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The aim of this study was to report the results of pediatric esophageal substitution by gastric pull-up (GPU) and gastric tube (GT) from a tertiary care pediatric center.
Retrospective analysis of the surgical techniques, results, complications, and final outcome of all pediatric patients who underwent esophageal substitution in a single institution was performed.
Twenty-four esophageal substitutions were performed over 15-year period. The indications were pure esophageal atresia (EA)-19, EA with distal trachea-esophageal fistula-2, EA with proximal pouch fistula-1, and esophageal stricture in two patients. Mean age and weight at operation were 17 months and 9.5 kg, respectively. GPU was the most common procedure (19) followed by reverse GT (4) and gastric fundal tube (1). Posterior mediastinal and retrosternal routes were used in 17 and 7 cases, respectively. Major complications included three deaths in GPU cases resulting from postoperative tachyarrhythmias leading to cardiac arrest, cervical anastomotic leak-17, and anastomotic stricture in six cases. Perioperative tachyarrhythmias (10/19) and transient hypertension (2/19) were observed in GPU patients, and they were managed with beta blocker drugs. Postoperative ventilation in Intensive Care Unit was performed for all GPU, but none of the GT patients. Follow-up ranged from 6 months to 15 years that showed short-term feeding difficulties and no major growth-related problems.
Perioperative tachyarrhythmias are common following GPU which mandates close intensive care monitoring with ventilation and judicious use of beta blocking drugs. Retrosternal GT with a staged neck anastomosis can be performed without postoperative ventilation.
Native esophagus is the best conduit, however there are circumstances when such a functional esophagus becomes unavailable and hence calls for esophageal substitution. Colonic interposition is the most favored method of esophageal substitution worldwide, but other techniques including gastric pull-up (GPU), gastric tube (GT). and jejunal interposition have been used with equal success in the hands of experts,[1,2,3,4,5] with each procedure having its own advantages and disadvantages.[6,7,8,9,10] The surgical techniques, complications, and long-term outcomes of esophageal substitution have all been well documented;[11,12] however, there is a paucity of data on the incidence and management of perioperative complications including tachyarrhythmia in patients undergoing esophageal substitution, especially by gastric pull-up (GPU). These complications if not recognized and managed appropriately can lead to adverse outcome. In this article, we present our experience of gastric esophageal substitution (GPU and GT) with emphasis on the management of the complications and the short-term results.
All pediatric patients who underwent esophageal substitution in the Lady Hardinge Medical College and Kalawati Saran Children's Hospital, New Delhi, from January 2001 to June 2015, were included in this report. Retrospectively collected data on the surgical techniques, results, complications, and final outcome were analyzed.
Preoperative workup included electrocardiogram and echocardiography to look for any associated congenital cardiac anomaly. Elective postoperative ventilation and intensive care monitoring were arranged for all patients of GPU. Preparedness to manage perioperative tachyarrhythmias included availability of beta blocking drug esmolol.
Posterior mediastinal trans-hiatal GPU was performed in patients with virgin mediastinum, and a retrosternal route was chosen if there was extensive fibrosis due to prior surgery or inflammation in posterior mediastinum. GPU was performed using standard surgical technique as described by Spitz et al. [Figure 1];[1,11] the only difference being omission of pyloroplasty. A feeding tube jejunostomy was routinely performed with an 8 Fr infant feeding tube, applying the Witzel technique. Jejunostomy tube was brought out through the previous gastrostomy site in the abdominal wall. A nasogastric tube was used for decompressing the stomach, and it was placed on dependent drainage with two hourly active aspirations. Patients who underwent posterior mediastinal pull-through were electively ventilated postoperatively without muscle paralysis and monitored in Pediatric Intensive Care Unit (PICU). Early jejunostomy feeds were initiated and were progressed as tolerated. Oral feeds were initiated on the 10th postoperative day if no leak was demonstrated on contrast study. In patients with anastomotic leak, oral feeding was delayed till leak subsided. Jejunostomy tube was removed during follow-up after ensuring adequate oral feeding.
Reverse GT was based on left gastro-epiploic artery [Figure 2], and fundal GT was fashioned using Rao's technique. GTs were constructed by serial applications of linear cutter stapler (75 mm, Ethicon Endo Surgery), starting 2-3 cm from pylorus over a 24 French chest drain tube, with a second layer of 4-0 polydioxanone suture; they were brought retrosternally in the neck and fixed as an end stoma preserving the entire length. A delayed esophago-gastric anastomosis was performed 6-8 weeks later. The feeding schedule was similar to the GPU group.
A total number of 24 gastric esophageal substitutions were performed (GPU – 19, GT – 4, and Fundal tube – 1) [Table 1]. The mean age and weight at the time of substitution was 17 months (range 8-60 months) and 9.5 kg (range 8-16 kg), respectively. The indications are shown in Table 2. There were no congenital cardiac anomalies in these patients.
Patients with pure esophageal atresia (EA) (n = 19) and long gap EA with proximal tracheoesophageal fistula (TEF) (n = 1) underwent cervical esophagostomy and Stamm gastrostomy in the neonatal period [Table 2]. Three patients from pure atresia group also underwent unsuccessful attempt of Kimura's extrathoracic elongation procedure. Two patients with EA and distal TEF underwent diversion following a major anastomotic leak. Patients with corrosive esophageal strictures were initially managed on jejunostomy feeding and had undergone multiple attempts by endoscopic management of esophageal stricture.
The predominant route for GPU was posterior mediastinal trans-hiatal (n = 17, 89.4%) in two patients (failed Kimura's and caustic esophageal stricture, one each); a retrosternal route for GPU was taken. All GT esophageal substitutions were taken through retrosternal route [Table 1].
All patients with GPU were electively ventilated in PICU; the mean duration of postoperative ventilation was 56 h (range 48 h to 8 days). None of the patients undergoing GT required postoperative ventilatory support and were managed in the pediatric surgical ward.
Postoperatively, jejunostomy tube feeds were initiated at a mean of 56 h. There were no jejunostomy tube-related complications, and feeds were well tolerated. Oral feeds were started between 10th and 23rd postoperative days, and complete oral feeds were established by 4-12th postoperative week. Once oral feeds were established, patients with GPU generally fared well as compared to GT esophageal substitution patients, who frequently encountered swallowing problems for a prolonged period with several hospital visits. During the follow-up period (ranged from 6 months to 15 years), there were no major growth-related problems.
There were no graft-related complications or any mediastinal leaks. The distal part of the fundal tube comprised the lower esophageal stump, appeared slightly devascularized, and needed trimming of a few centimeters. Severe excoriation around the GT stoma in the neck due to reflux of gastric juice occurred in one of the GT patients.
Intraoperatively, 10/17 (58.8%) patients undergoing posterior mediastinal GPU showed elevation in heart rate to variable levels during mediastinal dissection [Table 3]. In three patients, severe tachyarrhythmia (heart rate >180) required intraoperative administration of beta blockers to control heart rate (esmolol 250-500 mcg/kg/min intravenous [IV] bolus over 1 min followed by 50 mcg/kg/min IV infusion and with graded increase to 300 mcg/kg/min if needed). Elevation in heart rate was not associated with hypotension. Bradycardia was noticed in two patients during mediastinal manipulation which reverted to normal after stopping the dissection. One patient developed intraoperative bronchospasm. Two pneumothoraxes (8.3%) were detected in postoperative chest X-rays and were managed by intercostal tube drainage. Postoperative transient hypertension developed in two patients after posterior mediastinal GPU, necessitating infusion of labetalol (0.5 to 1 mg/kg/h) followed by enteral administration, which was tapered over the next 2 weeks. Cervical anastomotic leak developed in 17 (70.8%) patients, which healed spontaneously over a period of 2-4 weeks. Patients with anastomotic leak were kept on jejunostomy feeding till restoration of complete oral feeds. Cervical anastomotic stricture (6/24; 25%) developed in four patients of GT esophageal substitution and in two patients with GPU. All strictures were managed with esophageal dilatation. Overall, there were three deaths (3/24; 12.5%). All deaths occurred in the initial cases and in the early postoperative period following trans-hiatal posterior mediastinal GPU, resulting from uncontrolled tachyarrhythmia leading to cardiac arrest.
The best esophageal replacement procedure in children is still eluding as there are no randomized controlled trials comparing different techniques in practice. Although there are ample reports on the techniques and outcomes of esophageal substitution, there is a paucity of literature on the management of perioperative complications, especially cardiovascular complications in patients undergoing posterior mediastinal GPU as observed by us. Two large series on gastric transposition[16,17] showed negligible mortality, although the perioperative events and their management were not detailed in the reports.
It is important for the team undertaking such a procedure to be aware of these complications because if not recognized and managed timely, they can have a potentially fatal outcome. The cardiovascular complications could be inappropriate sinus tachycardia (IST), overt tachyarrhythmias, bradycardias, and postoperative hypertension. We earlier reported IST in GPU patients which were narrow, complex, sinus, persistent, and nonresponsive. None of our patients undergoing esophageal substitution had any associated congenital cardiac anomaly. The diagnosis of IST was made once other causes of tachycardia such as hypoxia, hypercarbia, hypotension, hyperthermia, inadequate analgesia, and electrolyte imbalance were ruled out. The potential explanation for these events could be the autonomic instability arising due to the proximity of the vagal and sympathetic nerves to the site of the repositioned stomach in posterior mediastinum, direct manipulation of atrium or pericardium during mediastinal dissection and manipulation, and postoperative hyper adrenergic state.[13,18,19] In adult patients undergoing trans-hiatal esophagectomy, a high incidence of arrhythmias (up to 50%) was reported during the phase of mediastinal manipulation, however they were transient and associated simultaneously with hypotension due to impaired cardiac filling.[20,21] In pediatric patients undergoing posterior mediastinal GPU, tachycardia or tachyarrhythmias may persist into postoperative period and may be associated with hypertension as observed in two of our cases. Similarly, respiratory distress may occur due to the bulk of the stomach in the chest and tracheal edema resulting from the surgical dissection being just behind the membranous trachea. Hence, elective ventilation becomes mandatory in the early postoperative period. Persistent heart rates above 200 bpm can lead to left ventricular dysfunction and rates more than 250 bpm may produce life-threatening heart failure. Judicious use of beta blocker drugs in such situations has resulted in favorable outcome in our cases. To address this potentially devastating complication, some surgeons have proposed reducing the bulk of the stomach at lesser curvature by including a part of lesser curve in the stapler used to close the esophageal stump (Personal communication, Dr. Satish K. Aggarwal). In the last two cases, we have applied this technique which also obviated the need for a separate esophageal stump closure.
The role of routine pyloroplasty in GPU has been questioned. In adults undergoing esophagectomy with gastric interposition, it has been shown that pyloroplasty does not influence the incidence of delayed gastric emptying. Rather routine pyloroplasty/pyloric drainage has been shown to be associated with increased incidence of biliary reflux in long term. We did not perform pyloroplasty during GPU and no adverse effects such as delayed gastric emptying or gastric conduit dilatation was seen. Tube jejunostomy feeding was found to be a very important adjunct in the management as the nutritional requirements were provided before the full oral feeds could be established. Tube jejunostomy was successfully used for even longer than 3 months in some of our patients. Most of the reported complications related to jejunostomy are tube dislodgment and intestinal obstruction. We have used longitudinal Witzel jejunostomy technique, employing an 8-10 cm serosal tunnel on the antimesenteric border, taking care not to narrow the intestinal lumen. Replacement of a dislodged jejunostomy tube can be easily done through the same track, which matures by 2nd postoperative week.
Our patients undergoing posterior mediastinal GPU had a difficult immediate postoperative course, but once this period was tied over their subsequent recovery, the outcome was excellent. Patients with staged GT though had a smoother postoperative recovery, they frequently encountered anastomotic strictures requiring multiple esophageal dilatations and feeding difficulties. Lee et al. also found very high incidence of long-term feeding and respiratory problems in patients with GTs. A long-term surveillance and follow-up are recommended as they may develop complications such as Barrett's changes in the proximal stump, peptic ulceration, and strictures due to reflux.[10,25]
The results of GPU for esophageal substitution in children are favorable in terms of less incidence of stricture formation and fewer postoperative hospital visits. However, the incidence of perioperative tachyarrhythmias is high and could be life-threatening and mandates close intensive care monitoring with postoperative ventilatory support and judicious use of beta blocker drugs. Reverse GT taken retrosternally with staged neck anastomosis can be performed without the need for postoperative ventilation. However, the rate of stricture formation is high requiring frequent hospital visits. The experience of the surgeon and the standard of institutional supportive care should play a vital role in the decision-making process.
There are no conflicts of interest.