Abstract
This chapter describes the surgical procedure for esophageal replacement as performed by the following approach: open, including both colon interposition and gastric tube. Indications for esophageal replacement in pediatrics include esophageal strictures, stenosis, or long-gap esophageal atresia. Conduits for the esophagus include colonic interposition, gastric tube, gastric transposition, and jejunal substitution. Colonic interposition with a vascular pedicle is the most commonly used conduit and will be described. Gastric tube will also be presented and involves the creation of a neo-esophagus from the greater curvature of the stomach with the right gastroepiploic artery as the vascular pedicle.
Alternatives to esophageal replacement include serial dilations of esophageal strictures/stenoses, delayed repair of long-gap esophageal atresia, and need for gastric/jejunal feeding. Risks of esophageal replacement include vascular insufficiency with necrosis, anastomotic stricture, leak, or ulcer, delayed gastric emptying, disordered peristalsis, and ulcers. Critical concepts for this procedure involve mobilization of the esophagus at the gastroesophageal junction with esophageal dissection in the mediastinum and connection of the dissection plane with a proximal neck incision. Both gastric and colonic conduits require mobilization and subsequent anastomosis to the cervical esophagus.
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Keywords
Indications and Benefits
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Esophageal stricture (from caustic injury, reflux esophagitis, anastomotic scarring after esophageal atresia repair, achalasia)
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Congenital esophageal stenosis (if not amenable to resection with end-to-end anastomosis)
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Long-gap esophageal atresia
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Benefits: Continuity of gastrointestinal tract to optimize enteral nutrition
Risks and Alternatives
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Standard risks (bleeding, infection, need for additional procedures, risks of anesthesia)
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Injury to adjacent structures (azygous vein, vagus nerve, posterior membranous trachea)
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Vascular insufficiency with necrosis
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Anastomotic stricture/leak/ulcer
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Delayed gastric emptying, disordered peristalsis, ulcers
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Long term: Dilation and dysmotility of the conduit
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Alternatives: Serial dilations of strictures, delayed repair of atresia/stenosis, gastric/jejunal feeding tubes for enteral nutrition
Essential Steps
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1.
Abdominal incision
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2.
Mobilization of esophagus
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3.
Mediastinal dissection of esophagus
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4.
Neck dissection of esophagus
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5.
If {Colon interposition}
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(a)
Division of gastrocolic ligament
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(b)
Mobilization of ascending and descending colon
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(c)
Conduit assessment for perfusion
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(d)
Ligation of left branch of the middle colic artery and the marginal artery (with preservation of the ascending branch of the left colic artery)
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(e)
Transection of transverse colon
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(f)
Mobilization of colon up mediastinum
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(g)
Division of descending colon
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(h)
Transection of stomach distal to gastroesophageal junction
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(i)
Withdrawal of esophagogastric specimen from mediastinum through neck
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(j)
Creation of colono-gastric anastomosis
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(k)
Creation of colo-colonic anastomosis
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(a)
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6.
If {Gastric tube}
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(a)
Gastrohepatic ligament divided down to pylorus
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(b)
Mobilization of greater curvature of stomach
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(c)
Ligation of left gastric artery
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(d)
{Pyloroplasty}
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(e)
Creation of gastric tube with sequential staple loads
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(f)
Withdrawal of esophagogastric specimen from mediastinum through neck
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(a)
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7.
Transection of cervical esophagus
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8.
Anastomosis between cervical esophagus and colon/gastric conduit
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9.
Penrose drain into neck
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10.
{Jejunostomy feeding tube}
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11.
Closure
Note These Variations
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Open, laparoscopic, robotic approach
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Conduit choice: Colonic interposition, gastric tube, gastric transposition, jejunal substitution
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Stapled/handsewn anastomoses
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Suture choices
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Placement of jejunostomy feeding tube
Template Operative Dictation (Open)
Preoperative Diagnosis
Esophageal stricture/stenosis/atresia
Postoperative Diagnosis
Same as preoperative diagnosis
Findings
Same as postoperative diagnosis
Procedure(s) Performed
Esophageal replacement
Anesthesia
General
Specimen
Esophagus/esophagogastrectomy
Drains
Penrose in neck
Implants
None
Estimated Blood Loss
___ mL
Indications
This is a/an ___-day/week/month/year-old male/female with esophageal stricture/stenosis/atresia, which was causing dysphagia/odynophagia/inability to maintain oral nutrition. He/she was deemed to be a suitable candidate for esophageal replacement with a colon transposition/gastric tube.
Procedure in Detail
Following satisfactory induction of anesthesia, the patient was placed in a supine position and appropriately padded. {A Foley catheter and nasogastric tube were placed.} Timeouts were performed using both pre-induction and pre-incision safety checklists with participation of all present in the operative suite. These confirmed the correct patient, procedure, operative site, and additional critical information prior to the start of the procedure. The abdomen and left neck were then prepped and draped in the usual sterile fashion. Prophylactic antibiotics were given.
An upper midline/transverse/subcostal incision was made into the abdomen and the peritoneal cavity entered. The pars flaccida was incised and dissected to the right crus of the diaphragm. The crural dissection was continued by coming across the anterior arch of the diaphragm. The left crus was similarly dissected as much as possible, which required ligation of the short gastric arteries, until the anterior aspect of the gastroesophageal junction was visualized. The esophagus was retracted laterally to expose the decussation of the crural fibers, and a retroesophageal window was developed until the esophagus was circumferentially mobilized. The esophageal hiatus was widened by incising it anteriorly. The phrenic vein was ligated in order to adequately expose the mediastinum.
The mediastinum was entered and the loose areolar tissue was bluntly dissected around the distal esophagus separating it from the surrounding mediastinal attachments and mobilization carried proximally toward the neck.
Attention was turned to the left neck. Just anterior to the sternocleidomastoid muscle and extending to just above the sternum, a small neck incision was made and carried down along the medial aspect of the sternocleidomastoid muscle. The omohyoid and sternohyoid muscles were divided. The dissection was carried deeper until the vertebral bodies were palpable posteriorly. The esophagus was bluntly dissected free of the posterior membranous trachea anteriorly, and from the vertebral bodies posteriorly. The cervical esophagus was encircled with a/an __-inch Penrose drain and retracted gently caudally allowing for blunt dissection inferiorly toward the previous mediastinal dissection from the transhiatal approach.
[Choose one:]
If {colon interposition}: {The patient pre-operatively received a colonic mechanical/antibiotic prep.} The gastrocolic ligament was incised, separating the transverse colon from the greater curvature of the stomach. The splenic and hepatic flexures were taken down. In a lateral-to-medial approach, the mobilization of the left colon was continued from the splenic flexure down the white line of Toldt, mobilizing the descending colon off the retroperitoneum to the level of the sigmoid colon. In a similar fashion, the ascending colon was mobilized to the level of the cecum dissecting down from the hepatic flexure sweeping the colon off the hepatorenal fossa and retroperitoneum, while protecting the ureter, duodenum, and kidney. The colon was grasped and elevated to identify the tenting of the mesentery to indicate the regions of the middle and left colic vascular pedicles. {Transillumination was used to identify the arteries.} The peritoneum was incised on either side of these vessels in order to isolate them. {The length of colon required for the conduit was estimated by measuring the distance from the angle of the mandible to the xiphoid process.} The conduit was assessed for adequate perfusion and viability by placing small bulldog clamps on the arteries to be ligated and reassessing for graft viability. After several minutes, the bowel appeared healthy/dusky {and flow was confirmed with fluorescein dye injection/mesenteric Doppler flow/inspected for venous congestion}. After demonstrating adequate perfusion, the left branch of the middle colic artery was ligated at its origin and the marginal artery was ligated. The remaining mesentery between the right colic artery and the right branch of the middle colic artery was divided, being cautious to leave the ascending branch of the left colic artery and arcades intact. Using the previously noted required length for guidance, the transverse colon was divided and brought up through the mediastinum and through the cervical neck incision in an isoperistaltic fashion, verifying that there were no twists in the mesentery. The distal colon was divided, verifying adequate conduit length to reach the stomach. An anastomosis was fashioned with a handsewn/stapled anastomosis to re-establish continuity of the colon. The stomach was stapled just distal to the gastroesophageal junction. A colono-gastric anastomosis was created with a handsewn anastomosis/linear cutting staples verifying no redundancy of the colon within the mediastinum.
If {gastric tube}: The division of the gastrohepatic ligament was continued along the lesser curvature of the stomach to the duodenum, exposing the lesser sac. {No accessory/replaced left hepatic artery was noted.} Attention was then directed to mobilizing the greater curvature of the stomach. The gastrocolic ligament was divided while the right gastroepiploic artery and arcade were carefully preserved. Retrogastric adhesions to the retroperitoneum and pancreas were taken down. Once the lesser sac was completely mobilized, the left gastric pedicle was ligated with a _________ before completely freeing the stomach. {A pyloroplasty was performed.} The nasogastric tube was withdrawn. The gastric conduit was created in an isoperistaltic/retroperistaltic fashion over a _____ French chest tube, using a stapler along the greater curvature of the stomach. The left gastroepiploic arcade was identified and preserved throughout this process. Sequential staple loads were used until adequate length of the tube was obtained to reach the cervical incision. {The suture line was oversewn with ___ suture.} The gastric conduit was withdrawn into the cervical neck wound and visualized directly from the abdomen to verify that the staple line remained lateral and the specimen did not twist.
The cervical esophagus was transected sharply and the esophagus and colon/gastric conduit were lifted out of the mediastinum via the neck incision. The colon/gastric conduit was opened and a heel stitch secured between the cervical esophagus and gastric/colonic conduit. A cutting stapler/handsewn anastomosis was used to create a side-to-side/end-to-end anastomosis between the cervical esophagus and the conduit. The remaining defect was then closed with interrupted __ sutures/TA stapler and a nasogastric tube was then passed distally into the neo-esophagus. After completing the anastomosis, the conduit was grasped and pulled down into the abdomen until the cervical anastomosis seated down into the neck, ensuring a straight conduit. Hemostasis was verified. The nasogastric tube was secured at __cm at the level of the nares. {A jejunostomy feeding tube was placed.}
The abdomen was irrigated and hemostasis verified. The abdominal fascia was closed with __ suture. The wound was irrigated and closed with ___. A Penrose drain was placed in the cervical neck incision and secured. The neck incision was closed with interrupted _ suture and the skin was reapproximated with __ and dressed.
Upon completion of the procedure, a debriefing checklist was completed to share information critical to the postoperative care of the patient. The patient tolerated the procedure well, was extubated in the operating room, and was transported to the post-anesthesia care unit in stable condition thereafter.
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Kollisch-Singule, M., Stanger, J. (2019). Esophageal Replacement. In: Papandria, D., Besner, G., Moss, R., Diefenbach, K. (eds) Operative Dictations in Pediatric Surgery. Springer, Cham. https://doi.org/10.1007/978-3-030-24212-1_4
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DOI: https://doi.org/10.1007/978-3-030-24212-1_4
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