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Laparoscopic Transhiatal Gastric Transposition Preserving the Abdominal Esophagus for Long Gap Esophageal Atresia

Nguyen Thanh Liem, Bui Duc Hau, Le Anh Dung

Department of Surgery

National Hospital of Pediatrics

Hanoi, Vietnam

 

Correspondence:

Nguyen Thanh Liem, MD,PhD

Associate Professor of Pediatric Surgery

National Hospital of Pediatrics

18/ 879 La thanh Road, Dong da District, Hanoi, Vietnam

Fax: 84.4.37754448 , Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

 

Abstract

We report the technique of laparoscopic transhiatal gastric transposition preserving the abdominal esophagus for long gap esophageal atresia. A 4-day old boy with Down syndrome had a long gap esophageal atresia. A gastrostomy and cervical esophagostomy were performed. Esophageal replacement was carried out at the age of 9 months. The operation was performed laparoscopically including complete mobilization of the stomach and lower esophageal stump, pyloroplasty and creation of posterior mediastinal route. The gastric pull-up was performed. The upper anastomosis between cervical esophagus and abdominal esophagus was completed with interrupted 5/0 PDS sutures. The duration of the operation was 4.5 hours. A leakage of the esophago-esophageal anastomosis occurred on day 5 postoperatively and was resolved spontaneously. Postoperative esophagogram showed a wide anastomosis and good gastric empty. Patient was discharged after 3 weeks. Laparoscopic transhiatal gastric transposition preserving the abdominal esophagus for long gap esophageal atresia is a safe and physiologic procedure.

Key words: esophageal atresia, laparoscopic gastric transposition

  

Introduction

Long-gap esophageal atresia is the main group requiring esophageal replacement in children. The esophagus could be replaced by the colon, jejunum or the stomach. Before 2003, this operation was carried out by open approach. In 2003, Ure reported first laparoscopic transposition for long gap esophageal atresia based on Spitz technique’s principles [1,2].

In this paper, we reported the first laparoscopic gastric pull-up preserving the abdominal esophagus for long-gap esophageal atresia.

Case report

A 4-day old boy with Down syndrome was admitted on February 27th, 2007 due to a long gap esophageal atresia without fistula. A gastrostomy and cervical esophagostomy were carried out. Esophageal replacement was performed at the age of 9 months.

The patient was placed in a supine position. The operation was carried out using 3 ports; one 5mm trocar at the umbilicus for the scope and two 5mm trocars at the right and left flanks for instruments. Carbon dioxide pressure was maintained at 8mmHg. The gastrostomy was loosened and closed with running sutures using PDS 5/0. Complete gastric mobilization was performed preserving the blood supply of the stomach via the right gastroepiploic and left gastric vessels, as described by Spitz [3]. The abdominal esophagus was mobilized and preserved intact.

A Heinecke-Mikulicz pyloroplasty was created and closed with running sutures using 5/0 PDS. Transhiatal dissection was continued and a tunnel was created widely in the posterior mediastinum up to the upper part of the thorax. The cervical esophagostomy was loosened and then the tunnel in the posterior mediastinum was dissected down digitally until reaching the lower tunnel under visualization of laparoscope.

Laparoscopically assisted gastric pull-up was performed using a clamp, which was introduced via the collar incision, as described by Ure [1].

The abdominal esophagus was opened and removed leaving 1 cm in length, then upper anastomosis between cervical esophagus and abdominal esophagus was completed with interrupted 5/0 PDS sutures.

The operating time was 4.5 hours. Blood loss was nonsignificant. The patient required ventilation for 2 days. An anastomotic leakage occurred on day 5 postoperatively and resolved spontaneously after 2 weeks. Postoperative esophagogram showed a wide anastomosis and good gastric empty. (Fig. 1) The patient got full oral feeding and discharged after 3 weeks.

transhiatal gastricFigure 1. Postoperative esophagogram

Discussion

There are some different options for esophageal replacement in children including jejunal interposition, colonic interposition, gastric tube esophagoplasty and gastric transposition [2-5]. In some centers, gastric transposition is the favored method because it provides a good quality of life in the long term follow-up [1,6]. The technique was introduced in children by Atwell in 1980 and was widely developed by Spitz in 1984 and thereafter [7,8]. The first laparoscopically assisted gastric pull-up for long gap esophageal atresia was reported by Ure in 2003 [1].

In 2007, Shalaby reported laparoscopic assisted transhiatal esophagectomy and gastric transposition for post-corrosive esophageal stricture [9]. They both showed that this technique was safe and feasible.

We performed successfully the second laparoscopic gastric transposition for long gap esophageal atresia with some important modifications. In this technique, the abdominal esophagus was preserved. The digestive continuity was established by the anastomosis between the cervical esophagus and abdominal esophagus instead of esophagogastrostomy as done by Ure [1]. In our technique, the lower esophageal sphincter was preserved and utilized, hence the gastroesophageal reflux could be prevented. The operation was carried out without any difficulty. Laparoscopic gastric mobilization and pyloroplasty were done easily. The creation of posterior mediastinal route was exact and safe because it was controlled under visualization through laparoscopy. Our experience showed that laparoscopic gastric transposition preserving the abdominal esophagus can be used for long gap esophageal atresia.

 

Acknowledgment

The authors thank Dr. John Taylor, Clinical Associate Professor, Department of Pediatrics, University of Washington, for his careful reading and valuable comments on the manuscript.

 

REFERENCES

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2. Spitz L. Gastric transposition for esophageal substitution in children. J Pediatr Surg 2002, 27:252-259

3. Cusick EL, Batchelor AAG, Spicer RD. Development of a technique for jejunal interposition in long gap esophageal atresia. J Pediatr Surg 1993, 28:990-993

4. Campell JR, Webber BR, Harrison MW, et al. Esophageal replacement in infants and children by colon interposion. Am J Surg 1982, 144:29-31

5. Ein SH. Gastric tubes in children with caustic esophageal injury. J Pediatr Surg 1998, 33:1363-1365

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7. Atwell JD, Harrison GSM. Observation on the role of esophagogastrostomy in infancy and childhood with particular reference to the longterm results and operative mortality. J Pediatr Surg 1980, 15:303-304

8. Spitz L. Gastric transposition via the mediastinal route for infants with long-gap esophageal atresia. J Pediatr Surg 1984, 19: 49-50

9. Shalaby R, Shams A, Soliman Sm, et al. Laparoscopically assisted esophagectomy with esophagogastroplasty for post-corrosive esophageal stricture treatment in children. Pediatr Surg Int 2007, 23:545-549.