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ORIGINAL ARTICLE
Year : 2020  |  Volume : 25  |  Issue : 1  |  Page : 34-37
 

A novel technique for prevention of gastroesophageal reflux in staged repair of long gap esophageal atresia with tracheoesophageal fistula


1 Department of Paediatric Surgery, King George's Medical University, Lucknow, Uttar Pradesh, India
2 Department of Anaesthesiology, King George's Medical University, Lucknow, Uttar Pradesh, India

Date of Submission06-Dec-2018
Date of Decision26-Jan-2019
Date of Acceptance12-Mar-2019
Date of Web Publication27-Nov-2019

Correspondence Address:
Dr. Vipul Prakash Bothara
Department of Paediatric Surgery, King George's Medical University, Lucknow - 226 003, Uttar Pradesh
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_239_18

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   Abstract 


Aim: The objective of the study is to report a novel technique of preventing gastroesophageal reflux and air leak from fistula to stomach in patients of tracheoesophageal fistula with long gap atresia, to buy time for the staged procedure.
Methods: Seven patients of tracheoesophageal fistula with upper pouch of esophagus at 2nd thoracic vertebra were selected for the staged procedure. Weight ranged from 1.7 to 1.8 kg. During the 1st stage surgery for gastrostomy, midline strip of linea alba attached to xiphoid process was harvested and slinged around the gastroesophageal junction, along with right cervical esophagostomy. After radio-nuclear scan, the demonstration of abolition of gastroesophageal reflux, gastrostomy feed was started. The 2nd stage surgery performed after 6 weeks, included mobilization of esophagostomy, release of sling, thoracotomy, and tension-free esophageal anastomosis. Outcome measurement includes (1) prevention of air leak from esophagus into the stomach, (2) abolition of gastroesophageal reflux, (3) ability to start gastrostomy feeds, and (4) reversal of occlusion after release of the sling.
Results: The placement of linea alba sling and elevation of gastroesophageal junction, abolished air leak from fistula to stomach in all. Radio nuclear scan demonstrated abolition of gastroesophageal reflux in 6 with weight gain after gastrostomy feeding. One patient expired due to sepsis. One patient underwent final repair with reversal of occlusion with release of the sling.
Conclusion: Using a sling of the linea alba around the cardioesophageal junction, prevents gastroesophageal reflux and escape of air from esophagus into the stomach, gives time to improve the respiratory and nutritional status of the patient, for a subsequent safer delayed primary anastomosis.


Keywords: Long gap esophageal atresia, staged repair of high-risk atresia, tracheoesophageal fistula


How to cite this article:
Bothara VP, Singh GP, Kureel SN. A novel technique for prevention of gastroesophageal reflux in staged repair of long gap esophageal atresia with tracheoesophageal fistula. J Indian Assoc Pediatr Surg 2020;25:34-7

How to cite this URL:
Bothara VP, Singh GP, Kureel SN. A novel technique for prevention of gastroesophageal reflux in staged repair of long gap esophageal atresia with tracheoesophageal fistula. J Indian Assoc Pediatr Surg [serial online] 2020 [cited 2019 Dec 14];25:34-7. Available from: http://www.jiaps.com/text.asp?2020/25/1/34/271792





   Introduction Top


Esophageal atresia with tracheoesophageal fistula is incompatible with life because the proximal blind pouch leads to collection and regurgitation of saliva into trachea through the larynx, which in turn causes pneumonitis. Reflux of acidic gastric content through the tracheoesophageal fistula into the bronchus further complicates the lung damage.

In the most common type, i.e., esophageal atresia with distal tracheoesophageal fistula; thoracotomy, disconnection of fistulous tract and primary tension-free anastomosis between proximal and distal esophagus, after optimizing the patient, is currently the procedure of choice.[1] Currently, as per Okamoto modification of the Spitz classification, Class 1 category is associated with nearly 100% survival.[2] However, there are patients who are not suitable for ideal repair. These patients present with proximal esophageal pouch as high as up to second thoracic vertebra with distal esophagus opening in trachea as tracheoesophageal fistula. Due to long gap between proximal and distal esophageal segment, tension-free anastomosis is not possible. Therefore, delayed primary repair becomes the compulsion.[3]

During the wait for delayed procedure or staged repair, the lung condition may further worsen, first - due to reflux of acidic gastric contents through the tracheoesophageal fistula,[4] second - due to regurgitation of saliva from blind pouch into the trachea,[4] and third - being the inspired air escaping through the fistula which contributes to abdominal distention and this, further complicates the respiratory distress.[5]

The purpose of this communication is to report a novel technique of staged repair, where during the time spent waiting for staged repair, the gastroesophageal reflux is abolished by elevating the gastroesophageal junction and temporarily obliterating the esophageal lumen by placing a sling around the cardioesophageal junction during the surgery for gastrostomy and right cervical esophagostomy.


   Methods Top


In the past 1 year, 64 patients of esophageal atresia with or without tracheoesophageal fistula were admitted at our center, out of which 13 patients had pure esophageal atresia.

The upper esophageal pouch was higher than the 3rd thoracic vertebral level in seven patients [Figure 1]. Two of these seven patients had progressive abdominal distention which led to worsening respiratory distress. Their weight ranged from 1.7 to 1.8 kg. These patients were selected for staged repair, i.e., right cervical esophagostomy and the gastrostomy through an upper abdominal midline incision with the placement of sling.
Figure 1: X-ray showing red rubber catheter in stretched upper esophageal pouch reaching between 2nd and 3rd thoracic vertebra

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After a midline skin incision from Xiphoid process to umbilicus [Figure 2]a, the linea alba was exposed up to the medial edge of the rectus muscle on both sides. A midline 6–7 mm wide strip of the linea alba was harvested between parallel incisions along the medial edge of the rectus muscle. The strip of linea alba was detached from the umbilical end but left attached to the xiphoid process [Figure 2]b. The peritoneum was incised, and the umbilical vein was ligated and divided. The small intestine was packed off with a moist sponge away from the operative field. Downward traction on anterior wall of the stomach with hand over a sponge placed on the anterior wall of the body and fundus of the stomach and upward retraction of the left lobe of the liver brought the cardioesophageal junction clearly into view. Peritoneum was disrupted along the right and left margin of abdominal esophagus. Without damaging the adjacent vasculature, through the disrupted peritoneum on each side, a paraesophageal space was developed with mounted peanut sponges by blunt dissection. Through the space thus created, a right-angled forceps was passed across the posterior wall of the abdominal esophagus exiting on the other side [Figure 2]c. Umbilical end of the linea alba strip was grasped and pulled across the gastroesophageal junction taking U-turn for sling effect. Gentle traction on the sling led to the elevation of the cardioesophageal junction, obliterating the lumen and abolishing the escape of air [Figure 2]d. A gastrostomy tube was placed through the anterior wall of the stomach. The sling was anchored to edge of rectus sheath at upper end of incision. At this point, the anesthetist was requested to hyperventilate the patient to check for gastric distention or escape of air through the gastrostomy tube. If necessary, tension on the sling was readjusted to stop the escape of air. Anterior and posterior edges of the rectus sheath and peritoneum were approximated using 2-0 polyglactin-910 sutures. Cervical esophagostomy was performed on the right side taking utmost care to spare the recurrent laryngeal nerve and the esophageal branch of the inferior thyroid artery.
Figure 2: Operative steps for creation of linea alba sling. (a) Incision line from Xiphoid process up to umbilicus. Operative steps for creation of linea alba sling. (b) Elevated strip of linea alba attached to xiphoid process. Operative steps for creation of linea alba sling. (c) Passage of right-angled forceps across the posterior aspect of abdominal esophagus. Operative steps for creation of linea alba sling. (d) Creation of sling by passing the linea alba across the posterior aspect of abdominal esophagus, attaching it to rectus sheath has elevated the gastroesophageal junction with reversible occlusion of esophageal lumen

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After the return of peristalsis and passage of stools, a radio-nuclear scan was done by instilling Tc99 through the gastrostomy tube. After the demonstration of absence of reflux and absence of radionuclear activity in the lung field [Figure 3]a and [Figure 3]b, gastrostomy feeding was commenced.
Figure 3: Radionuclear scan. (a) Radio nuclear scan showing radioactivity in stomach and no reflux in esophagus or radioactivity in lung fields. Radionuclear scan. (b) Radionuclear scan showing reflux has stopped at the level of sling

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Outcome measurement includes: (1) prevention of air leak from lower esophagus into stomach, (2) abolition of gastroesophageal reflux, (3) ability to start full gastrostomy feeds and weight gain, and (4) at final stage procedure reversal of occlusion after release of sling.

Final stage repair was done after 6 weeks in one patient by mobilization of right cervical esophagostomy, reversal of occlusion by release of sling in subcutaneous plane, thoracotomy, ligation, and division of tracheoesophageal fistula, and primary tension-free esophageal anastomosis.


   Results Top


After the placement of linea alba sling and elevation of gastroesophageal junction, air leak from fistula stopped in all patients. Radionuclear scan demonstrated abolition of gastro-esophageal reflux in six patients. Weight gain occurred in all patients. One patient expired due to sepsis after burst abdomen. One patient underwent staged repair with reversal of occlusion with release of sling.


   Discussion Top


Thoracotomy, dissection of distal fistula, mobilization of proximal esophagus, and tension-free primary anastomosis to establish esophageal continuity is ideal. Such 1st successful repair was reported by Haight and Towsley in 1941.[6] Unfortunately, tension-free primary anastomosis is not possible in all patients, especially with long gap atresia. The procedure for lengthening the upper pouch by esophagomyotomy described by Livaditis et al.'[7],[8] is associated with its own complications.[9],[10],[11],[12] Excessive mobilization of lower pouch carries the risk of devascularization,[13] which jeopardizes the success of the primary anastomosis.

Other techniques for long gap atresia like the Kimura technique of extra thoracic lengthening of the esophagus,[14],[15],[16] the Foker technique of using traction sutures through the chest wall,[17],[18] the creation of full thickness anterior flap of upper pouch by Gough and its different variations and modifications[19],[20],[21],[22],[23] are described. These techniques are associated with their own set of problems.[24],[25],[26],[27]

There is no report in literature of placing a sling around the cardioesophageal junction to temporarily occlude the lumen of the esophagus to buy time for staged procedure.

Advantages of placing the sling are as follows: (1) It is possible to perform the procedure through the same incision used for gastrostomy. (2) The occlusion of cardioesophageal junction is temporary, because upward traction of sling creates angulation of cardioesophageal junction resulting in reversible occlusion of esophageal lumen but the vascularity of lower esophagus is maintained through the esophageal branches of left gastric artery and aortic branches to the esophagus, which are not obliterated. Since the vascularity is maintained, there will be no ischemia and fibrosis and hence on release of sling, patency of the cardioesophageal junction is restored. (3) The lower end of the esophagus remains stretched due to the sling and it may help in gaining some length of lower esophagus. (4) While we are doing cervical mobilization a circular myotomy can be performed under vision without accident/perforation, enabling tension-free anastomosis yet preserving the natural continuity of the esophagus.

Thus, we have the advantage of buying time to build up the weight, nutritional status, and general condition of the patient by gastrostomy feeding. Since reflux is resolved temporarily, we also get time for pneumonitis to resolve.

Limitations of the procedure are that the problems of esophageal motility, gastroesophageal reflux after esophageal anastomosis, and tracheomalacia may persist even after successful completion of all stages of repair.


   Conclusion Top


The technique of using a sling of the linea alba around the cardioesophageal junction is feasible, through the same access as for gastrostomy. By temporarily abolishing the gastroesophageal reflux and prevention of escape of air from the lower segment of esophagus into stomach, gives time to improve the respiratory and nutritional status of the patient, for a subsequent safer delayed primary anastomosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Randolph JG, Newman KD, Anderson KD. Current results in repair of esophageal atresia with tracheoesophageal fistula using physiologic status as a guide to therapy. Ann Surg 1989;209:526-30.  Back to cited text no. 1
    
2.
Okamoto T, Takamizawa S, Arai H, Bitoh Y, Nakao M, Yokoi A, et al. Esophageal atresia: Prognostic classification revisited. Surgery 2009;145:675-81.  Back to cited text no. 2
    
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6.
Haight C, Towsley H. Congenital atresia of the esophagus with tracheoesophageal fistula: Extrapleural ligation of fistula and end-to-end anastomosis of esophageal segments. Surg Gynecol Obstet 1943;76:672.  Back to cited text no. 6
    
7.
Livaditis A, Okmian L, Eklöf O. Esophageal atresia. II. Anastomotic disruption following primary surgical management. Scand J Thorac Cardiovasc Surg 1969;3:39-43.  Back to cited text no. 7
    
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Livaditis A, Rådberg L, Odensjö G. Esophageal end-to-end anastomosis. Reduction of anastomotic tension by circular myotomy. Scand J Thorac Cardiovasc Surg 1972;6:206-14.  Back to cited text no. 8
    
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11.
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Lessin MS, Wesselhoeft CW, Luks FI, DeLuca FG. Primary repair of long-gap esophageal atresia by mobilization of the distal esophagus. Eur J Pediatr Surg 1999;9:369-72.  Back to cited text no. 13
    
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Kimura K, Soper RT. Multistaged extrathoracic esophageal elongation for long gap esophageal atresia. J Pediatr Surg 1994;29:566-8.  Back to cited text no. 14
    
15.
Takamizawa S, Nishijima E, Tsugawa C, Muraji T, Satoh S, Tatekawa Y, et al. Multistaged esophageal elongation technique for long gap esophageal atresia: Experience with 7 cases at a single institution. J Pediatr Surg 2005;40:781-4.  Back to cited text no. 15
    
16.
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Al-Qahtani AR, Yazbeck S, Rosen NG, Youssef S, Mayer SK. Lengthening technique for long gap esophageal atresia and early anastomosis. J Pediatr Surg 2003;38:737-9.  Back to cited text no. 17
    
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Foker JE, Linden BC, Boyle EM Jr., Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg 1997;226:533-41.  Back to cited text no. 18
    
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20.
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22.
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