Save the child's esophagus, part II: Colic patch repair

Abstract

Purpose: In a previous report, the authors documented the procedures necessary to regain esophageal continuity in infants who had massive disruption of the suture line following esophagoplasty. As a corollary, this study shows the feasibility of preserving the esophagus in older children by using an esophageal patch. Methods: Fifteen children ranging in age from 8 months to 16 years at the time of surgery had repair of esophageal strictures or tracheoesophageal fistulae by the use of a vascularized patch rather than esophageal resection and interposition with colon or stomach. The technique of “colonic-patch oesophagoplasty” was described by Hecker and Hollman in 1975. From 1976 to 1995, the authors have used a modification of their procedure in 14 children, and in one patient an intercostal muscle flap was interposed. The technique consists of esophagotomy through the area of stricture with application of a vascularized patch of colon to the resulting defect. Results: Ten of the patients were boys and four were girls with an additional girl considered for the procedure at 8 months of age. However, during surgery, an intercostal muscle flap interposition was used. Eight children had esophageal stricture caused by lye ingestion; two from anastomotic stricture; two from gastroesophageal reflux; two from recurrent tracheoesophageal fistula; and one from long-term nasogastric intubation. Follow-up showed excellent results in nine patients who had the colic patch operation. All had good swallowing. A tenth patient, the child with the vascularized intercostal muscle flap, is currently eating a regular diet but it has only been 4 months since the operation. However, one of these excellent patients continues to have a small focus of Barrett's esophagus and another one was killed in an automobile accident one year after operation. Three children have good results but with occasional difficulty in swallowing boluses of meat or with continuing reflux. Two patients had poor results and both have undergone reoperation. In one of these children with Down's syndrome and diabetes, the colic patch worked well for 6 years but because of continuing reflux, distal esophageal scarring and obstruction eventually ensued. After reoperation for distal esophageal resection and colic interposition, the patient died of pulmonary failure. The second child with poor results has recently undergone reoperation to extend the esophagotomy through the distal scarred esophagus and to revise the colic patch. Conclusion: The use of a vascular colic patch for treatment of severe esophageal strictures is a viable alternative to esophageal resection and interposition. However, patients with continuing reflux or Barrett's esophagus, or both, may progress with distal esophageal scarring and obstruction and subsequent dilation of the patch. Those patients will require reoperation.