Lower Pouch Research Articles

Feasibility of delayed anastomosis for long gap esophageal atresia in the neonatal period using internal traction and indocyanine green-guided near-infrared fluorescence.

Management of neonates with long gap esophageal atresia (LGEA) is one of the most challenging situations facing pediatric surgeons. Delayed anastomosis after internal traction for esophageal lengthening was reported as a useful technique for long gap cases. Additionally, the use of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in pediatric surgery, especially for blood perfusion validation. We report a novel technique for safe and secure anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence. A pregnant woman with polyhydramnios was admitted to the department of obstetrics in our hospital. At 29 weeks of gestation, ultrasound showed mild polyhydramnios and absence of the fetal stomach. A male neonate was born at 38 weeks of gestation with 21 trisomy. EA (Gross type A) was diagnosed based on an X-ray study that showed the absence of gastric bubble with a nasogastric tube showing the "coil-up" sign. Thoracoscopic internal traction and laparoscopic gastrostomy were performed on day 4 after birth. We confirmed the distance between the upper pouch and lower pouch on X-ray. On day 16 after birth, thoracoscopic anastomosis was performed. We successfully performed esophageal anastomosis without tearing the esophageal wall. Blood perfusion of the upper and lower pouch was validated after anastomosis using ICG-guided NIR fluorescence. Delayed anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence is safe and feasible.

Reparing a long gap Oesophageal Atresia (LGEA) using the combined procedures of foker and kimura

Primary repair of long gap oesophagus atresia (LGEA) requires interdisciplinary expertise to achieve promising results. We report a 9 month old refugee with a spit fistula and a gastrostomy who achieved primary anastomosis in our hospital using the combined surgical methods of Kimura on the upper pouch and Foker in the lower pouch.

CORRELATION BETWEEN POSITION OF RED RUBBER CATHETER ON X RAY AND GAP LENGTH IN TYPE C ESOPHAGEAL ATRESIA (EA)

BACKGROUND AND AIM: Gap length is important determinant for feasibility of primary repair in atresia and also for the preparedness and prognosis of delayed or staged operative procedures. A diagnostic plain radiograph with a red rubber catheter in situ might provide reliable information regarding the gap length without involving additional risk and cost. The present study was conducted to assess the gap length between the two esophageal pouches by preoperative plain radiography with in situ red rubber catheter in upper esophageal pouch and to know the correlation between position of red rubber catheter and measured gap length between upper and lower pouch. METHODOLOGY: Out of all patients admitted and diagnosed as gross's type C EA during September 2018 to November 2019 were included in the present study. The data regarding clinical history, general and systemic examination, pre-operative investigations including plain radiograph with in situ red rubber catheter and intraoperative measured gap length were recorded. Statistically correlation assessed between position of red rubber catheter and intraoperatively measured gap length among patients with type c EA. RESULTS: Total 283 patients were included in the present study. Radiologically position of red rubber catheter was found at level of T2, T3 and T4 in 18.7%, 55.5% and 25.8% respectively. A correlation was found between the preoperative radiological assessments of position of red rubber catheter with intra operatively measured gap length in this study and association between these two variable were found statistically signicant (r=-0.66, P=0). CONCLUSION: The preoperatively radiographic position of upper pouch should be assessed carefully to predict the gap width and it helps in preparedness of surgical management of the patients.

Distal esophagostomy tube feedings in the treatment of long gap esophageal atresia: Experience with 10 cases

Abstract There are different strategies for the treatment of long gap esophageal atresia (LEA), but many aspects of its management is still controversial. The best treatment is conserving the native esophagus through the connection of two esophageal pouches. In this study, we shared our experiences in management of LEA treatment and introduced a new approch for the conservative management of this condition. In our experience, ten patients with long gap esophageal atresia were treated, followed up and managed by our own designed method. In our technique, we lengthened the both upper and lower pouches instead of one pouches. On the one hand, with the effect of saliva pressure, the upper pouch became longer without proximal esophagostomy. On the other hand, the lower pouch was mechanically lengthened by the feeding effect of gavage. These reduced the distance between the two ends of the esophagus and provided the conditions for the primary anastomosis and saving the native esophagus. There were no complication in these ten patients but this procedure needs more investigation.

Surgical Surprise in a Case of Pure esophageal atresia: How High Can the Lower Pouch Be?

The gap between the upper and lower pouches in case of pure esophageal atresia (EA) is usually long and requires multistaged repair. However, in rare cases, the gap may be short and can be repaired primarily commonly through thoracotomy approach. We report an unusual case of a 2-day-old baby girl who presented with short gap EA where the lower esophageal pouch was found adjacent to the blind upper pouch in the neck and primary repair could be performed through the cervical route itself.

Crossover Upper Pouch in Type C Esophageal Atresia: An Uncommon Variant Causing Diagnostic Dilemma

Esophageal atresia with tracheoesophageal fistula (EA-TEF) is a well-known congenital anomaly and Type C variety of gross classification is the most common. Even for Type C variety, anatomy of upper pouch and lower pouch is not always the same. We are presenting three cases of Type C EA-TEF with unusual anatomy. In this type, upper pouch crosses over the lower pouch for a significant length. The cases are described here to highlight this variant of Type C EA-TEF which produces diagnostic dilemma. An early diagnosis of this variant, prevents morbidity and mortality.

Standard and Staged Thoracoscopic Repairs of Esophageal Atresia and Tracheoesophageal Fistulas

Abstract Introduction: Tracheoesophageal fistula (TEF) is a common congenital anomaly of the respiratory tract, which is seen in ∼1 in 3500 live births. Typically, TEF occurs with esophageal atresia (EA) and may be associated with other congenital heart or genitourinary anomalies as part of the VACTERL or CHARGE syndromes.1 Common complications after EA and TEF repair include esophageal stricture (35%), anastomotic leak (16%), and recurrent fistula (3%).2 Materials and Methods: Standard TEF repair: The standard TEF repair begins by positioning the patient in a semiprone position with 40°–45° of rotation. Three ports are utilized for optimal control and observation. First, the azygous vein is identified and ligated. During dissection of the esophagus, it is crucial to avoid damaging the vagus nerve, which can be seen near the lower pouch. Often, a preoperative bronchoscopy with insertion of a guidewire can help identify the fistula for accurate ligation. Subsequently, the anesthesiologist can aid in identi...

Pure Esophageal Atresia without a Gap: An Unusual Variant.

A (2.4 Kg) female full-term baby admitted with respiratory distress and frothing from the mouth since birth. The infantogram with the nasogastric tube in situ revealed the position of the tube was at T7-T8 vertebral level and there was no gas in the abdomen (Fig. 1). There was no other associated anomaly. At operation, the upper and lower pouches were almost in continuity but there was a 1cm long atretic segment between them, without tracheo-esophageal fistula (Fig. 2). The atretic segment was excised and primary anastomosis was done between the two ends with nasogastric tube in place. The patient was put on ventilator in postoperative period because of the pneumonitis. The chest tube was removed on 5th day and the patient was weaned off the ventilator; the nasogastric tube was removed on 10th day. The histopathological examination of atretic segment show fibromuscular layer without mucosa.

Experience with Thoracoscopic Repair of Long Gap Esophageal Atresia in Neonates.

This report evaluates the results of a two-surgeon experience with thoracoscopic repair in patients with long gap esophageal atresia (EA). From March 2000 to February 2015, 14 consecutive patients with pure EA were repaired thoracoscopically. The gap length was then evaluated by contrast gastrostomy tube study. Patients were operated on between 4 to 8 weeks of age. Patient weights ranged from 2.6 to 3.8 kg. The longest gap was 7½ vertebral bodies. Dissection was carried well up into the thoracic inlet on the upper pouch and down to the esophageal hiatus on the lower pouch. A 15th patient was not referred until 3 months of age. All 15 procedures were completed successfully thoracoscopically. Operative times ranged from 60 to 135 minutes. There were two leaks; both resolved with conservative therapy. Feeds were started on Day 5 in all other patients. Six of 13 patients required dilations (one to nine), and 8 required a Nissen fundoplication for severe reflux. All patients are currently on full oral feeds. No patient has any evidence of chest wall asymmetry, winged scapula, or clinically significant scoliosis. Thoracoscopic repair of long gap EA has proven to be an effective and safe technique when performed in the first 2 months of life. The improved visualization and access to the upper pouch and lower pouches allow for maximal mobilization. The results are superior to those of documented open series and avoid the morbidity of repeated operations in the neonatal period.

A rare variant case of pure esophageal atresia with an atretic segment

Pure esophageal atresia is typically characterized by a long gap between the upper and lower pouches, with a gasless abdomen and no fistula. The association of pure esophageal atresia with an atretic segment is extremely rare. We report a rare variant case of pure esophageal atresia in which the two blind esophageal pouches were joined by an atretic segment. Excision of the atretic segment and primary anastomosis were performed successfully.

Association of radiographic morphology with early gastroesophageal reflux disease and satiety control after sleeve gastrectomy.

Variable gastric morphology has been identified on routine upper gastrointestinal series after laparoscopic sleeve gastrectomy. This test might give us useful information beyond the presence of leak and obstruction. The aim of this study is to standardize a morphologic classification of gastric sleeve based on water-soluble contrast upper gastrointestinal series, and to determine possible clinical implications. One hundred morbidly obese patients underwent laparoscopic sleeve gastrectomy and had routine upper gastrointestinal on postoperative day 1 or 2. Images were reviewed by 4 radiologists who were blinded to outcomes, and sleeve shape was classified as upper pouch, lower pouch, tubular, or dumbbell. Inter-observer agreement was calculated. Clinical outcomes including weight loss, satiety control, and reflux symptoms were recorded. Comparisons were determined by 1-way ANOVA and t-test. Mean age was 46 ± 12 years and mean BMI was 45.1 ± 6 kg/m(2). Overall inter-observer agreement level for the sleeve shape classification was 76.3%. Sleeve shapes were tubular in 37%, dumbbell in 32%, lower pouch in 22%, and upper pouch in 8%. Mean excess body weight loss at 1, 3, and 6 months was 16.8%, 29.9%, and 39.1%, respectively. Excess body weight loss was not associated with sleeve shape. Mean hunger score was 213 ± 97, and patients with dumbbell shape had higher hunger scores (p= 0.003). Mean reflux score was 5.7 ± 8. Upper pouch shape was associated with greater severity of reflux symptoms (p= 0.02). This study suggests a standardized radiographic classification of gastric sleeve morphology. Although sleeve shape is not correlated with weight loss, gastric sleeves with retained fundus result in lower satiety control and higher severity of reflux symptoms. An adequate resection of the gastric fundus might avoid this potential complication.

Histopathologic profile of esophageal atresia and tracheoesophageal fistula

Purpose Few reports are available in the literature on the histology of the congenital atretic esophagus in humans. Histologic abnormalities including congenital esophageal stenosis (CES) may contribute toward the abnormal esophageal motility after successful repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF). The main aim of this study is to document the histopathologic profile in cases of EA. Methods One hundred and nineteen surgical specimens were collected from 69 consecutive EA patients who underwent surgical repair at the Aseer Central Hospital, Abha, and Armed Forces Hospital Southern Region, Saudi Arabia, from May 1999 through May 2009. This included 62 cases with EA and distal TEF, five cases of pure EA, and two cases of N-type TEF. Samples from tips of the upper pouch (UP), lower pouch (LP), and mid portion of the TEF were preserved in 10% formalin, sectioned, and stained with hematoxylin and eosin. Results The combined three elements of tracheobronchial tissue were observed in only three LP specimens. Gastrictype mucosa was seen in one UP and one LP specimen. Except for one N-type fistula, all sections showed fullthickness muscle coats. Distortion of muscles by fibrosis was most commonly seen in the UP. The muscle layer in the LP was more commonly distorted by glands with or without cartilage. Fourteen samples (10.8%) showed a histological picture consistent with CES. Conclusion Glands in the submucosa may be abnormal innumber and type, and may extend to different esophageal coats. Muscle distortion by fibrosis, glands, or cartilage and associated CES may contribute toward esophageal dysmotility and stricture after surgery. Cutting the TEF B3–5mm distal to its origin from the trachea is adequate histologically for primary anastomosis of the atretic esophagus. The histological changes associated with the TEF need to be revised. Keywords : congenital esophageal stenosis, esophageal atresia, esophageal dysmotility, histopathology

Preliminary investigation of the diagnosis of neonatal congenital esophageal atresia using high-resolution ultrasonography: A report of three cases

ObjectiveTo investigate the clinical value of high-resolution ultrasonography (US) in the diagnosis of neonatal congenital esophageal atresia. Materials and MethodsLongitudinal or oblique mediastinal and abdominal scans were performed using a high-frequency, linear array Philip IU22 probe of 5–13MHz to measure the length and diameter of the upper and lower esophageal pouches, as well as the gap length. ResultsThree neonates with esophageal atresia received surgical treatment. For each case, the length and diameter of the blind upper and/or lower esophageal pouches were measured by ultrasonography. The gaps in two of three cases were long (>3cm), and in one case, it was short (<2cm). ConclusionsHigh-resolution ultrasonography can demonstrate clearly the upper and lower pouches, as well as wall features, and has a clear advantage in measuring the length of the lower esophageal pouch and the gap, which is impossible with plain radiography and esophagography. The drawback is that ultrasonography failed to clearly demonstrate the fistula between the esophagus and the trachea. Despite this, high-resolution ultrasonography is a promising modality in the clinical diagnosis of esophageal atresia.

A Radiological Chronicle of the Presentation and Management of a Long Gap Oesophageal Atresia

Long gap oesophageal atresia is a clinically and technically challenging condition to manage. Documentation of the gap between the upper and lower pouches is critical to deciding the timing and feasibility of a primary anastamosis. Integral to this process is the role of radiology. We present a case of long gap oesophageal atresia accompanied by chronological radiography demonstrating its' staged management and highlighting some common complications.

Efficacy of postoperative elective ventilatory support for leakage protection in primary anastomosis of congenital esophageal atresia

Anastomotic complications after primary repair of congenital esophageal atresia (EA) are recognized and feared complications. A close association exists between anastomotic leakage and the tension of the anastomosis on the suture line. This study aimed to evaluate the efficacy of postoperative elective ventilation support (PEVS) under paralysis with neck flexion after primary repair of EA. Forty-two EA patients; 4 cases with type A and 38 with type C by Gross classification received primary or delayed primary anastomosis between 1979 and 2003. PEVS has been introduced in the postoperative management of all EA cases since 1998. Vecuronium bromide was administered together with fentanyl citrate for five postoperative days. Patients were retrospectively divided into two groups: with or without PEVS management. There was no difference in operation data such as gastrostomy construction, gap between esophageal upper and lower pouch, primary or delayed primary anastomosis. PEVS under paralysis with neck flexion reduced postoperative anastomotic leakages in primary anastomosis with or without a Livaditis procedure. PEVS did not adversely increase anastomotic stricture, atelectasis, severe gastro-esophageal reflux, prolong days on ventilatory support or decrease survival rate. PEVS is an effective management method to decrease anastomotic complications for EA neonates.

A new variant of esophageal atresia with tracheoesophageal fistula and duodenal atresia: a diagnostic dilemma

A new variant of esophageal atresia (EA) with tracheoesophageal fistula (TEF) associated with duodenal atresia is reported. The TEF was between the lower pouch and the trachea, with a cystic dilatation in the midportion. The tracheal end of the fistula was obstructed by a membranous septum at both ends of a cystic dilatation, leading to a diagnosis of pure EA (gasless abdomen). After the lower pouch was opened beyond the cystic dilatation, 100 ml nonbilious fluid was obtained. A laparotomy revealed a type III atresia of the first part of the duodenum.

A new variant of esophageal atresia with tracheoesophageal fistula and duodenal atresia: a diagnostic dilemma

A new variant of esophageal atresia (EA) with tracheoesophageal fistula (TEF) associated with duodenal atresia is reported. The TEF was between the lower pouch and the trachea, with a cystic dilatation in the midportion. The tracheal end of the fistula was obstructed by a membranous septum at both ends of a cystic dilatation, leading to a diagnosis of pure EA (gasless abdomen). After the lower pouch was opened beyond the cystic dilatation, 100 ml nonbilious fluid was obtained. A laparotomy revealed a type III atresia of the first part of the duodenum.

Double Application of TA-90 B Four-Row AutoSuture(c) Stapling Instrument: A Safe, Effective Method of Staple-line Production Indicated by Follow-up GI Series.

BACKGROUND: Controversy continues, concerning the best method of isolating upper and lower gastric pouches in Roux-Y gastric bypass. This paper reports a technique used from August 1991 through May 1996, in which there was a double application of the TA-90 B Four-Row AutoSuture Stapling Instrument to form the proximal gastric pouch. Because of a significant staple-line failure rate historically, many are separating the pouches. However, due to recent reports of gastro-gastric fistula formation when pouch separation is done, a second look has been taken at stapling the division without separation of the pouches. METHODS: There were 650 patients in this series, and 160 asymptomatic patients 1-4 years postoperatively agreed to have limited upper series. RESULTS: Only one of this group had staple-line failure. Failures were seen in four of 19 symptomatic patients with dyspepsia or rapid weight regain. Putting these two groups together, our staple-line failure rate has been less than 1% using this technique. CONCLUSION: Whether stapling in continuity or dividing the stomach, the two methods appear to be equally effective with comparable morbidity. Patients with staple-line failure or gastro-gastric fistulae will ultimately be forced by their symptoms of rapid weight regain and/or peptic ulcer disease and reflux esophagitis to return for follow-up. Asymptomatic patients very rarely have a connection between upper and lower pouches, and routine follow-up upper GI series are not indicated.

Heterotopic Gastric Tissue in the Scrotum

A 2-year-old boy who underwent right inguinal herniotomy as a neonate presented with a right hydrocele. Exploration revealed a large hydrocele sac containing a creamy fluid with 2 interconnecting compartments and no patent processus vaginalis. The upper pouch was excised and the lower pouch was opened, according to Jaboulay’s operation. Histology of the sac revealed gastric heterotopia (see figure). Postoperatively a 99mtechnetium pertechnetate scan failed to demonstrate any residual gastric tissue. The patient presented 2 years later with recurrent hydrocele, which was aspirated (pH 7.34). Ten months later he is asymptomatic. DISCUSSION Heterotopia refers to the presence of tissues at sites where they are not normally found. Heterotopic gastric mucosa has been described throughout the length of the gastrointestinal tract, including the hepatobiliary system, and in the skin of the abdominal wall.’ To our knowledge we report the first case of heterotopic gastric mucosa in the scrotum. The embryonic foregut initially comprises a continuous endodermal tube encased in a thick stratum of mesoderm, which provides most of the mural and connective tissue framework of the foregut wall. In the region of the future stomach this mesodermal thickness forms a part of the primitive peritoneal cavity by clefting, cavitation and subsequent coalescence. During this process a portion of gastric mucosa, while remaining in the midline, may have been displaced into the primitive peritoneal cavity, and then may have migrated down with the testis into the scrotum. In contrast, ectopic splenic tissue has been noted only in the leR scrota1 compartment.z Our second hypothesis is that ectopic tissue developed from existing pluripotential cells in that region, which is supported by the fact that aberrant adrenal tissue has been described in the wall of the hernial sac and in the In conclusion, our case illustrates that heterotopia is not only of

Heterotopic Gastric Tissue in the Scrotum

A 2-year-old boy who underwent right inguinal herniotomy as a neonate presented with a right hydrocele. Exploration revealed a large hydrocele sac containing a creamy fluid with 2 interconnecting compartments and no patent processus vaginalis. The upper pouch was excised and the lower pouch was opened, according to Jaboulay’s operation. Histology of the sac revealed gastric heterotopia (see figure). Postoperatively a 99mtechnetium pertechnetate scan failed to demonstrate any residual gastric tissue. The patient presented 2 years later with recurrent hydrocele, which was aspirated (pH 7.34). Ten months later he is asymptomatic. DISCUSSION Heterotopia refers to the presence of tissues at sites where they are not normally found. Heterotopic gastric mucosa has been described throughout the length of the gastrointestinal tract, including the hepatobiliary system, and in the skin of the abdominal wall.’ To our knowledge we report the first case of heterotopic gastric mucosa in the scrotum. The embryonic foregut initially comprises a continuous endodermal tube encased in a thick stratum of mesoderm, which provides most of the mural and connective tissue framework of the foregut wall. In the region of the future stomach this mesodermal thickness forms a part of the primitive peritoneal cavity by clefting, cavitation and subsequent coalescence. During this process a portion of gastric mucosa, while remaining in the midline, may have been displaced into the primitive peritoneal cavity, and then may have migrated down with the testis into the scrotum. In contrast, ectopic splenic tissue has been noted only in the leR scrota1 compartment.z Our second hypothesis is that ectopic tissue developed from existing pluripotential cells in that region, which is supported by the fact that aberrant adrenal tissue has been described in the wall of the hernial sac and in the In conclusion, our case illustrates that heterotopia is not only of