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Oliver DH, Martin S, Belkis DMI, Lucas WM, Steffan L. Favorable Outcome of Electively Delayed Elongation Procedure in Long-Gap Esophageal Atresia. Front Surg 2021; 8:701609. [PMID: 34295918 PMCID: PMC8290357 DOI: 10.3389/fsurg.2021.701609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2021] [Accepted: 05/27/2021] [Indexed: 11/13/2022] Open
Abstract
The ideal approach to long gap esophageal atresia is still controversial. On one hand, preserving a patient's native esophagus may require several steps and can be fraught with complications. On the other hand, most replacement procedures are irreversible and disrupt gastrointestinal physiology. The purpose of this study was to evaluate the short- and medium-term outcome of electively delayed esophageal elongation procedures before esophageal reconstruction in patients with long-gap esophageal atresia. Since the neonatal esophagus grows over-proportionally and can increase its wall thickness in the first few months of life, we hypothesized that postponing the elongation steps until 3 months of age would lead to a lower complication rate. We thus retrospectively recorded complications such as mediastinitis, anastomotic leakage, stricture formation, or gastroesophageal reflux requiring surgery, and compared it to reported outcomes. In our treatment protocol, patients born with long-gap esophageal atresia underwent gastrostomy placement and were sham fed until 3 months of age. We then assessed the gap between the esophageal ends and started serial elongation procedures. We only proceeded to the reconstruction of the esophagus when its length allowed a tension-free anastomosis. From April 2013 to April 2019, we treated 13 Patients with long-gap esophageal atresia. Nine patients without prior surgical procedures underwent Foker procedures. Four patients arrived with a pre-existing cervical esophagostomy and thus underwent Kimura's procedure, two of them with a concomitant Foker elongation of the lower pouch. Esophageal reconstruction was feasible in all patients, while none of them developed mediastinitis at any point in their treatment. We managed the only anastomotic leak conservatively. Almost half of the patients did not require any further intervention following reconstruction, while three patients required multiple (≥5) anastomotic dilatations. All but one patient achieved full oral nutrition. Only one child required a fundoplication to manage gastroesophageal reflux symptoms. Electively delayed esophageal elongation procedures in patients with long-gap esophageal atresia allowed preservation of the native esophagus in all patients. The approach had low peri-procedural morbidity, and patients enjoy favorable functional outcomes. Therefore, we suggest considering this method in the management of patients with long-gap esophageal atresia.
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Affiliation(s)
- Diez H Oliver
- Department of Pediatric Surgery, Klinikum Stuttgart, Stuttgart, Germany
| | - Sidler Martin
- Department of Pediatric Surgery, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Wessel M Lucas
- Department of Pediatric Surgery, University Medical Centre Mannheim, Heidelberg University, Mannheim, Germany
| | - Loff Steffan
- Department of Pediatric Surgery, Klinikum Stuttgart, Stuttgart, Germany
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Baird R, Lal DR, Ricca RL, Diefenbach KA, Downard CD, Shelton J, Sømme S, Grabowski J, Oyetunji TA, Williams RF, Jancelewicz T, Dasgupta R, Arthur LG, Kawaguchi AL, Guner YS, Gosain A, Gates RL, Sola JE, Kelley-Quon LI, St Peter SD, Goldin A. Management of long gap esophageal atresia: A systematic review and evidence-based guidelines from the APSA Outcomes and Evidence Based Practice Committee. J Pediatr Surg 2019; 54:675-687. [PMID: 30853248 DOI: 10.1016/j.jpedsurg.2018.12.019] [Citation(s) in RCA: 44] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 11/17/2018] [Accepted: 12/26/2018] [Indexed: 02/07/2023]
Abstract
BACKGROUND Treatment of the neonate with long gap esophageal atresia (LGEA) is one of the most challenging scenarios facing pediatric surgeons today. Contributing to this challenge is the variability in case definition, multiple approaches to management, and heterogeneity of the reported outcomes. This necessitates a clear summary of existing evidence and delineation of treatment controversies. METHODS The American Pediatric Surgical Association Outcomes and Evidence Based Practice Committee drafted four consensus-based questions regarding LGEA. These questions concerned the definition and determination of LGEA, the optimal method of surgical management, expected long-term outcomes, and novel therapeutic techniques. A comprehensive search strategy was crafted and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were utilized to identify, review and report salient articles. RESULTS More than 3000 publications were reviewed, with 178 influencing final recommendations. In total, 18 recommendations are provided, primarily based on level 4-5 evidence. These recommendations provide detailed descriptions of the definition of LGEA, treatment techniques, outcomes and future directions of research. CONCLUSIONS Evidence supporting best practices for LGEA is currently low quality. This review provides best recommendations based on a critical evaluation of the available literature. Based on the lack of strong evidence, prospective and comparative research is clearly needed. TYPE OF STUDY Treatment study, prognosis study and study of diagnostic test. LEVEL OF EVIDENCE Level II-V.
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Affiliation(s)
- Robert Baird
- Department of Pediatric General and Thoracic Surgery, BC Children's Hospital, University of British Columbia, 4480 Oak, Vancouver V6H3V4, British Columbia.
| | - Dave R Lal
- Division of Pediatric Surgery, Department of Surgery, Medical College of Wisconsin
| | - Robert L Ricca
- Division of Pediatric Surgery, Naval Medical Center, Portsmouth, Virginia
| | - Karen A Diefenbach
- Department of Pediatric Surgery, Nationwide Children's Hospital, The Ohio State University, Columbus, OH
| | - Cynthia D Downard
- Hiram C. Polk Jr, MD Department of Surgery, University of Louisville, Louisville, KY
| | - Julia Shelton
- University of Iowa Stead Family Children's Hospital, Iowa City, IA
| | - Stig Sømme
- Division of Pediatric Surgery, Children's Hospital Colorado, University of Colorado, Aurora, CO
| | - Julia Grabowski
- Division of Pediatric Surgery, Department of Surgery, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Tolulope A Oyetunji
- Department of Surgery, Children's Mercy Kansas City, University of Missouri-Kansas City School of Medicine, Kansas City, MO
| | - Regan F Williams
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Tim Jancelewicz
- Division of Pediatric Surgery, Le Bonheur Children's Hospital, Memphis, TN
| | - Roshni Dasgupta
- Division of Pediatric General and Thoracic Surgery, Cincinnati Children's Hospital Medical Center, University of Cincinnati, Cincinnati, OH
| | - L Grier Arthur
- Division of General, Thoracic, and Minimally Invasive Surgery, St. Christopher's Hospital for Children, Drexel University, Philadelphia, PA
| | - Akemi L Kawaguchi
- Department of Pediatric Surgery, University of Texas Health Science Center at Houston, Houston, TX
| | - Yigit S Guner
- Department of Surgery University of California Irvine and Division of Pediatric Surgery Children's Hospital of Orange County
| | - Ankush Gosain
- Division of Pediatric Surgery, Department of Surgery, University of Tennessee Health Science Center, Children's Foundation Research Institute, Le Bonheur Children's Hospital, Memphis, TN
| | - Robert L Gates
- Clinical University of South Carolina-Greenville, Division of Pediatric Surgery, Greenville, SC
| | - Juan E Sola
- Division of Pediatric Surgery, University of Miami Miller School of Medicine, Miami, FL
| | - Lorraine I Kelley-Quon
- Division of Pediatric Surgery, Children's Hospital Los Angeles, Keck School of Medicine, University of Southern California, Los Angeles, CA
| | - Shawn D St Peter
- Children's Mercy Hospital, 2401 Gillham Rd, Kansas City, MO 64108
| | - Adam Goldin
- Department of Pediatric General and Thoracic Surgery, Seattle Children's Hospital, Seattle, WA
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Sun S, Pan W, Wu W, Gong Y, Shi J, Wang J. Elongation of esophageal segments by bougienage stretching technique for long gap esophageal atresia to achieve delayed primary anastomosis by thoracotomy or thoracoscopic repair: A first experience from China. J Pediatr Surg 2018; 53:1584-1587. [PMID: 29395153 DOI: 10.1016/j.jpedsurg.2017.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2017] [Revised: 12/16/2017] [Accepted: 12/16/2017] [Indexed: 11/25/2022]
Abstract
OBJECTIVES The treatment of long gap esophageal atresia (LGEA) is one of the most challenging congenital malformations in neonatal surgery. A preoperative bougienage stretching technique for elongation of the two segments of esophagus is applied to achieve utilizing the native esophagus to establish esophageal continuity by open or thoracoscopic approach. METHODS From January 2015 to May 2017, 12 neonates who suffered from LGEA were admitted to our department. They were divided into 2 groups (A and B) according to their admission time. They all accepted bougienage stretching technique before esophageal anastomosis. RESULTS Initially the lengths of esophageal gap in 12 infants ranged from 4 to 7.5 vertebral bodies (M=5.8±1.1). The gap lengths became -1 to 2.5 vertebral bodies after bougienage stretching technique and tension-free anastomosis were performed successfully for all 12 cases: Group A (n=5) by thoracotomy and group B (n=7) by thoracoscopic approach. 12 cases have been followed up for 1-25 months (M=12.4±8.5) after definitive surgery. CONCLUSIONS Bougienage stretching technique for LGEA is feasible with satisfactory clinical results. Thoracoscopic approach is a good choice for primary anastomosis in LGEA. LEVELS OF EVIDENCE Treatment Study Level IV.
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Affiliation(s)
- Suna Sun
- Department of Pediatric Surgery, Xinhua hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, 200092, Shanghai, China
| | - Weihua Pan
- Department of Pediatric Surgery, Xinhua hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, 200092, Shanghai, China
| | - Wenjie Wu
- Department of Pediatric Surgery, Xinhua hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, 200092, Shanghai, China
| | - Yiming Gong
- Department of Pediatric Surgery, Xinhua hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, 200092, Shanghai, China
| | - Jia Shi
- Department of Pediatric Surgery, Xinhua hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, 200092, Shanghai, China
| | - Jun Wang
- Department of Pediatric Surgery, Xinhua hospital affiliated to Shanghai Jiao Tong University School of Medicine, No. 1665, Kongjiang Road, 200092, Shanghai, China.
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Chumfong I, Lee H, Padilla BE, MacKenzie TC, Vu LT. Esophagoesophagopexy technique for assisted fistulization of esophageal atresia. Pediatr Surg Int 2018; 34:63-69. [PMID: 29124403 DOI: 10.1007/s00383-017-4164-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/18/2017] [Indexed: 11/29/2022]
Abstract
PURPOSE We describe our experience using a modified suture fistula technique for addressing tension in longer gap esophageal atresia (EA). Esophagoesophagopexy (EEP) is the tacking of the proximal and distal ends of esophageal pouches without formal anastomosis. In this retrospective cohort, we review the outcomes of patients with EA after EEP. METHODS We reviewed the operative reports of EA cases treated at our institution from 1997 to 2016 and identified all patients described as having EEP. RESULTS Of 129 EA cases, five patients underwent EEP. Formal anastomosis was not done due to patient's instability, prematurity, or long gap. Median birth weight was 1.4 kg (0.6-2.2 kg), and median gestational age at birth was 29 weeks (25-34 weeks). Age at time of EEP ranged 0-5 months. Esophagoesophageal fistula was confirmed in three patients. All three had strictures requiring weekly dilations. One of these patients died. The two surviving patients underwent fundoplication. CONCLUSION We describe an alternative technique for esophageal anastomosis in patients for whom a standard anastomosis is not possible. EEP can lead to a functional anastomosis through fistulization and avoid the morbidity of multiple thoracotomies and lengthening procedures. Families should be educated on the potential need for dilations and antireflux procedures.
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Affiliation(s)
- Isabelle Chumfong
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, 94158-0570, USA
| | - Hanmin Lee
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, 94158-0570, USA
| | - Benjamin E Padilla
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, 94158-0570, USA
| | - Tippi C MacKenzie
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, 94158-0570, USA
| | - Lan T Vu
- Division of Pediatric Surgery, University of California San Francisco, 550 16th Street, 5th Floor, San Francisco, CA, 94158-0570, USA.
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Wanaguru D, Langusch C, Krishnan U, Varjavandi V, Jiwane A, Adams S, Henry G. Is fundoplication required after the Foker procedure for long gap esophageal atresia? J Pediatr Surg 2017; 52:1117-1120. [PMID: 28063681 DOI: 10.1016/j.jpedsurg.2016.12.014] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Revised: 10/17/2016] [Accepted: 12/21/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND Fundoplication has been performed almost universally in children treated with the Foker procedure (FP) for long gap esophageal atresia (LGEA). We report our experience with pharmacological management and endoscopic surveillance rather than early routine fundoplication in infants treated with the FP. METHODS A retrospective chart review was performed of all children treated with the Foker procedure at our institution. RESULTS Nine children have undergone the FP since 2007. Median time between FP and definitive anastomoses was 22days. All nine children kept their native esophagus. There were three minor anastomotic leaks, all treated nonoperatively. All children required dilatation of anastomotic strictures (range 2-15). All have been treated with proton pump inhibitors. Three children had eosinophilic esophagitis and one had Barrett's esophagus. Only two children in this series have undergone fundoplication, which was performed for symptomatic and persistent erosive esophagitis. CONCLUSION The question of early versus delayed fundoplication in LGEA patients managed with the FP remains unanswered. Our series demonstrates that it is possible to achieve good long-term outcomes when the operation is reserved for children with gastroesophageal reflux disease resistant to maximal medical therapy. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Dylan Wanaguru
- The Toby Bowring Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, Australia.
| | - Catherine Langusch
- The Toby Bowring Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, Australia
| | - Usha Krishnan
- Department of Paediatric Gastroenterology, Sydney Children's Hospital, Sydney, Australia
| | - Vincent Varjavandi
- The Toby Bowring Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, Australia
| | - Ashish Jiwane
- The Toby Bowring Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, Australia
| | - Susan Adams
- The Toby Bowring Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, Australia
| | - Guy Henry
- The Toby Bowring Department of Paediatric Surgery, Sydney Children's Hospital, Sydney, Australia
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Mochizuki K, Shinkai M, Take H, Kitagawa N, Usui H, Miyagi H, Nakamura K, Obatake M. Impact of an external lengthening procedure on the outcome of long-gap esophageal atresia at our hospitals. Pediatr Surg Int 2015; 31:937-42. [PMID: 26276428 DOI: 10.1007/s00383-015-3772-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/06/2015] [Indexed: 01/03/2023]
Abstract
PURPOSE To demonstrate the outcome of external lengthening for long-gap esophageal atresia (LGEA) at our hospitals. METHODS Five patients with LGEA underwent external lengthening between 2010 and 2014 (group A), and 11 patients with LGEA underwent other lengthening techniques between 1990 and 2011 (group B). We compared the procedure and outcome between these two groups. RESULTS The mean birth weight was 2001 g in group A and 2485 g in group B (p = 0.06). The mean age at esophageal reconstruction was 28 days in group A and 227 days in group B (p = 0.03). Although primary esophageal anastomosis without myotomy was feasible in all patients in group A, a myotomy was needed for primary esophageal anastomosis in half of the patients in group B. Anastomotic leakage occurred in none in group A and in six patients in group B (p = 0.03). The mean age at the establishment of full oral feeding was 76 days in group A and 686 days in group B (p = 0.009). CONCLUSION External traction for LGEA can effectively lengthen the esophagus to enable primary anastomosis at an earlier age. This may facilitate oral intake.
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Affiliation(s)
- Kyoko Mochizuki
- Department of Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-0066, Japan.
| | - Masato Shinkai
- Department of Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-0066, Japan
| | - Hiroshi Take
- Department of Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-0066, Japan
| | - Norihiko Kitagawa
- Department of Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-0066, Japan
| | - Hidehito Usui
- Department of Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-0066, Japan
| | - Hisayuki Miyagi
- Department of Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-0066, Japan
| | - Kaori Nakamura
- Department of Surgery, Kanagawa Children's Medical Center, 2-138-4 Mutsukawa, Minami-ku, Yokohama, 232-0066, Japan
| | - Masayuki Obatake
- Division of Pediatric Surgery, Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
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Uygun I, Zeytun H, Otcu S. Immediate primary anastomosis for isolated oesophageal atresia: A single-centre experience. Afr J Paediatr Surg 2015; 12:273-9. [PMID: 26712295 PMCID: PMC4955473 DOI: 10.4103/0189-6725.172572] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022] Open
Abstract
BACKGROUND Isolated oesophageal atresia without tracheo-oesophageal fistula represents a major challenge for most paediatric surgeons. Here, we present our experience with six neonates with isolated oesophageal atresia who successfully underwent immediate primary anastomosis using multiple Livaditis circular myotomy. MATERIALS AND METHODS All six neonates were gross type A isolated oesophageal atresia (6%), from among 102 neonates with oesophageal atresia, treated between January 2009 and December 2013. Five neonates were female; one was male. The mean birth weight was 2300 (range 1700-3100) g. RESULTS All six neonates successfully underwent immediate primary anastomosis using multiple myotomies (mean 3; range 2-4) within 10 (median 3) days after birth. The gap under traction ranged from 6 to 7 cm. One neonate died of a major cardiac anomaly. Another neonate was lost to follow-up after being well for 3 months. Three anastomotic strictures were treated with balloon dilatation, and four anastomotic leaks were treated conservatively. The mean duration of follow-up was 33 months. CONCLUSIONS To treat isolated oesophageal atresia, an immediate primary anastomosis can be achieved using multiple myotomies. Although, this approach is associated with high complication rates, as are other similar approaches, these complications can be overcome.
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Affiliation(s)
- Ibrahim Uygun
- Department of Paediatric Surgery, Medical Faculty, Dicle University, 21280 Diyarbakir, Turkey
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Inoue S, Kosaka T, Takatsuki M, Kuroki T, Eguchi S. Histological study of the elongated esophagus in a rat model. J Surg Res 2015; 195:495-501. [PMID: 25791827 DOI: 10.1016/j.jss.2015.02.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2014] [Revised: 01/16/2015] [Accepted: 02/06/2015] [Indexed: 10/24/2022]
Abstract
BACKGROUND Esophageal elongation by traction suture is used in pediatric patients to manage long-gap esophageal atresia (EA). There was no histological evidence of the esophageal elongation. Here, we sought to clarify the histologic effects of traction on the esophagus by using a rat EA model simulating Foker's method. MATERIALS AND METHODS Rats were randomly assigned into three groups (n = 5 each). The traction group underwent daily stretching of the distal segment of the esophagus. The nontraction group underwent a sham operation, and the normal group served as controls. Seven days after the operation, the distal segments of the esophagus were removed. The length and thickness were measured, and samples were stained with Ki-67, nNOS, and S-100. RESULTS The whole length of the esophagus in the traction group was significantly longer than that in the nontraction group (P < 0.01). The thickness of esophageal mucosa and muscle tended to become thin by traction, but not significantly. The Ki-67-positive ratio of mucosa and muscle was significantly higher in the traction group (P < 0.05). There were no significant differences in Ki-67 between two segments (cardia-middle and middle-stump) in any group. Auerbach's plexus was identified at all sites of elongated esophagus by nNOS and S-100 staining. CONCLUSIONS By traction, the esophagus was elongated uniformly and cell proliferation activity was promoted in all parts of the elongated esophagus in the rat EA model.
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Affiliation(s)
- Satoshi Inoue
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Taiichiro Kosaka
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Mitsuhisa Takatsuki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Tamotsu Kuroki
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan
| | - Susumu Eguchi
- Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.
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