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EDITORIAL |
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| Year : 2016 | Volume
: 21
| Issue : 3 | Page : 96-97 |
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Surgical diseases of the esophagus in children
Subhasis Roy Choudhury
Director, Professor and Head, Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi - 110 001, India
| Date of Web Publication | 18-May-2016 |
Correspondence Address:
Subhasis Roy Choudhury
Director, Professor and Head, Department of Pediatric Surgery, Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi - 110 001
India
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/0971-9261.182579
How to cite this article:
Choudhury SR. Surgical diseases of the esophagus in children. J Indian Assoc Pediatr Surg 2016;21:96-7 |
The survival of patients with esophageal atresia and tracheoesophageal fistula (EA-TEF) is an epitome of the success of neonatal surgery. The first successful repair of TEF from India was reported by Professor Subir K. Chatterjee from Kolkata in 1963. In the developed countries, the current survival rate of EA-TEF is above 90%, and the major cause of mortality is associated with cardiac malformations. However, the scenario is different in the developing countries where the survival rates are far below expectation because of several factors including late diagnosis, poor transport facility, and suboptimal perinatal care. Due to high birth rate, the number of EA-TEF patients treated is large in major institutions in India caring for children (80-100 cases/year) with the survival rates varying from 60% to 85%. The general condition of the patients plays a major role in addition to the standard of newborn care provided. On the other hand, technical advancement such as thoracoscopic repair of TEF is now being reported from selective centers. Although the learning curve is stiff but the future appears to be promising. Preservation of the native esophagus by delayed repair in cases of long gap esophageal atresia is a preferred technique worldwide; however, such a management mandates prolonged hospitalization and dedicated nursing care. This is often not possible in most Indian centers, and hence diversion by esophagostomy becomes a compulsion. Innovative techniques of diversion such as the thoracic and abdominal esophagostomy have been effectively applied by some centers in the country.
Restoring the continuity of a functional food pipe in children with absent or damaged esophagus continues to pose a significant challenge to the pediatric surgeons. The two common causes requiring esophageal substitution in children are EA and stricture of the esophagus. Esophageal corrosive injuries in children could be prevented by the implementation of regulatory instructions and public awareness as adopted by the developed countries. Because of the large number of cases in India, every pediatric surgery center faces the challenge to handle those unfortunate children requiring esophageal substitution. Multiple operations and prolonged period of treatment often lead to significant economic loss with psychological stress to the family. The quality of life in these children is also a matter of concern.
There are several surgical procedures for esophageal substitution and pediatric surgeons trained from major pediatric surgical centers in the country are generally exposed to those techniques. When it comes to the handling of an individual patient, there is always a big dilemma regarding the choice of the procedure. Several factors come into play in the decision-making process importantly the standard of care available in a particular center, the surgeon's experience, and the patient's condition.
Colonic substitution of the esophagus in children is associated with a significant short-term (graft necrosis) and long-term (stricture and redundancy) complications hence going out of favor in most of the centers. Currently, gastric pull-up operation is the preferred procedure as practiced in most of the centers in the Unites States and Europe. This is a relatively simple operation with the advantage of a single neck anastomosis and avoiding a thoracotomy. The posterior mediastinal route is the shortest and most physiological. A few experts are now available to even perform such procedure with the minimally invasive approach. The postoperative care mandates elective ventilation and close monitoring in an intensive care unit set up. The postoperative course could be stormy with two dreaded early complications of cardiac arrhythmias and respiratory compromise which may even be life-threatening. The long-term results are satisfactory in 90% patients regarding feeding, growth, and particularly parental satisfaction. Since the anastomotic complications are few, the numbers of hospital visits are also less resulting in a less economic loss to the parents.
Gastric tubes are a suitable alternative to gastric pull-up and the route to the neck can be retrosternal or posterior mediastinal. Retrosternal gastric tubes with a staged neck anastomosis appear to be a safer procedure as arrhythmias and respiratory problems are rare and postoperative ventilation is not mandatory and often not required. However, the incidences of anastomotic strictures are high, and long-term surveillance is recommended as they may develop Barrett's changes in the proximal stump.
Serial esophageal elongation techniques (Foker, Kimura) with end-to-end esophageal anastomosis has the theoretical advantage of restoring the native esophagus and can be performed safely without the need for mandatory postoperative ventilation in the post neonatal period. However, these procedures not only require multiple operations but also has a high incidence of anastomotic stricture in the thorax and invariably results in gastroesophageal reflux requiring multiple operations and frequent hospital visits resulting in a long duration of treatment. Since these techniques are relatively new, the long-term results are currently unavailable. Bioengineered neo-esophagus as an effective replacement remains a dream for the future.
The ideal age of replacement may be between 6 months and 1 year, except the elongation procedure which can be done at an early age. EA patients on esophagostomy should be encouraged to 'Sham feeding' as feeding difficulties are frequent after replacement due to esophageal uncoordinated peristalsis. Feeding jejunostomy plays an immense adjunct to any esophageal replacement procedures as it provides the route for enteral nutrition during the postoperative recovery period. The role of pyloromyotomy is now questionable, and many have managed without it.
Coming to the issue of choice of procedures, it appears that the gastric pull-up is currently the best functional esophageal substitution operation provided it is done in a center having proper intensive care unit set-up, with a few days of mandatory postoperative ventilation. In resource-strained centers, staged retrosternal gastric tubes, and esophageal elongation techniques appear to be safer alternative, but one should be ready for multiple interventional procedures with several hospital visits and long duration of continued care particularly with the elongation techniques. The importance of surgeons training and experience in the field need not be over emphasized, and one without adequate expertise should not hesitate to refer those patients to more experienced centers.
Advances in endoscopic procedures have made it possible to treat many intrinsic esophageal diseases such as stricture, membranous web, some achalasia, and foreign bodies.
The problems of dysphagia and nutritional issues, particularly in adulthood, in these children treated for esophageal diseases calls for long-term follow-up. It is therefore suggested that there should be a concerted effort among all pediatric surgeons in the country to maintain a joint registry of these patients to evaluate the results of different operations and the quality of life in these patients. It is also important to improve public awareness by addressing these issues through different media including web sites.
In this issue, articles pertaining to various pediatric esophageal surgical diseases form different centers and their current management including endoscopic and minimally invasive approach are presented.
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