Esophageal Substitution Research Articles

Long gap esophageal atresia and esophageal replacement: moving toward a separation?

Background/Purpose Treatment of long gap esophageal atresia (EA) is still a major challenge. Gastric transposition and colon interposition are the 2 most popular choices for esophageal replacement, but there is general agreement that the child’s own esophagus is the best. The aim of the study was to critically evaluate the feasibility and outcome of primary repair of long gap EA with or without tracheoesophageal fistula (TEF) by direct esophago-esophageal anastomosis as the only technique. Methods Seventy-one neonates with EA+/−TEF were considered. Nineteen cases were classified as long gap (≥3 cm). All infants underwent either primary or shortly delayed repair. In the latter group, a gastrostomy was performed along with an x-ray evaluation of the gap a few days before surgery (mean age, 46.4 days). To avoid disruptive anastomotic force, all infants were kept paralyzed and mechanically ventilated for an additional 6 days after esophageal anastomosis. Before starting feeding, postoperative esophagogram was done on day 7. Endoscopy was done routinely, starting 1 month after surgery; pH monitoring was conventionally performed at 1 year of age or even earlier, should gastroesophageal reflux disease (GERD) be suspected. Follow-up ranged from 11 months to 7 years. Results In all 19 long gap EA infants an esophago-esophageal anastomosis was performed. Six of them (31%) required an anterior esophageal flap to bridge residual gap. Complications included minor anastomotic leak in 2 cases and anastomotic stricture (<5mm) in 12 (80%) cases, which were treated with an average of 5 dilatations (1 of which with resection of the stricture). GERD occurred in 8 cases (53.3%), of which, 3 required fundoplication. None of the patients had esophageal swallowing difficulties or persistent dysphagia. Two children experienced food aversion. Mean hospital stay was 66.2 (22 to 230) days. There were 4 deaths (very low birth weight, 1; associated anomalies, 1; and late sepsis, 2). Conclusions Considering heat gap determination remains imprecise, it seems possible to conclude that in a well-established tertiary care level referral center: (1) long gap EA could be treated successfully with primary repair and anastomosis; (2) strictures and GER represent the most frequent postoperative problem, but additional procedures required seem “acceptable” to maintain the patient’s own esophagus and avoid replacement; (3) esophageal substitution in long gap EA should be reserved for cases in which a previous attempt of esophageal reconstruction failed.

Transhiatal esophageal resection for corrosive injury.

To analyze the feasibility and safety of transhiatal approach for resection of corrosively scarred esophagus. BACKGROUND SUMMARY DATA: The unrelenting corrosive strictures of esophagus merit esophageal substitution. Because of the risk of complications in the retained esophagus, such as malignancy, mucocele, gastroesophageal reflux, and bleeding, esophageal resection is deemed necessary. Transthoracic approach for esophageal resection is considered safe. The safety and feasibility of transhiatal resection of the esophagus is not established in corrosive injury of the esophagus. Transhiatal approach was used for resection of the scarred esophagus for all patients between January 1986 and December 2001. The intraoperative complications, indications for adding thoracotomy, and postoperative outcome were studied in 51 patients. Follow-up period varied from minimum of 6 months to 15 years. Esophageal resection was achieved in 49 of 51 patients whereas thoracotomy was added in 2 patients. In 1 of the patients tracheal injury occurred whereas in other patient there were dense adhesions between tracheal membrane and esophagus. Gastric tube was used for esophageal substitution in 40 (78.4%) patients whereas colon was transplanted in 11 (21.6%) patients. Colon was used only when stomach was not available. One patient (1.9%) had tracheal membrane injury whereas 4 patients (7.8%) had recurrent laryngeal nerve palsy. One patient each had thoracic duct injury and intrathoracic gastric tube leak. There was no operative mortality. Anastomotic complications like leak were present in 19.6% and stricture in 58.8% patients. All the patients were able to resume their normal duties and swallow normal food within 6 months of the surgery. One-stage transhiatal esophageal resection and reconstruction could be safely used for the extirpation of scarred esophagus. Use of gastric conduit was technically simple, quicker, and offered good functional outcome. Postoperative anastomotic stricture amenable to dilatations was the commonest complication.

Gastric transposition in children—a 21-year experience

Purpose The purpose of this study was to analyze the outcome in 173 children (104 M, 69 F) undergoing transposition since 1981. Methods The most common indications for esophageal replacement included failed repair of different varieties of esophageal atresia (127), caustic injury (23), and peptic strictures (8). A total of 81% of the patients were referred from other hospitals (50% from other countries). Age at operation ranged from 7 days to 17 years. The gastric transposition was performed using blunt mediastinal dissection only in 90 patients with an additional 81 patients undergoing lateral thoracotomy. The retrosternal position was used in 2 patients. Results There were no graft failures including those who had previously failed gastric tube or Scharlilike operations. Anastomotic leakage occurred in 12% (all but 1 resolved spontaneously). Anastomotic stricture requiring dilatation occurred in 19.6%. Half of these patients had previous caustic esophageal injury. There were 9 deaths in the group (5.2%). One death occurred intraoperatively, 5 in the early postoperative period, and there were 3 late deaths. In more than 90% of our patients, the outcome was considered good to excellent in terms of absence of swallowing difficulties or other gastrointestinal symptoms. Many, however, preferred to eat small frequent meals. Poor outcome was particularly associated with multiple previous attempts at esophageal salvage. There was no deterioration in the function of the gastric transposition in those patients followed up for more than 10 years. Conclusions Gastric transposition for esophageal substitution is an acceptable procedure. It is attended by 5% mortality and a 12% leak rate. A total of 19.6% of the patients needed anastomotic dilatation for stricture. In the long term, good function has been maintained. Gastric transposition compares favorably with alternative methods of esophageal replacement.

Experience in oesophageal substitution in Lagos, Nigeria

This is an audit of five years work (1996 - 2001), in oesophageal substitution at the Cardiothoracic Surgery Unit of Lagos University Teaching Hospital, Nigeria. The study aimed at highlighting the current trends in indication and methods of oesophageal substitution in the context of our experience. We did a retrospective study of all who required oesophageal substitution during the period of study. We studied the various aspects of the patients' care including the indications for oesophageal substitution, the substituting organs and the results of surgery. We saw fifty-nine patients comprising 19 patients oesophageal carcinoma, 31 corrosive strictures of the oesophagus, 4 peptic strictures and 3 achalasia cases. Two patients had oesophageal substitution because of mediastinitis. Fifty-five patients underwent oesophageal substitution. The substituting organs were stomachs in 36 patients and colon in 19 patients. There were three anastomotic strictures, two grafts failed, and five cases of anastomotic leaks. In all, operative mortality was 9.1% . We concluded that oesophageal substitution was done more for benign reasons in our centre. We also emphasised the positive aspects of colon interposition and the prospects of doing more of it in the near future.

Neonatal gastric pull up: reality or myth?

Between 1991 and 1998, 28 out of 356 neonates with esophageal atresia and tracheoesophageal fistula (EATEF) required esophageal substitution. As only 8 returned (28%) for the esophageal replacement after initial esophagostomy and gastrostomy at our center, we were prompted to offer single-stage esophageal replacement when the primary repair had either failed or was not found feasible. Twelve full-term neonates (mean birth weight 2.32 kg) with EATEF who underwent esophageal replacement by gastric pull-up between 1998 and 2000 were reviewed. The indications were: major leak after primary repair (n=9); pure EA (n=2); and EATEF with a very wide gap (n=1). The average ages at presentation and gastric pull-up were 6.0 and 8.5 days, respectively. The patients were evaluated for gastric transit by a colloid radiopharmaceutical, for duodenogastric reflux (DGR) by hepatic immunodiacetic acid (HIDA) scan, and for gastric clearance and transit by contrast studies. Three patients had minimal leaks from the neck site, all of which healed well. Follow-up with nuclear scans and contrast studies to evaluate gastric emptying revealed obstruction in 1 case and DGR in 25% of cases. There were 2 deaths (16%), 1 due to complex congenital cardiac disease and the other due to septicemia. In view of the acceptable morbidity, mortality, and functional outcome following gastric pull-up, we recommend this procedure if it becomes inevitable in the neonatal period.

Effects of PEEP on Residual Vascularization in Oesophageal Substitution Gastroplasty by Surface Oximetry-Capnometry and Photoplethysmography

Objective: To evaluate the effects of positive end-expiratory pressure (PEEP) on residual vascularization in gastric tubes for oesophageal replacement. Design: Experimental open study. Materials: Eleven mongrel dogs. Methods: Intestinal parietal blood flow was evaluated by photoplethysmography (PPG) and measurement of surface oxygen (PsO₂) and carbon dioxide (PsCO₂) tensions under basal conditions. After Akiyama’s tubular gastroplasty, three levels of PEEP were administered. At each level, fluids were infused to counter the drop in cardiac output. PPG, surface gas tensions, arterial pressure, cardiac output and arterial blood gas tensions were monitored. Control sections of the bowel were also monitored by PPG. Results: Cardiac output dropped for each level of PEEP and returned to basal levels on volume restabilization and on removal of PEEP. Central venous pressure and pulmonary arterial and capillary pressures increased for each level of PEEP and only returned to basal levels on removal of PEEP. PsO₂ values dropped for each level of PEEP and returned to basal levels on volume restabilization and on removal of PEEP. PsCO₂ levels rose, and PPG wave amplitude dropped, for each level of PEEP; these two variables only returned to basal levels on removal of PEEP. PPG values for the control sections reflected those of the anastomotic area. Conclusions: PEEP affects surface oxygen values at the level of the gastroplasty by means of its effect on cardiac output. PEEP also creates a venous return compromise and PPG wave amplitude and surface carbon dioxide values are related to this compromise. All three variables could be significant in anastomotic wound healing.

IS-004 Esophageal Substitution with Interposed Intestinal Segment

IS-004 Esophageal Substitution with Interposed Intestinal Segment

Second primary carcinoma in the gastric tube constructed as an esophageal substitute after esophagectomy.

The prognosis of esophageal carcinoma has improved, but along with this improvement, concern has increased about the occurrence of second primary carcinoma, especially gastric carcinoma, in tubes constructed from the stomach after esophagectomy. We describe our experience in the diagnosis and treatment of gastric tube carcinoma. We retrospectively examined 31 cases of gastric tube carcinoma; these cases occurred in 26 patients who received esophagectomy between September 1968 and October 2000. Surgical resection was performed in 10 patients. Gastrectomy with regional lymph node dissection was performed in 7 patients and partial resection of the stomach without lymph node dissection in 3 patients. In 6 patients leakage was encountered after gastrectomy; 3 of these patients died of multiple organ failure. Only one of the gastrectomy patients is alive without disease. Over the past 7 years, 15 patients with 20 lesions have been treated by endoscopic mucosal resection (EMR). Three of these patients required additional operation because of massive submucosal invasion by the tumor. One complication occurred at EMR, but it was successfully treated by conservative therapy. All patients treated by EMR alone were alive with neither local nor distant metastasis during a median followup period of 27.5 months. Of those patients who received surgical resection initially and were diagnosed as inoperable, all 10 had not received periodic checkups and had some symptoms. In contrast, of 15 patients who underwent EMR, all 20 lesions were found by annual followup endoscopic examination in the absence of symptoms. EMR for gastric tube carcinoma is safe and has few complications, in contrast to surgical resection of the gastric tube, which places a severe burden on the patient and has high morbidity and mortality. Early detection of the tumor by annual endoscopic examination is recommended for achieving good outcomes in gastric tube carcinoma after esophagectomy.

Late complications of coloesophagoplasty and long-term features of adaptation.

Revisional surgery of late complications after 141 substernal by-pass operations (1962-1990), except three cases with isoperistaltic (except seven with anisoperistaltic) transverse colon grafts for caustic esophageal strictures, are presented. Long-term adaptation of the grafts was investigated with cineradiographical and histochemical methods. Correction of the "pseudodiverticulum" of the proximal anastomosis as a complication of the standard by-pass procedure (in five patients) was achieved by closure of the esophagus below the anastomosis or by end-to-end reanastomosis. Cervical anastomosis stricture (in seven) was solved either by plasty or resection and a similar reanastomosis. Delayed passage due to an intra-abdominal redundant graft (in five) was managed by abdominal shortening coloplication or by side-to-side gastrocolostomy. Late pyloric obstruction as a cause of gastrocolic reflux required pyloroplasty in two instances. Mixed barium-bread bolus for a cineradiographical transit study and periodic acid Schiff reaction plus Alcian Blue staining for a mucopolysaccharide search were used 8 years after the operations. In all but one case, redo surgery was successful. Characteristic coordinated multihaustral propulsive movement developed in the distal colonic segment, playing a secondary but active role in the final phase of swallowing in isoperistaltic substitution. These grafts were free from gastrocolic reflux. Augmentation of neutral mucopolysaccharide was observed on the surface and in the Lieberkühn glands of colonic mucosa. This experience attests that the majority of late complications following colonic esophageal substitution may be corrected by revisional surgery. The predominantly automatic propulsive movements of the isoperistaltically interposed grafts seem to provide an effective antireflux barrier against the gastrocolic reflux if some technical requirements (high gastric anastomosis, good gastric drainage, etc.) are respected. The graft mucosa showed signs of a positive adaptation. The best functional results were achieved by isoperistaltically interposed left colic transplants, which may be considered as an ideal graft (both technically and functionally) in extensive caustic strictures.

Denervated stomach as an esophageal substitute recovers intraluminal acidity with time.

To determine whether the denervated stomach as an esophageal substitute recovers normal intraluminal acidity with time. Bilateral truncal vagotomy to the stomach as an esophageal substitute reduces both gastric acid production and antral motility, but a spontaneous motor recovery process takes place over years. Intraluminal gastric pH and bile were monitored during a 24-hour period 1 to 195 months after transthoracic elevation of the stomach as esophageal replacement in 91 and 76 patients, respectively. Nine patients underwent a second gastric pH monitoring after a 3-year period. The percentages of time that the gastric pH was less than 2 and bile absorbance exceeded 0.25 were calculated in reference to values from 25 healthy volunteers. Eighty-nine upper gastrointestinal endoscopies were performed in 83 patients. Patients were divided into three groups depending on length of follow-up: group 1, less than 1 year; group 2, 1 to 3 years; group 3, more than 3 years. The prevalence of a normal gastric pH profile was 32.3% in group 1, 81.5% in group 2, and 97.6% in group 3. The percentage of time that the gastric pH was less than 2 increased from group 1 (27.3%) to group 2 (56.1%) and group 3 (70.5%), parallel to an increase in the prevalence of cervical heartburn and esophagitis. The percentage of time that the gastric pH was less than 2 increased from 28.7% to 81.2% in the nine patients investigated twice. Exposure of the gastric mucosa to bile was 12.8% in patients with a high gastric pH profile versus 19.3% in those with normal acidity. In the esophageal remnant in six patients, Barrett's metaplasia developed, intestinal (n = 2) or gastric (n = 4) in type. Early after vagotomy, intraluminal gastric acidity is reduced in two thirds of patients, but the stomach recovers a normal intraluminal pH profile with time, so that in more than one third of patients, disabling cervical heartburn and esophagitis develop. The potential for the development of Barrett's metaplasia in the esophageal remnant brings into question the use of the stomach as an esophageal substitute in benign and early neoplastic disease.

Human stomach has a recordable mechanical activity at a rate of about three cycles/minute.

To discover whether the human stomach contracts every 20 seconds or not. Manometric study. Teaching hospital, Belgium. 10 healthy volunteers, and 31 patients who had had the whole stomach denervated and pulled up to the neck for oesophageal replacement. Analysis of selected strips of manometric tracings obtained with intraluminal perfused catheters. 13 patients were given erythromycin (1 g/day) by mouth. Estimation of the rate and frequency distribution according to amplitude of intraluminal pressure waves with the vertical axis of the tracings scaled up to reflect contractions within the gastric wall. Microwaves (<9 mmHg) that came in between conventional macrowaves (>9 mmHg) were found, showing that the human stomach undergoes mechanical activity (amplitude ranging from 0.2-310 mmHg) at the pacemaker's rate which varied from 2.43 to 3.60 cycles/minute from one subject to another. Phase I of the interdigestive motor complex contained microwaves only, phase II and the fed pattern consisted of a mixture of microwaves and macrowaves, and phase III contained macrowaves only. The fasting rate of mechanical activity was lower in patients who were given erythromycin than in those not given erythromycin (p = 0.003) and in healthy volunteers (p=0.002), and it increased significantly after a meal (p < 0.0001). Microwaves in strips in which they were the most prominent were of higher amplitude in patients than in healthy volunteers (median: 3.5 compared with 2.5 mmHg; p < 0.0001). The human stomach has mechanical activity at the rate at which the pacemaker generates electrical slow waves. The classic phases of the gastric motor activity seem to differ from each other by the frequency distribution of pressure waves according to amplitude rather than by the contraction rate. Weak mechanical activity is much more readily detectable after the stomach has been denervated and tailored for oesophageal substitution.

Human stomach has a recordable mechanical activity at a rate of about three cycles/minute.

To discover whether the human stomach contracts every 20 seconds or not. Manometric study. Teaching hospital, Belgium. 10 healthy volunteers, and 31 patients who had had the whole stomach denervated and pulled up to the neck for oesophageal replacement. Analysis of selected strips of manometric tracings obtained with intraluminal perfused catheters. 13 patients were given erythromycin (1g/day) by mouth. Estimation of the rate and frequency distribution according to amplitude of intraluminal pressure waves with the vertical axis of the tracings scaled up to reflect contractions within the gastric wall. Microwaves (<9 mmHg) that came in between conventional macrowaves (>9 mmHg) were found, showing that the human stomach undergoes mechanical activity (amplitude ranging from 0.2-310 mmHg) at the pacemaker's rate which varied from 2.43 to 3.60 cycles/minute from one subject to another. Phase I of the interdigestive motor complex contained microwaves only, phase II and the fed pattern consisted of a mixture of microwaves and macrowaves, and phase III contained macrowaves only. The fasting rate of mechanical activity was lower in patients who were given erythromycin than in those not given erythromycin (p = 0.003) and in healthy volunteers (p = 0.002), and it increased significantly after a meal (p < 0.0001). Microwaves in strips in which they were the most prominent were of higher amplitude in patients than in healthy volunteers (median: 3.5 compared with 2.5 mmHg; p < 0.0001). The human stomach has mechanical activity at the rate at which the pacemaker generates electrical slow waves. The classic phases of the gastric motor activity seem to differ from each other by the frequency distribution of pressure waves according to amplitude rather than by the contraction rate. Weak mechanical activity is much more readily detectable after the stomach has been denervated and tailored for oesophageal substitution.

Prevalence of Barrett's esophagus by endoscopy and histologic studies: a prospective evaluation of 306 control subjects and 376 patients with symptoms of gastroesophageal reflux.

The classic endoscopic diagnosis of a Barrett's esophagus (BE) is based on the finding of > or =3 cm, of distal esophagus covered by specialized columnar epithelium. However, currently, it is based on the finding of intestinal metaplasia (IM) at the squamous-columnar mucosal junction, independent of its extent. The aim of this study was to determine the prevalence of Barrett's esophagus by endoscopic and histological findings in control subjects and in patients with symptoms of gastroesophageal reflux (GER). Three hundred and six control subjects and 376 patients with symptoms of gastroesophageal reflux were included in this prospective study. Patients with Barrett's esophagus were classified in three groups as follows. 1. Intestinal metaplasia at the cardia. When endoscopy showed non-Barrett's esophagus, but histological intestinal metaplasia was found. 2. Short-segment Barrett's esophagus. When <3 cm, was covered with tongues or finger-like or creeping substitution of distal esophagus. 3. Long-segment Barrett's esophagus. When > 3 cm, of distal esophagus was covered by specialized columnar epithelium. Two biopsies at the antrum, four biopsies at the squamous-columnar junction and one or two at the distal esophagus were taken. In control subjects, 1.6% showed histological IM at the esophagogastric junction. In patients with GER without esophagitis or with erosive esophagitis, IM was found in 18% and 10.7% respectively. 'Short-segment' Barrett's esophagus was three times more frequent than 'long-segment' Barrett's esophagus. Patients with Barrett's esophagus were significantly older than the other groups. The presence of complications or erosions, peptic ulcer or stricture were significantly more frequent among patients with 'long-segment' Barrett's esophagus (p < 0.0001). The prevalence of dysplasia was similar in all groups of patients with Barrett's esophagus. Complications such as ulcers, stricture and dysplasia were exclusively seen among patients with BE, whereas non-Barrett's patients did not exhibit these complications. In control subjects, IM can be found in a low percentage of cases. Among patients with symptoms of GER, the classic endoscopic diagnosis of a Barrett's esophagus can underestimate this condition in 80% of the cases. Patients with intestinal metaplasia at the cardia already present 17% of the cases with low-grade dysplasia. In all patients with symptoms of GER, systematic biopsies at the squamous-columnar junction should be taken.

Clinicopathological features of esophageal cancer simultaneously associated with gastric cancer.

We usually use the stomach for esophageal substitution in the surgical treatment of esophageal cancer, although it is often associated with gastric cancer. In order to improve the likelihood of safe and curative surgery of esophageal cancer, we investigated the clinicopathological characteristics of synchronous esophageal and gastric cancer. Among 288 patients with primary esophageal cancer who had undergone esophageal resection, this cancer was associated with gastric cancer in 11 cases, and 1,416 gastric cancer patients operated on during the same period, were analyzed. The clinicopathological characteristics and surgical procedures of the 11 patients were compared with those of the other esophageal cancer patients and with those with the gastric cancer only. There were significant differences between the synchronous double cancer and the gastric cancer only in sex (P < 0.01) and location of the gastric cancer (P < 0.05). All of the patients with the synchronous double cancer were men, and the incidence of patients with cardiac cancer was high. Our findings suggest that, in cases of synchronous esophageal and gastric cancer, an adequate surgical procedure must be chosen in terms of the stage, location, and operative burden.

Colon Interposition for Esophageal Replacement: Current Indications and Long-Term Function

Background. In contrast to the use of the stomach as an esophageal substitute, the use of the colon is becoming uncommon. Methods. From 1985 to 1995, 60 patients underwent colon interposition for esophageal cancer (n = 37), benign stricture (n = 13), iatrogenic fistula (n = 5), achalasia (n = 3), or necrosis of a previous substitute (n = 2). A long isoperistaltic conduit based on the left colonic artery could be used in 52 patients (86.7%). The surgical route used was through the esophageal bed in 38 patients (63.3%), under the sternum in 21 patients, and under the skin in 1 patient. Results. Colon interposition represented 18.5% of all operations performed for esophageal substitution during the study period. The choice of the colon resulted from an inadequate stomach in 33 cases (55%). The operative mortality rate was 8.3%. Seven patients (13.5%) required dilation of the esophagocolonic anastomosis. At last follow-up, 34 patients (65.4%) had no difficulty eating. Multivariate analysis identified the conduit position in the posterior mediastinum as the sole independent predictor of a good functional result ( p = 0.002). Conclusions. Colon interposition for esophageal substitution, usually performed when the stomach is not available, provides satisfactory function when placed in the esophageal bed.

Oesophageal substitution by jejunal free graft: follow-up data and an evaluation

We have developed a new technique for oesophageal substitution using a jejunal free graft and now present a 3-5 year follow-up study of five infants who had this procedure performed for long gap oesophageal atresia. Swallowing is excellent in two, good in two and fair in one. We conclude that jejunal interposition, though technically difficult, can produce excellent results and we particularly recommend this technique, when the oesophageal substitute has to reach high in the thorax or to the neck.

Esophageal substitution with colon — the Waterston operation

Twenty-three interpleural (Waterston) colon replacements of the esophagus are reported, 21 for esophageal atresia and 2 for corrosive strictures. Twenty patients are alive with an intact replacement; 17 are swallowing well and 3 have some dysphagia. Two grafts were converted to reverse gastric tubes, 1 for venous infarction and the other because of difficult vascular anatomy. One child died from disseminated intravascular coagulation following gastroenteritis shortly after successful completion of the interposition. Technical details of the operation are described. The need for replacement has been much less in recent years because of improved surgical techniques for esophageal atresia, particularly elective ventilation and the upper pouch flap operation. Recognition that corrosive and reflux strictures, if a dilatable channel can be maintained, will improve if dilatation is persevered with for 2 years may avoid the need for replacement.

The reversed gastric tube for esophageal replacement in children

The reversed gastric tube provides a relatively simple method of esophageal replacement in children. A thirty year experience of this technique is described together with the long-term results in 34 patients. Complications such as anastomotic leakage and stricturing have responded well to treatment and only one patient died. The reversed gastric tube remains a useful alternative to other methods of esophageal substitution.

Application of collis gastroplasty to the management of esophageal atresia

Establishment of esophageal continuity in the presence of an isolated esophageal atresia frequently requires deferred esophageal substitution. The author describes the use of Collis gastroplasty as an esophageal lengthening technique for the distal esophagus. This technique permitted the performance of primary repair of the esophagus in an infant with a 6-cm gap that otherwise would have required an esophageal substitution procedure. Morbidity after this procedure is comparable to that occurring after a number of established techniques.

Colon patch esophagoplasty for caustic esophageal stricture

Severe caustic injury with stricture may require esophageal reconstruction. The available methods of esophageal substitution do not satisfactorily replace the peristaltic and antireflux properties of the native esophagus. The authors report the results of two children treated with colon patch esophagoplasty and preservation of the injured esophagus. Both were 2 years of age when they accidently swallowed lye. Long esophageal strictures developed, which were resistant to repeated dilatation. Eleven and 13 months after the injury, the patients underwent colon patch esophagoplasty. A segment of the left colon was tailored to the length and shape of the opened stricture and was anastomosed side-to-side to the esophagotomy. One child later had a short recurrent stricture and diverticulum, which required revision of the distal end of the anastomosis. Follow-up endoscopic examination has shown healing of the esophagus and resolution of the strictures; both children are eating normally 3 years after surgery, without symptoms of gastroesophageal reflux. Colon patch esophagoplasty is an alternative to esophageal replacement for long caustic esophageal strictures. Its advantage is preservation of the peristaltic and antireflux mechanisms of the conserved esophagus.