INTRODUCTION
To date, there is no better substitute for the native oe- sophagus because the ideal graft does not exist. Many studies have been done and different organs are used: the jejunum, the stomach as a tube or as the whole organ, and the colon. There is no agreement on a single organ or a single route. The colon is the most commonly used organ, and experienced centres con- sider it as a good substitute in most of the cases.
Indications include oesophageal atresia failed af- ter repair or a wide gap. Full-thickness injury to a long segment of the oesophagus after caustic inges- tion invariably results in an intractable stricture that fails to respond to repeated dilatation and requires substitution. Other indications include multiple ex- tensive strictures, marked irregularity or pocketing of the oesophagus, and the need for frequent dilata-
tions. Extensive infection with candida, epidermoly- sis bullosa or, very rarely, massive varices due to por- tal hypertension and strictures after injection are rare causes for replacement.
Over the last 30 years more than 850 oesophageal replacements have been performed in the Pediatric Surgery Department of Ain-Shams University. The technique has evolved from gastric pull-up to colon replacement, initially subcutaneously, then retroster- nally. In the last 13 years we started transhiatal oe- sophagectomy with posterior mediastinal colon re- placement. The left colon based on the left colic ar- tery as a graft in all cases of oesophageal replacement or bypass has been used since 1972. The graft is usu- ally isoperistaltic.
of the Oesophagus
Alaa Hamza
All patients are given intestinal antiseptics 3 days be- fore surgery (metronidazole and colimycin). Colonic washouts are done three times per day 48 h prior to surgery. Patients with a gastrostomy have saline infu- sions through the tube at 20 ml/kg body weight over 30 min. This is repeated three times every 2 h. Intra- venous cephalosporin and metronidazole are given with premedication.
The patient is placed in the supine position with a small sandbag under the shoulder with the neck ex- tended and turned to the right side. A tube is placed through the nose into the oesophagus to allow easy dissection. Skin preparation includes neck, chest and abdomen.
Left transverse supraclavicular incision is made, which can be extended upwards in a hockey stick manner over the anterior border of the sternomas- toid. If oesophagostomy is present stay sutures are placed around the oesophagus and an elliptical inci- sion around the oesophagostomy is made. Dissection of the oesophagus should not extend proximally more than 4–5 cm to avoid ischaemic injury to the wall.
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Figure 8.1
After incising the skin, subcutaneous tissue and pla- tysma the cervical fascia is opened along the anterior border of the sternomastoid. Dissection continues with the strap muscles either divided (easier for dis- section) or retracted. Internal jugular vein and the common carotid artery all retract laterally. The oe- sophagus is identified and the dissection distal to the stricture is started to avoid proximal devasculariza- tion. Isolation of the oesophagus is done after visual- ising the recurrent laryngeal nerve and retracting it medially. If the oesophagus is severely adherent to the trachea, distal dissection and identification of the nerve at its entry to the neck is important to avoid nerve injury. Now the oesophagus is encircled with a tape and mobilized proximal to the strictured seg- ment for only 2–3 cm to prevent devascularization in- jury of the blood supply. Distal dissection, around the oesophagus is usually done bluntly through the pos- terior mediastinum.
Figure 8.2
Figure 8.3
The abdomen is entered through a midline incision.
Mobilization of the colon is done carefully and it should be freed from the ascending to the descend- ing colon and exteriorized for examination of the vascular supply. The graft is chosen on the territory supplied by the upper left colic artery with the length equal to the distance from the antrum to the stricture
site (insert). Usually division of the middle colic ves- sels is needed and before that the blood supply is clamped by bulldog clips and the colon is left inside the abdomen to verify adequate circulation. If there are any vascular anomalies, the right or even the middle colic artery are utilized.
Figure 8.1
Medial colic nerve
Resection line
Figure 8.3
Recurrent laryngeal nerve Strap muscle
Sternocleidomastoid muscle
Esophagus
Figure 8.2
Figure 8.4
The dissection starts by incising the left triangular ligament of the liver followed by dissection of the oe- sophagus at the hiatus and incising the phreno-oe- sophageal ligament. The vagi are evident at this stage and both are divided. Sometimes the posterior vagus can be saved with meticulous intra-thoracic dissec- tion. The oesophagus is encircled with a tape to facil- itate mobilization. The hiatus is explored utilizing two malleable retractors. Under direct vision all oe- sophageal vessels are diathermized. Traction is ob- tained with the help of the tape and the dissection is
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kept very close to the oesophageal wall to avoid inju- ry to the surrounding structures
With blunt and sharp dissection the oesophagus is freed as high as possible. Care is taken to avoid enter- ing the pleura or an intercostal tube drain has to be inserted. The blunt dissection is continued from above and below until the oesophagus is freed com- pletely. It is essential to avoid aggressive dissection in the region of the aortic arch and to stay close to the oesophageal wall.
Figure 8.5, 8.6
The two tapes encircling the oesophagus are both moved up and down to be sure of having freed the oesophagus from all attachments. Oesophagectomy is then done by dividing the oesophagus at the cardia with occlusion of the gastric end with an intestinal clamp. The oesophagus is then passed upward by traction with a long silk suture to the gastric end of the oesophagus. The silk suture is left in place to be
used for the passage of the colon through the hiatus later on.
The colon is re-evaluated and the pulsation of the marginal artery is carefully examined. The exact measurement of the colon is examined after oesoph- ageal resection; extra length leads to redundancy lat- er on. The graft is washed with diluted povidone io- dine solution and left open with no clamps.
Liver
Anterior vagal nerve
Stomach Esophagus
Figure 8.4
Figure 8.5 Figure 8.6
Figure 8.7
Then, the colon is resected and passed behind the stomach in an isoperistaltic manner taking care to avoid either stretch or torsion of the pedicle. To facil- itate passage through the chest, the silk suture previ- ously present is sutured to the proximal end of the colon and pulled through the cervical incision until the colon is in place in the posterior mediastinum.
Care should be taken regarding the position of the pedicle and repositioning should be done immedi- ately in case of torsion or traction of the vessels. Vi- ability of the graft is confirmed by noting bleeding from its cervical end. Redundant parts are resected at
the cervical and gastric end, avoiding injury to the pedicle.
If the oesophagus has not been resected and a co- lon bypass procedure is planned, then a retrosternal tunnel is made by blunt dissection, dividing the en- dothoracic fascia very close to the sternum, at the upper end from the neck incision after division of the muscles at the supra sternal notch and at the lower end by incising the posterior aspect of the lower end of sternum. The tunnel is enlarged using fingers, tak- ing care not to injure the pleura, and a long silk su- ture is passed through the tunnel.
Figure 8.8
The oesophageal end is examined to rule out any proximal strictures. According to the oesophageal size and disparity to the colonic end, the type of anastomosis is chosen. If both sizes are equal or without marked disparity, an end-to-end single layer anastomosis is made using 4/0 absorbable sutures. If the colonic end is slightly bigger, a posterior incision of the oesophagus to accommodate a larger size of colon can facilitate the anastomosis. A single layer, end-to-side, oesophago-colic anastomosis is made, with closure of the colonic stump if the oesophagus is much smaller in diameter than the colon. Fixation of the colon to the neck muscles is done to avoid trac- tion.
Suturing the strap muscles is important to avoid blowing of the neck during swallowing. Closure of the wound is done in layers, leaving a drain in place.
In cases of caustic pharyngeal strictures the pha- ryngo-colic anastomosis is made as an end-to-side to the wall of the pharynx. First, the incision should ex- tend to the angle of the mandible. Then, the dissec- tion should reach the wall of the pharynx, opened on stay sutures, and healthy mucous membrane should be available for anastomosis. The colonic graft should be long enough to reach the pharynx. A wide single-layer end-to-side anastomosis is made with no tension. Sometimes a wide bore tube is left as a splint for 1 week and endoscopy is done before discharge to check the anastomosis.
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Figure 8.7
Figure 8.8
Figure 8.9
After passage of the colonic graft to the neck the gas- tro-colic anastomosis is performed in two layers. It is done at the cardia with a 270º anti-reflux wrap of the stomach to avoid injury to the pedicle. In cases of ret- rosternal colon the anastomosis is made to the ante- rior wall of the stomach near the antrum and the co- lon should be positioned correctly since it could be hinged by the liver edge. The colon should be fixed to the edges of the tunnel in cases of retrosternal colon and to the edge of the hiatus in cases of posterior mediastinal colonic replacement.
Pyloroplasty is done in all cases with posterior mediastinal replacement. It is performed as a Heinz- Mickulikz type with single-layer anastomosis. The colo-colic anastomosis is performed and care should
be taken to close the window after the colonic resec- tion and this could be achieved by fixing the colon to the edge of duodenum. In patients with no gastrosto- my, a Stamm-type gastrostomy is preformed. The ab- domen is closed in layers with a mediastinal drain.
Patients usually stay in the Intensive Care Unit for 2–4 days. The drains are removed after 48 h, and the patients are fed by the gastrostomy for 7–10 days. A contrast study is performed and, if there is no leak- age, feeding is started The gastrostomy tube is clamped and removed 3 months after surgery unless there is dysphagia. In cases with proximal anasto- motic strictures, if dilatation is unsuccessful, surgical revision of the colo-oesophageal anastomosis is undertaken.
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Figure 8.9
CONCLUSION
We share the view of many authors, that an isoperi- staltic left colon segment based on the left colic ves- sels is the best method of oesophageal replacement for benign caustic oesophageal strictures in children.
A sufficient length is available to replace the whole oesophagus and even the lower pharynx if needed.
The blood supply from the left colic vessels is robust and rarely prone to anatomic variation. The close re- lationship between the marginal vessels and the bor- der of the viscus results in a straight conduit with lit- tle redundancy or tendency to kinking. The left colon seems to transmit solid food more easily than the
right colon and fewer problems are associated with its removal. The colon has proved to be relatively ac- id-resistant, and significant ulceration in the inter- posed segment is unusual.
In a survey of the last 475 cases, we had five deaths related to respiratory problems. No instance of graft necrosis occurred in this series; however, three pa- tients developed late graft stenosis, two of which were at the distal part. Both patients required surgi- cal revision, and the third patient developed an un- usual proximal stenosis that was corrected by gastric pull-up.
SELECTED BIBLIOGRAPHY
Bahnassy AF, Bassiouny IE (1993) Esophagocoloplasty for caustic strictures of the esophagus: changing concepts. Pe- diatr Surg Int 8 : 103
Bassiouny IE, Bahnassy AF (1992) Transhiatal esphagectomy and colonic interposition for caustic strictures. J Pediatr Surg 27 : 1091–1096
Freeman NV, Cass DT (1982) Colon interposition: a modifica- tion of the Waterstone technique using the normal esopha- geal route. J Pediatr Surg 17 : 17–21
Hamza AF, Abdelhay S, Sherif H et al (2003) Caustic esopha- geal strictures in children: 30 years experience. J Pediatr Surg 38 : 828–833
Spitz L (1988) Esophageal replacement in children. In: Coran A, Fonkalsrud E, O’Neil J, Grosfeld J (eds) Pediatric surgery, 6th edn, Mosby Year Book, St Louis
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