Gastric tube-pericardial fistula: a remote complication of esophageal replacement for long gap esophageal atresia

Surgical outcomes of different approaches to esophageal replacement in long-gap esophageal atresia: A systematic review

BACKGROUND

Esophageal replacement (ER) surgery has been widely used in long-gap esophageal atresia (LGEA) over the past few decades. The most commonly used surgical approaches in many pediatric surgical centers include colon interposition (CI), gastric pull-up (GPU), jejunal interposition (JI), and gastric tube reconstruction (GTR). However, there is no systematic evidence on which is the optimal conduit for the native esophagus. The aim of this systematic review was to evaluate the short- and long-term outcomes among these 4 replacement approaches in LGEA cases based on current evidence.

METHODS

PubMed, Web of Science, Cochrane Library, and EMBASE were searched for relevant literature on November 18 2016. Studies on ER in LGEA were reviewed and selected according to eligibility criteria. We focused on surgical outcomes regarding to different replacement approaches, including postoperative complications and long-term follow-up. Both detailed descriptions of single studies and pooled data analysis were conducted. Data were computed by Reviewer Manager 5.3.

RESULTS

Twenty-three studies were included (4 comparative retrospective, 3 prospective, and 16 retrospective) with a total of 593 patients (393 LGEA, 66.3%). The number of patients with available data for analysis was 534 (90.1%), including 127 patients (98 LGEA) of GPU, 335 (223 LGEA) of CI, 45 (all LGEA) of JI, and 27 (all LGEA) of GTR. Follow-up information was provided in 15 studies. Anastomotic leak and stricture, respiratory problems, and gastroesophageal reflux were analyzed as major postoperative complications. Long-term follow-ups were concentrated on growth and feeding conditions.

CONCLUSION

Current evidence on short- and long-term outcomes of ER in LGEA patients was limited, and proper prospective comparative studies were lacking. This present systematic review indicates CI and GPU as comparable and favorable approaches, especially CI in the long-term outcomes. Studies on JI and GTR were limited, which need larger sample size to assess their validity and outcomes.

Ultrastructural study of cell populations in the gastric transplant after esophagoplasty

Ultrastructural characteristics of cell populations in the gastric tube mucosa were studied after plastic surgery for benign esophageal disease. The foveolar epithelium mainly consisted of secretory active mucocytes with small changes in cytoplasmic organelles. Functionally immature parietal cells and gland cells in the epithelium of fundal glands were characterized by atrophy and degeneration. Ultrastructural features of the epithelial compartment attest to adaptive cellular hypersecretion of the mucoid against the background of impaired acid production and enzyme secretion. The stromal compartment was characterized by low pinocytotic activity of endothelial cells in blood vessels and polymorphism of smooth muscle cells. Hypertrophic leiomyocytes were shown to dominate in the population of these cells. Some cells had signs of biosynthesis and reduction of filaments. Single leiomyocytes were degenerated. The observed ultrastructural modification of epithelial and connective cells can be interpreted as structural adaptation of the gastric transplant.