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Published on: February 10, 2020
Ileal pedicle grafting for esophageal replacement in children
N M A Bax1, K M Van Renterghem
1Department of Pediatric Surgery, Wilhelmina Children's Hospital, University Medical Center, P.O. Box 85090, 3508AB Utrecht, The Netherlands. N.Bax@wkz.azu.nl
Insights
Reconstructing the upper esophagus in children is difficult. This study successfully used a terminal ileum pedicle graft for esophageal reconstruction in a pediatric patient, offering a new surgical option.
Area of Science:
- Pediatric Surgery
- Gastrointestinal Surgery
- Reconstructive Surgery
Background:
- Esophageal reconstruction in pediatric patients presents unique challenges due to anatomical limitations.
- Established techniques like free jejunal interposition are often unsuitable for small children.
- Previous methods using jejunal pedicle grafts may not provide sufficient length for upper esophageal reconstruction.
Observation:
- A case of esophageal atresia with a distal fistula and a very short upper esophageal pouch in an infant is presented.
- Initial attempts at primary repair and anastomosis were unsuccessful, necessitating a cervical esophagostomy and gastrostomy feeding.
- The patient underwent successful upper esophageal reconstruction using a pedicle graft of terminal ileum at 10 months of age.
Findings:
- The terminal ileum pedicle graft facilitated successful esophageal reconstruction in a pediatric patient with complex esophageal atresia.
- Postoperative complications included a minor proximal anastomotic leak that healed spontaneously and the need for distal anastomotic dilation.
- One-year follow-up demonstrated good oral intake without gastrostomy support, with imaging showing a tortuous but functional ileal graft.
Implications:
- Terminal ileum pedicle graft reconstruction offers a viable and effective solution for challenging pediatric esophageal reconstructions.
- This technique expands the surgical armamentarium for pediatric surgeons managing esophageal atresia and other complex esophageal defects.
- The study highlights the potential of the ileal pedicle graft for achieving functional restoration of the esophagus in infants and children.
Abstract:
Reconstruction of the upper esophagus in small children remains a challenge. Free jejunal interposition as frequently used in adults is much less appropriate in children because of the limited vessel size. The use of a jejunal pedicle graft in children has been described, but gaining enough length may be a problem. A pedicle graft of terminal ileum may be a better option, but this technique has never been described. We report a child with esophageal atresia and distal fistula who had a very short upper esophageal pouch. Primary repair was impossible. The fistula was ligated and a gastrostomy created. A second attempt at anastomosis was not successful either, and a cervical esophagostomy was created. The child was fed by gastrostomy and received sham feeding orally. When the child was 10 months old, the upper esophagus was successfully reconstructed with a pedicle graft of terminal ileum. Postoperatively there was a limited leak of the proximal anastomosis, which healed spontaneously. The distal anastomosis had to be dilated on a few occasions. With a follow-up of 1 year, the child is eating well without gastrostomy supplementation. On imaging, the ileal pedicle graft looks somewhat tortuous but contracts nicely. We feel that ileal pedicle graft reconstruction of the esophagus should be part of the instrumentarium of pediatric surgeons dealing with esophageal reconstruction.
