Jejunal pedicle grafts for reconstruction of the esophagus in children

Abstract

Objective Reconstruction of the esophagus in children remains a challenge. Although jejunal grafts retain peristaltic activity, large series with long-term follow up are rare. We like to present our experience in a series of 24 children. Methods In the period 1988 through 2005, 24 children received an orthotopic jejunal pedicle graft reconstruction of the esophagus. Nineteen had esophageal atresia (18 had no distal fistula; all but 1 had a jejunal graft as a primary procedure), 3 had an extensive caustic stricture, and 2 had a peptic stricture. All strictures had been dilated many times, and peptic strictures had been treated with antireflux surgery as well. Median age at reconstruction was 76 days in the esophageal atresia group. The technique involves a right-sided thoracotomy with preparation of the esophageal ends or resection of the diseased esophagus. At laparotomy, a small pediculated jejunal graft is prepared and placed transhiatally in an orthotopic position in the right chest. Results All patients survived, and none of the grafts were lost. There were 5 intrathoracic leaks, 4 in the esophageal atresia group and 1 in peptic stricture group, requiring reoperation in 1. In the esophageal atresia group, there was 1 early distal stenosis requiring reoperation. In patients in which the distal esophagus was preserved (esophageal atresia and caustic stricture group), there were always signs of distal functional subobstruction, responding to dilatation in all but 1 patient. Gastroesophageal reflux was not a problem except for 1 patient with esophageal atresia, in whom the distal esophagus was resected because of ongoing distal obstruction with dilatation of the graft. Most patients eat and grow well, and respiratory problems were rare. Conclusion Orthotopic jejunal pedicle graft reconstruction of the esophagus in children is a demanding operation with considerably morbidity but good long-term results.