Total esophagogastric dissociation: an alternative approach

The authors report experience with five children, four of whom underwent esophagogastric dissociation with a Roux-en-Y esophagojejunal anastomosis and jejuno-jejunostomy after recurrent failure of fundoplication to control gastroesophageal reflux. A fifth child had a similar temporary gastric dissociation because of life-threatening aspiration caused by reflux into a colonic neoesophagus. Reversal is planned when the child has achieved sufficient physical growth and accepts a substantial oral intake. Feeding into the dissociated stomach was by intermittent catheterization of a nonrefluxing gastrostomy in four children and a Stamm tube gastrostomy in one child. The postoperative course and follow-up were notable for the rapid improvement in the children's general condition and nutritional status and the reduction in the frequency of pneumonitis. Reflux did not recur.

Review of the postoperative course led to a restructuring of surgical management with the development of tailored 'patient-specific' plans based on short-term and long-term prognosis. Failure to thrive, difficulty in child handling, gastroesophageal reflux, and neurological and physical impairment are particular considerations.

The author's limited experience leads us to suggest that esophagogastric dissociation with Roux-en-Y esophagojejunostomy and a nonrefluxing feeding gastrostomy is a useful temporary or permanent 'rescue' procedure. Furthermore, it is the author's view that the procedure may have a useful role as the primary form of management when normal oral feeding is unlikely to become established.