Long-term follow-up after esophageal replacement in children: 45-Year single-center experience

Functional, nutritional, and developmental assessment of gastric transposition and colonic interposition: Long-term follow-up outcome analysis

PURPOSE

The choice of Esophageal replacement (ER) depends on surgeons' preference and patients' anatomical condition. A cross-sectional study was done to compare the long-term outcomes of two methods of ER, Gastric transposition (GT) and Colonic interposition (CI).

METHODS

Children who had undergone ER from January 1997 to December 2017 with a minimum of two-year post-ER follow-up were evaluated by anthropometry, hepatobiliary scintigraphy, gastroesophageal reflux study, gastric emptying test, pulmonary function test and blood tests.

RESULTS

Twenty-six (Male:female=17:9) children were recruited. The median age at ER was 13 months (interquartile range 9-40 months) and mean follow-up post-ER was 116.7 ± 76.4 months (range 24-247 months). GT:CI was done in 15(57.7%):11(42.3%) cases. A greater number of abnormal oral contrast studies (p = 0.02) and re-operations (p = 0.05) were documented as baseline characteristics with CI group. The presence of gastroesophageal reflux 9/23(39.1%), duodenogastric reflux 6/24(25%), delayed gastric emptying 6/25(24%), abnormal pulmonary function test 14/22(63.6%) were documented during the study period. However, there was no significant(p>0.05) difference in nutritional, developmental and functional outcomes of both operative methods of ER in the study.

CONCLUSION

Assessment of nutritional, developmental and functional parameters in children after ER reveals good long-term results. There was no significant difference in CI and GT.

LEVEL OF EVIDENCE

Comparative study; II.

14 Years’ experience of esophageal replacement surgeries

BACKGROUND

Esophageal replacement is a challenge to the therapeutic skills of surgeons and a technically demanding operation in the pediatric age group. Various conduits and routes have been described in the literature, each with their specific advantages and disadvantages. We carried out this retrospective study to share our experience of esophageal replacement.

METHODOLOGY

This study was conducted at the department of pediatric surgery The Children's Hospital and The Institute of Child Health, Lahore. The records of patients treated for esophageal replacement were reviewed. The patients under follow-up were called for clinical evaluation and assessed of long terms complications if any.

RESULTS

A total of 93 patients with esophageal replacement were included in the study. Esophageal replacement was done with gastric transposition in 84 cases (90%), colon interposition in 7 cases (7.5%) including one case of redo colonic interposition, and jejunal interposition in 2 cases (2%). Routes of esophageal replacement were trans-hiatal in 71 (76%), retrosternal in 13 (14%), and trans-hiatal with thoracotomy in 9 (10%) patients. Postoperatively, all of the conduits maintained viability. Wound infection was seen in 10 (11%), wound dehiscence in 5 (5%), anastomotic leak in 9 (10%), anastomotic stenosis in 12 (13%), fistula formation in 4 (4%), aortic injury 1 (1%), dumping syndrome 8 (9%), reflux 18 (19%), dysphagia 15 (16%) and death occurred in 12 patients (13%).

CONCLUSION

There are problems with esophageal replacement in developing countries. In this context, gastric conduit appeared as the best conduit for esophageal replacement, using the trans-hiatal route for replacement, in the authors' experience.

Health-related quality of life experiences in children and adolescents born with esophageal atresia: A Swedish-German focus group study

BACKGROUND

Esophageal atresia (EA) is a rare malformation of the esophagus, which needs surgical treatment. Survival rates have reached 95%, but esophageal and respiratory morbidity during childhood is frequent. Child and parent perspectives and cultural and age-specific approaches are fundamental in understanding children's health-related quality of life (HRQoL) and when developing a pediatric HRQoL questionnaire. We aimed to increase the conceptual and cross-cultural understanding of condition-specific HRQoL experiences among EA children from Sweden and Germany and investigate content validity for an EA-specific HRQoL questionnaire.

METHODS

Eighteen standardized focus groups (FGs) with 51 families of EA children aged 2-17 years in Sweden (n = 30 families) and Germany (n = 21 families) were used to explore HRQoL experiences, which were content analyzed into HRQoL domains. The Swedish HRQoL domains were analyzed first and used as framework to evaluate HRQoL content reported in the German FGs. HRQoL experiences were then categorized as physical, social, and emotional HRQoL burden or resource.

RESULTS

One thousand nine hundred eight HRQoL statements were recorded. All nine EA-specific HRQoL domains identified in the Swedish FGs (eating, social relationships, general life issues, communication, body issues, bothersome symptoms, confidence, impact of medical treatment, and additional difficulties due to concomitant anomalies) were recognized in the FGs held in Germany, and no additional EA-specific HRQoL domain was found. The HRQoL dimensions referenced physical burden (n = 655, 34.5%), social burden (n = 497, 26.0%), social resources (n = 303, 15.9%), emotional burden (n = 210, 11.0%), physical resources (n = 158, 8.3%), and emotional resources (n = 85, 4.5%).

CONCLUSION

This first international FG study to obtain the EA child and his or her parents' perspective on HRQoL suggests Swedish-German qualitative comparability of the HRQoL domains and content validity for a cross-cultural EA-specific HRQoL questionnaire. EA children make positive and negative HRQoL experiences, but prominently related to physical and social burden, which underlines appropriate follow-up care and future research.

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

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.

Topical Mitomycin C Application Is Effective Even in Esophageal Strictures Resistant to Dilatation Therapy in Children

PURPOSE

Several treatment techniques may be used in the treatment of esophageal strictures. The purpose of this study was to present the effects of topical mitomycin C (TMC) as an useful adjunct to dilatation therapy in esophageal strictures.

MATERIALS AND METHODS

A retrospective analysis of patients who underwent TMC between February 2015 and July 2016 was performed. Dysphagia score, periodic dilatation index, and number of dilatations were compared before and after intervention to investigate the efficacy of TMC.

RESULTS

TMC was performed on 20 patients with a median age of 3.5 years (2 to 17 y). The diagnosis was corrosive esophageal strictures in 14 patients, anastomotic strictures in 5 patients, and congenital esophageal stricture in 1 patient. The length of the stricture was long in 10 patients (50%). The median dysphagia score decreased from 2 (1 to 3) to 0 (0 to 2) after application (P<0.001). The median number of dilatation sessions decreased from 5 (1 to 41) to 1 (0 to 11) after intervention (P<0.001). The median periodic dilatation index decreased from 1 (0.66 to 1.34) to 0 (0 to 1.33) after TMC (P<0.001). Regular esophageal dilatation was not necessary in 16 patients after application (80%). The length of the stricture did not affect the efficacy of TMC. The success of treatment was lower in patients with a long treatment period before TMC (>3 y) (50%). No complications were seen in a median follow-up period of 16 months (7 to 22 mo).

CONCLUSIONS

TMC application has a significant positive effect as an adjunct to dilatation therapy in most of the patients with different types of esophageal strictures. It should be performed as a safe and efficient treatment option even in patients who were resistant to dilatation therapy.

Ileocolonic Transposition Esophagogastric Bypass as an Antireflux Treatment for Corrosive Esophageal Injury

Because most surgeons perform an esophagectomy and colonic transposition as the main reconstruction method for patients with esophageal stenosis caused by swallowing corrosive materials, we report 2 cases in which ileocolonic transposition was used to treat such patients. Both patients displayed stenosis in the middle third of the esophagus. Their chief complaint was dysphagia. Ileocolonic transposition using vascularization of the Drummond and ileal arteries was followed by a prepared ileocolic graft by ligating ileocolic vessels. We performed an ileocolonic transposition esophagogastric bypass without an esophagectomy. All surgeries resulted in minimal intraoperative bleeding. Patients experienced no leakage, postoperative fistulas, dysphagia, or postoperative reflux. Three weeks after surgery, 1 patient experienced reversible hoarseness caused by extensive laryngeal-nerve manipulation. Cumulatively, ileocolonic transposition with cervical anastomosis for the treatment of patients with esophageal stenosis caused by corrosive esophageal injury can be considered to be an antireflux treatment because the ileocaecal sphincter is maintained.

Long-term functional outcomes after replacement of the esophagus in pediatric patients: A systematic literature review

BACKGROUND

The indications of esophageal replacement (ER) in pediatric patients include long gap esophageal atresia (LGEA), intractable post-corrosive esophageal strictures (PCES), and some rare esophageal diseases. Various conduits and procedures are currently used worldwide with a lack of consensus regarding the ideal substitute to replace the esophagus replacement. The short-term outcomes of these advanced procedures are well known; there are few data available describing long-term functional outcomes of these patients with long life expectancy.

OBJECTIVES

The objective of this study is to investigate the long-term functional outcomes of the most widely used techniques for ER in pediatric patients based on a comprehensive literature search covering the last 10years.

METHODS

Eligible were all clinical studies reporting outcomes after esophagectomy in pediatric patients, which contained information on at least 3years of follow-up after the operation. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. A systematic web-based search using MEDLINE, the Cochrane Library and EMBASE databases was performed, reviewing all medical literature published between January 2006 and December 2015.

RESULTS

The scientific quality of the data was generally poor, converging toward only 14 full-text articles for the final analysis. The stomach was the preferred organ for esophageal replacement, where the tubulization of the stomach resulted in significant gastroesophageal reflux. Dysphagia symptoms were more seldom reported, but several authors presented growing figures with the length of follow-up. Dumping syndrome and delayed gastric emptying were only scarcely reported upon. Following colonic graft, chronic gastrocolic reflux affects these patients, in the range of 35-70.8%, while 4 studies reported any dysphagia from 2.7% to 50% of the children. Only one study reported the outcome of the use of a long jejunal segment, where presence of symptoms of functional obstruction was mentioned in 46% of cases. Very few if any data were available on a structured assessment of postprandial dumping and disturbed bowel functions.

CONCLUSIONS

Available data in pediatric patients, on the long-term functional outcomes after esophageal replacement with a gastric tube, colonic graft or a long jejunal segment, are of poor scientific quality. Although symptoms are frequently reported currently no conclusions can be drawn regarding potential advantages of one graft over another.

TYPE OF STUDY

Treatment study, systematic review.

LEVEL OF EVIDENCE

IV.

Surgical techniques for esophageal replacement in children

PURPOSE

Surgical techniques for esophageal replacement (ER) in children include colon interposition, gastric tube, gastric transposition, and jejunal interposition. This review evaluates the merits and demerits of each.

METHOD

Surgical techniques, complications, and outcome of ER are reviewed over last seven decades.

RESULTS

Colon interposition is the time-tested procedure with minimal and less serious complications. Long-term complications include reflux, halitosis, colonic segment dilatation, and anastomotic stricture, sometimes requiring surgical interventions especially for dilatation and reflux. Gastric tube is technically more risky, and associated with early serious complications like prolonged leak in neck or mediastinum, graft necrosis, and ischemia leading to stricture of the tube. Long-term results are good. Gastric transposition is much simpler, can be performed in emergency and in newborns. It involves a single anastomosis in the neck. Post-operative complications include gastric stasis, bile reflux, restricted growth, and decreased pulmonary functional capacity. Jejunal interposition has not been used extensively due to short mesentery but long-term results are good in expert hands.

CONCLUSION

Colon is the most preferred and safest organ for ER. Stomach is a vascular and muscular organ with lower risk of ischemia. Gastric tube is a demanding technique. Jejunum or ileum is alternative for redo cases.

Coping strategies used by children and adolescents born with esophageal atresia - a focus group study obtaining the child and parent perspective

BACKGROUND

Esophageal atresia (EA) is a rare malformation, which requires surgical treatment. Survival rates today reach 95%, but EA remains a significant cause of chronic morbidity with increased risk of psychosocial problems and impaired health-related quality of life (HRQOL). No study of coping strategies of children with EA has been reported in the literature to date, but increased knowledge could lead to improved outcomes and better HRQOL.

METHODS

Standardized focus groups with children with EA and their parents were conducted to identify issues related to health care needs and HRQOL, with group members relating their coping experiences. Identified coping statements were content analysed using a card sorting procedure and descriptive statistics.

RESULTS

Thirty families (18 children 8-17 years; 32 parents of children with EA 2-17 years) participated in 10 focus groups. A total of 590 coping statements were recorded. Nine coping strategies were identified: problem solving (n = 116), avoidance (n = 95), recognizing responsibility (n = 71), confronting (n = 70), seeking social support (n = 63), positive reappraisal (n = 58), emotional expression (n = 46), acceptance (n = 40) and distancing (n = 31). Nine situational contexts were identified: nutritional intake (n = 227), communication of one's health condition (n = 78), self-perception when experiencing troublesome symptoms (n = 59), appearance of body or scar(s) (n = 57), physical activities like sport and play (n = 43), sleep (n = 34), hospital care (n = 33), stigmatization and social exclusion (n = 30) and medication intake (n = 29).

CONCLUSIONS

Focus group methodology contributed to an increased understanding of disease-specific coping processes among children and adolescence with EA. Findings illustrate that they use several coping strategies, some of which they seem to adopt at early age and use in disease-related contexts of physical, social and emotional character. Such coping may influence health and HRQOL in children with EA. In view of the importance of establishing good coping strategies early in life, health care professionals should integrate coping aspects into care management. Future studies are warranted.

The use of ileocolic segment for esophageal replacement in children

AIMS

To evaluate and describe the procedure and outcome of ileocolic replacement of esophagus.

MATERIALS AND METHODS

We review 7 children with esophageal injuries, who underwent esophageal replacement using ileocolic segment in Christian Medical College, Vellore, India between 2006 and 2014.

RESULTS

The ileocolic segment was used in 7 children with scarred or inadequate esophagus. There were 4 girls and 3 boys, who underwent esophageal replacement using isoperistaltic ileocolic segment in this period. Age at presentation varied from 1 month to 14 years with an average of 4.6 years. The indications for ileocolic replacements were corrosive strictures in 5, failed esophageal atresia repair in one and gastric volvulus related esophageal stricture in another. The average follow-up duration was 37 months. One child with corrosive stricture lost to follow-up and died 2 years later in another center. Other 6 children were free of dysphagia till the last follow-up.

CONCLUSIONS

Although the ileocolic segment is not commonly used for esophageal substitution, it can be useful in special situations where the substitution needs to reach the high cervical esophagus and also where the stomach is scarred and not suitable for gastric pull-up.

Esophageal replacement in children: Challenges and long-term outcomes

Replacement of a nonexistent or damaged esophagus continues to pose a significant challenge to pediatric surgeons. Various esophageal replacement grafts and techniques have not produced consistently good outcomes to emulate normal esophagus. Therefore, many techniques are still being practiced and recommended with no clear consensus. We present a concise literature review of the currently used techniques and with discussions on the advantages and anticipated morbidity. There are no randomized controlled pediatric studies to compare different types of esophageal replacements. Management and graft choice are based on geographical and personal predilections rather than on any discernible objective data. The biggest series with long-term outcome are reported for gastric transposition and colonic replacement. Comparison of different studies shows no significant difference in early (graft necrosis and anastomotic leaks) or late complications (strictures, poor feeding, gastro-esophageal reflux, tortuosity of the graft, and Barrett's esophagus). The biggest series seem to have lower complications than small series reflecting the decennials experience in their respective centers. Long-term follow-up is recommended following esophageal replacement for the development of late strictures, excessive tortuosity, and Barrett's changes within the graft. Once child overcomes initial morbidity and establishes oral feeding, long-term consequences and complications of pediatric esophageal replacement should be monitored and managed in adult life.

Health-related quality of life experiences among children and adolescents born with esophageal atresia: Development of a condition-specific questionnaire for pediatric patients

BACKGROUND/PURPOSE

The aims were to present the framework for the development a condition-specific health-related quality-of-life (HRQOL) questionnaire for children with esophageal atresia (EA) and to describe HRQOL experiences reported by children and by their parents.

METHODS

Utilizing the well-established DISABKIDS methodology, standardized focus group discussions were held and transcribed. HRQOL experiences were identified, content analyzed and evaluated using descriptive statistics.

RESULTS

30 families (18 children 8-17years, 32 parents of children 2-17years) participated in ten focus group discussions. 1371 HRQOL experiences were identified referencing social, emotional and physical aspects of eating and drinking (n=368), relationships with other people (n=283), general life issues; physical activity, sleep and general health (n=202), communicative/interactive processes of one's health condition (n=161), body issues (n=109), bothersome symptoms (n=81), impact of health care use/medical treatment (n=78), confidence in oneself and in the future (n=65) and difficulties because of concomitant anomalies (n=24). A basis of two age-related HRQOL questionnaires for children with EA (2-7years, 8-17years) was subsequently constructed.

CONCLUSIONS

EA interacts with various aspects of the child's life. In addition to HRQOL issues of eating and drinking, social dimensions like relationships and interactions with other people seem to be prominent condition-specific HRQOL parameters. The settings for the development of the first condition-specific HRQOL questionnaires for patients with EA are established.