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Reverse Gastric Tube Esophagoplasty with and without Lower Esophageal Stump Wrap - Comparison of Outcome
Prema Menon1, Katragadda Lakshmi Narasimha Rao1, Ram Samujh1
1Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Insights
Using the lower esophagus as a fundoplication wrap after reverse gastric tube esophagoplasty in children with long-gap esophageal atresia may improve growth and reduce reflux. Complete wraps, however, can cause dysphagia to solids.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Esophageal Atresia Management
Background:
- Long-gap esophageal atresia presents significant surgical challenges.
- Reverse gastric tube esophagoplasty (RGTE) is a reconstructive option.
- Optimizing outcomes after RGTE, particularly regarding reflux and growth, remains an area of investigation.
Purpose of the Study:
- To compare outcomes in children with long-gap esophageal atresia treated with RGTE.
- To evaluate the utility of using the lower esophageal stump as a fundoplication wrap.
- To assess the impact of this technique on complications, reflux, and growth.
Main Methods:
- Retrospective analysis of children undergoing RGTE between 2008 and 2018.
- Comparison of patients with lower esophageal stump excision (Group 1) versus those with a lower esophageal wrap (Group 2).
- Assessment of postoperative complications, need for dilatation, dysphagia, reflux, and growth parameters (weight and height centiles).
Main Results:
- Nineteen patients were analyzed (9 in Group 1, 10 in Group 2).
- Both groups had similar early complications and stricture dilatation rates.
- Group 2 showed a trend towards less reflux (P=0.118) and significantly better height and weight percentiles at follow-up.
- Complete lower esophageal wraps were associated with dysphagia to solids in some cases.
Conclusions:
- A novel technique using the lower esophageal stump as a fundoplication wrap following RGTE is described.
- Preservation of vagal nerves is recommended.
- Partial lower esophageal wraps appear to improve growth and reduce reflux, while complete wraps may lead to dysphagia and are not recommended.
Aim And Objectives:
The aim of the study is to compare the outcome in children born with long-gap esophageal atresia following reverse gastric tube esophagoplasty (RGTE) with or without the lower esophageal stump as a "fundoplication" wrap.
Materials And Methods:
All children who underwent RGTE between 2008 and 2018 were retrospectively analyzed. Patients in whom the lower esophagus (LE) had been excised as is done routinely in RGTE (Group 1) were compared with those where the LE was wrapped partially or completely around the intraabdominal neo-esophagus (Group 2). Both vagal nerves were preserved to the extent possible. Complications and final outcome, including weight and height centiles were assessed. Follow-up upper gastrointestinal contrast study and reflux scans were studied.
Results:
Nineteen patients (mean age: 15.78 ± 5.02 months [range 10-30 months] at RGTE) were studied; nine in Group 1 and ten in Group 2. Both groups had similar early postoperative complications as well as the requirement of dilatation for anastomotic stricture. Dysphagia for solids was noticed in two patients with complete lower esophageal wrap (n = 4), one requiring removal. More patients in Group 2 had absent reflux (n = 7) compared to Group 1 (n = 3) (P = 0.118). At a mean follow-up period of 45.75 ± 18.77 months (14-84 months), Group 2 children reached better height and weight percentiles compared to Group 1.
Conclusion:
We have described a novel method of using the LE as a "fundoplication" wrap following RGTE. Vagi should be preserved. Those with complete esophageal wrap may develop dysphagia to solids and this is, therefore, not recommended. Lower esophageal wrap patients appeared to have a better outcome in terms of growth and less reflux.
