Esophagus replacement by free, autologous jejunal mucosa transplantation in long-gap esophageal atresia

Esophageal atresia repair with thoracotomy: the Cincinnati contemporary experience

Esophageal atresia/tracheoesophageal fistula (EA/TEF) repair using an open muscle-sparing thoracotomy has been the standard approach used in our institution. Whereas perioperative mortality is now very uncommon, short- and long-term morbidity is very common in these patients. However, the complexity of the esophageal anatomy and significant comorbidities appear to be important contributors to significant complications in these patients. At least 30% of the EA/TEF patients required esophageal dilatations for anastomotic stricture; this increased to 50% for patients with pure EA. Gastroesophageal reflux requiring an antireflux procedure was performed 23% of the time for EA/TEF and 30% for EA patients. In addition, there were a few complications, such as winging of the scapula and scoliosis, that were attributed in part to the utilization of a nonmuscle-sparing thoracotomy. The standard muscle-sparing thoracotomy remains a very versatile and useful approach to repairing esophageal atresia, and it is the standard for repairing more complex anatomical variants. The self-reported long-term quality of life in these patients is very good, except for a few individuals with protracted feeding disorders and severe dysphagia.

Preoperative home care for esophageal atresia--a survey

BACKGROUND/PURPOSE

Long gap esophageal atresia may require months of preoperative management before definitive repair. When 2 recent patients prompted the authors to consider preoperative home care, no published protocol could be identified. This survey is undertaken to determine pediatric surgeons' experience with preoperative home care for long gap atresia.

METHODS

A total of 543 surgeons were asked if any patients with long gap atresia had been treated preoperatively at home. For patients sent home, information on nursing care, insurance issues, complications, and timing or type of repair was requested.

RESULTS

A total of 380 surveys (70%) were returned. A total of 165 surveys representing 348 patients were included. Forty-one of 165 surgeons (25%) treated 63 of 87 patients (72%) with long gap atresia and an intact upper pouch at home. Home nursing care was provided for 44 patients (70%): 16 (36.4%) night shift, 2 (4.5%) day shift, 3 (6.8%) 24 hour, and 23 (52.3%) intermittent care. No complications referable to preoperative home care were reported.

CONCLUSIONS

Significant hesitancy and practice variance exists regarding preoperative home care of patients with long gap esophageal atresia. Many surgeons are satisfied with the safety and cost effectiveness of this technique, although a prospective, multicenter trial is needed to study it in a randomized, controlled fashion.

Colon interposition in children

Since 1960 we have performed 80 colonic interpositions on 79 children. We present a retrospective review of their progress. Sixty-nine interpositions were for long-gap oesophageal atresia, while the remainder followed oesophagectomies, eight for strictures and two others. Overall, the transthoracic route was used in 69 per cent of cases, while 29 per cent were retrosternally placed and one was retropleural. The mean follow-up was 11.08 years. The mortality rate was 12 per cent, with one-third of deaths unrelated to the operation. Graft failure, which occurred on eight occasions (10 per cent), was due to ischaemia in four, intractable stricture in two and stomal ulceration in two. Leakage from the proximal anastomosis occurred in 31 per cent of cases and stricture formation in 27 per cent. Thirty per cent of patients complained of acid reflux, of whom one-third developed stomal ulceration. We present data concerning other complications, including long-term recurrent respiratory infections, malabsorption, gastrointestinal haemorrhage, diarrhoea, intestinal obstruction and redundancy of the graft. Staging the procedure did not affect the outcome, however the higher incidence of serious complications encountered following retrosternal interposition finally led us to abandon this procedure in favour of the transthoracic route. There has been little improvement in the growth rate, but in terms of swallowing ability the outcome was satisfactory in 94 per cent of cases.