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Esophageal replacement in children: evaluation of the one-stage procedure with colic transplants
1Service de Chirurgie Pédiatrique, Centre Hospitaier Universitaire Vaudois, Lausanne, Switzerland.
Insights
The one-stage esophagoplasty is a shorter, more effective surgical technique for children with esophageal caustic burns, offering better morphological outcomes and reduced reflux compared to the two-stage method. This approach avoids common complications and improves transplant function.
Area of Science:
- Pediatric Surgery
- Gastrointestinal Surgery
- Thoracic Surgery
Background:
- Two-stage esophagoplasties using retrosternal isoperistaltic colic transplants have been performed since 1966.
- A one-stage procedure was introduced in 1989, involving transplant placement in the posterior mediastinum after closed-chest esophagectomy.
- Both techniques were applied to pediatric patients with esophageal caustic burns.
Purpose of the Study:
- To evaluate the effects of one-stage versus two-stage esophagoplasty.
- To compare operative times, complications, and morphological outcomes.
- To assess the impact on transplant function and reflux rates.
Main Methods:
- Comparison of two uniform series of esocoloplasties: 32 in the two-stage group and 41 in the one-stage group.
- Patients aged 1.2 to 13.9 years, operated on for caustic esophageal burns.
- Focus on optimizing proximal and colo-gastric anastomosis and creating an anterior anti-reflux hemi-valve.
Main Results:
- One-stage esophagoplasty is shorter (mean 4.9h vs 5.7h) with no increased per-operative complications.
- One-stage procedure yields superior morphological results, avoiding colon redundancy and narrowing at critical junctures.
- Mediastinal colon in the one-stage group is straighter, improving gravity-dependent emptying and reducing reflux to 12%.
Conclusions:
- The one-stage esophagoplasty offers significant advantages in terms of operative efficiency and morphological outcomes for pediatric esophageal reconstruction.
- Improved anastomosis techniques in the one-stage approach effectively reduce transplant reflux.
- While postoperative care requires longer ICU stays due to potential respiratory complications, all patients survived the intervention.
Abstract:
After having practiced two-stage esophagoplasties by retrosternal Iso-peristaltic colic transplant since 1966, we introduced the one-stage procedure in 1989, placing the transplant in the posterior mediastinum following a closed-chest esophagectomy. We have performed 121 such esophagoplasties in children until now. To evaluate the possible effects of the different techniques as accurately as possible, we recorded two uniform series of 32 and 41 esocoloplasties carried out under identical conditions by two operators respectively. All of the children, aged 1.2 to 13.9 years (mean age: 4.3 years and 4.8 years, limits 1.2-13.9 years), were operated upon for caustic burns of the esophagus. The general concept of both interventions is the same. Improvements such as optimizing the proximal and the colo-gastric anastomosis and the creation of an anterior anti-reflux hemi-valve were aimed for. The one-stage esophagoplasty has become a shorter procedure (mean 4.9 h) than the two-stage one (mean 5.7 h). The one-stage procedure has no higher rate of per-operative complications than those observed during the two-steps of the staged operation. One-stage esophagoplasty provides better morphological results. The redundancy of the transposed colon, the narrowing effect of the upper cervical passage and of the point of re-entry into the abdominal cavity are avoided. The mediastinal colon is straighter, which allows better emptying by gravity. The improvement of the lower anastomosis decreases the reflux rate in the transplant to 12%. Postoperative care demands a longer stay in the intensive care unit because of pharyngeal and left pulmonary respiratory complications. For these reasons we kept our patients intubated for a period of 2 to 5 days (mean period: 3.4 days). All patients survived the intervention.