intractable gastro-esophageal reflux. Despite these advances,

replacement of the esophagus may still be necessary. The two most commonly

used procedures for replacing the esophagus are colonic interposition and

gastric transposition. Experience with 236 gastric transposition operations

reveal a mortality of 2.5%, leak rate of 12%, and stricture of 20%. The follow-

up shows a satisfaction of over 90%. New methods of overcoming the need

for esophageal replacement are in progress with tissue engineering with a

scaffold to produce a tubular graft to bridge the gap in the continuity of the

esophagus.

Keywords: esophageal replacement; gastric transposition; colon

interposition; gastroesophageal reflux

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The necessity to replace the esophagus has receded significantly in recent

years as a result of three main developments: 1. improvements in the

management of esophageal atresia particularly with reference to “long gap”

atresia, 2. avoidance of caustic injuries, and 3. early treatment of severe

gastro-esophageal reflux to prevent intractable strictures.

Improvements in the management of esophageal atresia.

In all cases in the management of esophageal atresia, complications such as

anastomotic leaks and strictures can be avoided by employing a gentle,

meticulous, and accurate technique. Willis Potts in 1959 1. wrote

“To anastomose the ends of an infant’s esophagus, the surgeon must

be as delicate and precise as a skilled watchmaker. No other

operation offers a greater opportunity for pure technical artistry”.

It is almost always possible to achieve a primary anastomosis in “wide”

esophageal atresia where there is a distal tracheo-esophageal fistula, but where

the distance between the proximal and distal segments appears too far apart.

By constructing an anastomosis even under extreme tension and electively

paralyzing and mechanically ventilating the infant for an arbitrary period of

around 5 days, it is possible to effect a satisfactory primary repair with a low

leak rate but a high incidence of strictures and the need for surgery for gastro-

esophageal reflux.2..

Numerous methods have been described to reduce the gap between the

proximal and distal pouches in “pure or isolated” atresia. Of primary

importance is to exclude the presence of a proximal fistula which is present up

to 15% of cases 3, which severely limits the mobility of the upper esophagus.

Methods include delayed primary anastomosis, stretching of the esophagus,

Lividitis esophagomyotomy, and the Foker technique of inducing esophageal

growth by applying internal and external traction. With the delayed approach,

it is generally unproductive to wait longer than 12 weeks in the expectation

that the gap will narrow sufficiently to permit a primary anastomosis.

While it is generally accepted that the child’s own esophagus is best, there are

instances where replacement is a better option, particularly in cases where

persisting with futile attempts to retain the native esophagus are detrimental to

the well-being of the child and the family. Examples are repeated failed

procedures to achieve esophageal continuity, the development of

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complications such as empyema from anastomotic leaks, refractory or

extensive stricturing, or multiple recurrences of fistulas.

There is a clear need to centralize the management of the “difficult

esophagus” to a limited number of special centers. The concentration of a

large volume of cases will serve to enhance expertise, improve outcome, and

generate research into new methods of treatment.

Caustic esophageal damage.

Injury to the mucosal surface occurs within seconds of the ingestion of the

strong alkali. The liquifaction necrosis rapidly extends through the epithelial

layer and submucosa and may extend into and through the muscle layer. The

ultimate outcome in severe cases is extensive stricture formation. The

provision of child proof containers of caustic soda has had a major

preventative effect in developed countries, whereas in the developing world,

particularly in rural areas where caustic agents are used extensively for soap

making and drying fruit, and where cleaning material is stored in unsuitable

containers, caustic injuries continue to be a major health hazard4.. The

prevalence of caustic injuries among children in the United States is estimated

to be 1.08 per 100,000 population. The number of hospitalizations is down

from 5,000 – 15,000 per year in the 1980’s to 807 in 20095.. Early

esophagoscopy is important to confirm the ingestion and to assess the severity

of the damage. The continuing need for regular dilatation 6 – 12 months

following the injury constitutes an indication for esophageal resection and

replacement.

Reflux strictures.

Early antireflux surgery of severe pathological gastro-esophageal reflux will

prevent intractable strictures from developing. It is particularly in the severely

neurologically disabled child that symptoms of reflux are ascribed to the

developmental delay while irreversible strictures occur. Most cases of

severely strictured and inflamed esophaguses will resolve following

fundoplication and regular postoperative dilatations. A small minority will

eventually require esophageal replacement 6..

.

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Other indications for esophageal replacement.

Other indications for esophageal replacement include tumors of the

esophagus, such as diffuse leiomyoma or inflammatory pseudotumor or rarely

carcinoma, prolonged impaction of foreign bodies, such as aluminum ring can

tops7, which are radiolucent and may escape detection for prolonged periods,

and button batteries causing wide tracheoesophageal fistula, intractable

achalasia, epidermolysis, and human immunodeficiency (HIV) strictures 8..

Esophageal replacement.

The four most commonly used methods of esophageal replacement are

1. colonic interposition

2. reversed gastric tube

3. jejunal interposition

4. gastric transposition

Each method has its own problems and complications, but in our experience

the gastric transposition is associated with the lowest complication rate and is

the least complicated procedure.

Colon interposition has a precarious blood supply, usually arising from the

ascending branch of the left colic artery. It is complicated by a high incidence

of anastomotic leaks and strictures and in the long-term by redundancy of the

interposition with stasis, which may require surgical revision.

Gastric tube esophagoplasty involves a very extensive suture line with a

high incidence of leaks and strictures. There is also the problem of Barrett’s

esophagitis developing from acid reflux into the cervical stump.

Jejunal interposition is favored by some, but the blood supply is precarious,

although the interposed jejunal segment is of appropriate calibre and is

reputed to retain peristaltic activity.

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Gastric transposition involves transposing the whole stomach into the

cervical region. The blood supply of the stomach is excellent, length is not a

problem, and the procedure is relatively straight forward. The anastomotic

leak rate is low and most close spontaneously, but strictures occur in 20% of

cases with the highest incidence in replacement for caustic injury (58%).

Reflux, dumping, and poor gastric emptying are problems mainly in the short-

term, and Barrett’s esophagitis may develop long-term.

Surgical technique for gastric transposition (Fig.1). 9,10

The preferred route for gastric transposition is a transhiatal retromediastinal

approach without thoracotomy. The procedure has been performed

laparoscopically with good results 11

. The stomach is fully mobilized, dividing

the left gastric and left gastro-epiploic vessels, and a pyloroplasty or myotomy

is performed. The highest point on the mobilized stomach is the top of the

fundus, which is marked with two different sutures to prevent rotation during

transfer through the mediastinum. The stomach is passed via the hiatus

through the retromediastinum into the neck, where it is anastomosed to the

cervical esophageal stump. A trans-gastric or jejunal feeding tube is placed for

temporary enteral feeding in children who have never taken nutrition orally.

Postoperatively, elective paralysis and ventilation are used for a few days.

Results. 12

The surgical team at Great Ormond Street Hospital (GOS), London, has

performed a total of 236 gastric transposition procedures since 1980. There

were 147 male and 89 female patients. The primary condition affecting the

infants were esophageal atresia in 177 cases, of which 95 were atresia with

distal tracheoesophageal fistula, 65 isolated atresia, 15 atresia with proximal

fistula, and two H-fistula. In addition, 32 had extensive stricture following

caustic ingestion, and 9 suffered intractable gastroesophageal reflux strictures.

The remaining 16 patients included congenital stricture (4), amotile esophagus

(3), achalasia, diffuse leiomyomatosis, and prolonged foreign body impaction

(2 each, respectively). Eighty-one percent of cases were referred to us from

abroad (110) or from other centers in the United Kingdom (81), leaving 41

patients undergoing all their treatment at GOS, less than 1% of the case load.

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A prior attempt at replacement had been carried out in 33 patients (14%) of

which 19 involved colon, 5 partial gastric replacement, 3 each Scharli

procedures and gastric tube esophagoplasty, and one attempt at the Foker

procedure.

The route for the replacement was via the posterior mediastinum without

thoracotomy in 109 cases, transthoracic in 95 cases due to extensive scarring

from previous surgery, retrosternal in 7, and recently laparoscopically in 25

cases, of which 8 needed to be converted to open approach due to dense

adhesions. A pyloroplasty or myotomy was performed according to surgeon

preference. All patients were electively ventilated postoperatively except for

the first 4 cases.

Eleven patients died, 5 from conditions unrelated to the gastric transposition,

giving a procedure related mortality of 2.5%. Anastomotic leaks occurred in

28 patients (12%) and strictures in 48 cases (20%), of which 17 were

secondary to caustic scarring. Swallowing problems postoperatively were

almost universal, but in 55 (29%) patients it was significant, moderate in 26,

and severe in 29 cases. Delayed gastric emptying was a problem in 21 (8.8%)

cases in some patients necessitating conversion of pyloromyotomy to plasty or

more radically to gastrojujenostomy. Eight patients developed problematic

dumping syndrome which eventually resolved and 4 others a Horner’s

syndrome which also eventually resolved. A late complication encountered in

6 patients was herniation of small intestine into the chest via the esophageal

hiatus. This complication was eliminated by narrowing the hiatus and suturing

the edge of the hiatus to the antrum of the stomach.

Follow-up showed that weight generally was in the lower centiles for age,

while height was normally distributed. Overall, more than 90% of patients

were highly satisfied with the procedure, and there did not appear to be any

deterioration in functioning of the transposed stomach in the long-term.

Conclusion.

Significant progress has been made in recent years to reduce the need for

esophageal replacement. These include improved management of esophageal

atresia, prevention of caustic injury by child proof containers, and earlier

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surgery for intractable gastro-esophageal reflux, particularly in the

neurologically impaired child.

Despite these advances, there are occasions when the esophagus needs to be

replaced. Of the two most commonly used methods of replacement, gastric

transposition is favored because of the excellent blood supply of the stomach,

the ease of the procedure, and lower leak and stricture rates. There is a clear

need to centralize the management of the “difficult” esophageal atresia cases

as well as for replacing the esophagus to few specialist centers to improve

outcomes, enhance expertise, and carry out research.

Progress is being made with tissue engineering in the creation of a tubularized

graft of the esophagus which may supercede current methods of

replacement.13.

The new esophagus will be comprised of a scaffold of

synthetic or natural origin and cells which could be derived from fetal tissue if

the diagnosis of pure atresia is suspected prenatally or from bone marrow and

mucosa if replacement is required after birth.

Acknowledgements:

Thanks are due to Edward Kiely, Agostino Pierro, David Drake, and Joe

Curry for allowing inclusion of their patients, to Paolo De Coppi for

information on tissue engineering, and to Marcia Matias for collecting the

data.

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References.

1. Potts W.J. In The Surgeon and the Child; Philadelphia. Saunders 1959

2. Spitz L. Esophageal Atresia: Past , Present and Future. J. Pediatr Surg

1996; 31: 19-25.

3. Spitz, L. Esophageal atresia – Lessons I have learned in a 40 year

experience. J. Pediatr. Surg. 2006 ; 41 ; 1635-1640.

4. Millar A.J.W. and Numanoglu A. Caustic Strictures of the Esophagus. In

Pediatric Surgery 7th

Ed. Edit Coran AG, Adzick NS, Krummel TM,

Laberge J-M, Shamberger RC and Caldamone AA. Elsevier Saunders

2012, 919 – 926.

5. Johnson CM, Brigger MT. The public health impact of pediatric caustic

ingestion injuries. Arch Otolaryngol Head Neck Surg.2012,138:1111-

1115.

6. Spitz L, Roth K, Kiely EM, Drake DP, Milla PJ. Operation for

gastrooesophageal reflux associated with severe mental retardation.

Arch Dis Child 1993; 68: 347-351

7. Spitz L, Hirsig J. Prolonged foreign body impaction in the oesophagus.

Arch Dis Child 1982; 57: 551-553

8. Loveland JA, Mitchell CE, van Wyk P, Beale P. Esophageal replacement

in children with AIDS. J Pediatr. Surg. 2010, 45, 2068-70

9. Spitz L. Gastric transposition via the mediastinal route for infants with

long-gap esophageal atresia. J Pediatr Surg 1984; 19: 149-154.

10. Spitz L,Pierro A. Gastric replacement of the esophagus in Operative

Pediatric Surgery 7th

Ed. Edited Spitz L and Coran AG, CRC Press

Taylor and Francis Group. Boca Raton FL 2013, 163-173.

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11. Stanwell J, Drake D, Pierro A, Kiely E, Curry J. Pediatric laparoscopic-

assisted gastric transposition: early experience and outcomes. J

Laparoendosc. Adv. Surg. Tech A 2010, 20, 177-81

12. Spitz L, Kiely E, Pierro A. Gastric transposition in children – a 21-year

experience. J.Pediatr. Surg. 2004; 39: 276-281

13. Totonelli G, Maghsoudlou P, Fishman JM, Orlando G, Ansari T,

Sibbons P, Birchall MA, Pierro A, Eaton S, De Coppi P. Esophageal

tissue engineering: a new approach for esophageal replacement.

World J Gastroenterol. 2012 ,47: 6900-7.

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Figure 1.

Illustration of the technique of gastric transposition.

a – closure of gastrostomy e – esophago-gastric anastomosis

b – closure of gastro-esophageal junction f – transposed stomach

c – pyloroplasty / myotomy g – pyloroplasty below hiatus

d – sutures of top of fundus of stomach h – jejunal feeding tube

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