CHAPTER 9
INTRODUCTION
Gastric Transposition for Oesophageal
Replacement
While every attempt should be made to retain the child’s own oesophagus there are circumstances in which this aim cannot be achieved. These include:
쐽 Oesophageal atresia: in particular very long gap pure atresia where delayed primary anastomosis has failed, and, in addition, complicated oesopha- geal atresia when the primary repair has disrupt- ed and a cervical oesophagostomy established
쐽 Caustic oesophageal damage that fails to respond to dilatation
쐽 Injuries to the oesophagus by prolonged foreign body impaction
쐽 Tumours of the oesophagus, e.g., diffuse leiomat- osis, inflammatory pseudo-tumour
쐽 Motility disorders
There are four recognized methods of oesophageal substitution, which include:
쐽 Colon interposition
쐽 Gastric tube oesophagoplasty
쐽 Jejunal interposition
쐽 Gastric transposition
Gastric transposition has been my procedure of choice for oesophageal replacement for over 20 years.
It has the following advantages:
쐽 The stomach has an excellent blood supply.
쐽 Adequate length to reach the cervical region can usually be achieved.
쐽 The procedure involves a single anastomosis.
쐽 The leak and stricture rates are relatively low.
쐽 The procedure itself is simple to perform.
It is recommended that bowel preparation is carried out to ensure an empty colon in the event that the stomach is unavailable for the transposition proce- dure. The surgeon should be capable of performing the various alternative methods of oesophageal re- placement.
Lewis Spitz
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A midline upper abdominal incision is made. An el- liptical incision around the cervical oesophagostomy or, alternatively, a right or left low transverse cervical incision is made to expose the cervical oesophagus.A lateral thoracotomy may be required if the surgeon
encounters any difficulty in mobilizing the thoracic oesophagus, which may have been damaged by caus- tic oesophagitis or repeated attempts at retaining the child’s own oesophagus.
Figure 9.2
The stomach is exposed, the gastrostomy site is taken down and the defect in the stomach closed. The greater and lesser curvatures of the stomach are mo- bilized, preserving the integrity of the right gastroep- iploic and right gastric arcades. The mobilization of
the stomach continues proximally by dividing the short gastric vessels between the fundus of the stom- ach and the spleen and by ligating and dividing the left gastric artery and vein.
Chapter 9 Gastric Transposition for Oesophageal Replacement 79
Figure 9.1
Figure 9.2
9
The stump of the distal oesophagus (in the case of long gap atresia) is mobilized from the posterior mediastinum by dividing the phreno-oesophageal membrane and dissecting out the oesophagus. The
anterior and posterior vagal nerves are divided. The oesophagus is divided at the oesophago-gastric junc- tion and the defect in the stomach repaired.
Figure 9.4
A pyloroplasty is performed. The sutured gastrosto- my site and the closed-off gastro-oesophageal junc- tion are shown. The highest point on the stomach and the place for the oesophago-gastric anastomosis is the top of the fundus. Two sutures of different ma-
terials are placed in the fundus. The orientation of these sutures is used to ensure that rotation of the stomach does not occur while it is being pulled up into the neck.
Chapter 9 Gastric Transposition for Oesophageal Replacement 81
Figure 9.3
Figure 9.4
9
Via the cervical incision, full thickness of the oesoph- agus is mobilized. It is easy to enter into the submu- cosal plane during the dissection but this should be
avoided as the vascularity of the oesophagus will be impaired. The recurrent laryngeal nerves must be preserved during the mobilization procedure.
Figure 9.6
The plane of dissection for the mediastinal tunnel is directly anterior to the prevertebral fascia. From above the dissection proceed immediately posterior to the trachea posteriorly and caudally into the pos- terior mediastinum. From below, through a widened hiatus, dissection is carried out under vision in the prevertebral space behind the heart. The tunnel is completed from above and from below by gentle dig- ital dissection in the posterior mediastinum.
If any problems are encountered in creating the posterior mediastinum tunnel by blunt finger dissec- tion, it is advisable to perform a lateral transpleural thoracotomy and complete the dissection under di- rect view. This approach is also essential to remove a scarred oesophagus or a tumour of the oesophagus.
Chapter 9 Gastric Transposition for Oesophageal Replacement 83
Figure 9.5
Figure 9.6
9
Using the “stay-sutures” as guides, the stomach is pulled up through the hiatus in the diaphragm, through the posterior mediastinal tunnel until the fundus appears at the cervical incision. The transpo-
sition should be smooth and under no tension, and the stay-sutures should be correctly orientated to avoid twisting of the stomach in the posterior medi- astinum.
Figure 9.8
The anastomosis between the end of the cervical oe- sophagus and the top of the fundus of the stomach is fashioned using a single layer of 5/0 or 6/0 sutures, taking the full thickness of the walls of the oesopha- gus and the stomach. Before completing the anterior wall of the anastomosis a size 10F–12F nasogastric tube is passed with the tip in the intrathoracic stom- ach. The wounds are closed with a soft rubber drain
at the cervical incision. A feeding-tunnelled jejunos- tomy is highly recommended for infants with oe- sophageal atresia who have not previously been es- tablished on oral feeding. In addition to the usual post-operative management following any major procedure, it has been our practice to electively para- lyse and mechanically ventilate our patients for a minimum of 48–72 h post-operatively.
Chapter 9 Gastric Transposition for Oesophageal Replacement 85
Figure 9.7
Figure 9.8
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Mortality of this procedure is in the region of 5%
while the morbidity is significant and includes:
쐽 Anastomotic leak rate 12%
쐽 Anastomotic stricture rate 19.6%
쐽 Swallowing problems 30%
쐽 Delayed gastric emptying 8.7%
쐽 Complications with the jejunal feeding tube 4%
쐽 Dumping syndrome 3%
Most of the children prefer to take small frequent meals, although in the older children a normal eating pattern is generally established. Many of the patients grow at a slower rate than normal and are in the low- er half of the growth charts for both weight and height. This applies particularly to children who are born with oesophageal atresia.
SELECTED BIBLIOGRAPHY
Ludman L, Spitz L (2003) Quality of life after gastric transposi- tion for oesophageal atresia. J Pediatr Surg 38 : 53–57 Spitz L (1984) Gastric transposition via the mediastinal route
for infants with long-gap esophageal atresia. J Pediatr Surg 19 : 149–154
Spitz L (1995) Gastric transposition of the esophagus. In: Spitz L, Coran AG (eds) Pediatric surgery, 5th edn. Chapman and Hall, London, pp 152–158
Spitz L (1998) Esophageal replacement. In: O’Neill JA, Rowe MI, Grosfeld JL, Fonkalsrud EW, Coran AG (eds) Pediatric Surgery, 5th edn. Mosby Year Book, St Louis, pp 981–995 Spitz L, Kiely EM, Pierro A (2004) Gastric transposition in chil-
dren – a 21-year experience. J Pediatr Surg 39 : 276–281
Part III
