Esophageal Replacement In Children Research Articles

Enhanced recovery after surgery (ERAS) novel protocol for management of esophageal replacement in children: A single surgeon's experience of 116 cases

BackgroundPerioperative management of esophageal replacement is challenging due to significant disturbance in internal milieu of the body. To mitigate mediastinal dissection induced systemic inflammatory response, there is an unmet need to design and test a goal directed, resource conscious protocol for enhanced recovery, which will serve as a template to reduce morbid surgical complications and length of hospital stay. MethodsA retrospective cohort study was designed by convenience sampling method to group patients to compare outcomes of pediatric esophageal replacement using conventional protocol vs enhanced recovery after surgery novel protocol. Primary outcome measure was post-operative total length of stay in hospital. Secondary outcome measures were frequency of cardio-pulmonary complications, anastomotic leaks, infections, mortality, and initiation of early enteral jejunostomy feeding. ResultsA total of 116 children with corrosive esophageal injury [n = 21(19%)] and esophageal atresia [n = 95(81 %)] were analyzed in this study. Novel protocol group(n = 62) when compared to conventional protocol group (n = 54) had lower mean total length of stay days (13.05 ± 7.92 days vs.21.96 ± 6.5 days p < 0.0001), shorter mean ICU days (5.74 ± 4.16 days vs 7.13 ± 3.16 days; p ≤ 0.048) and Novel protocol group had lower cardiac [3/62 (5 %) vs 12/54(22 %) p = 0.012]; and pulmonary [4/62 (6.5 %) vs 13/54(24 %) p = 0.007] complications. Novel protocol group had lower mean days to initiation of enteral feeding (3.13 ± 0.71 vs 5.45 ± 0.75 days; p < 0.0001) and lower rates of post-operative infections [5/62(8 %) vs 18/54 (33 %); p = 0.001]. ConclusionsEnhanced recovery after surgery novel protocol has the potential to change clinical practice due to mitigation of major complications.

Assessment of jejunal interposition perfusion using indocyanine green

IntroductionJejunal interposition (JI) is an option for oesophageal replacement in children; ensuring good graft perfusion is essential. We report three cases where Indocyanine Green (ICG) with Near-Infrared Fluorescence (NIRF) was used to assess perfusion during graft selection, passage into the chest and anastomotic assessment. This extra assessment may reduce risk of anastomotic leak and/or stricture. MethodsWe describe the technique and salient features of all patients who have undergone ICG/NIRF-assisted JI in our centre. Patient demographics, indications for surgery, intra-operative plan, video of NIR perfusion assessment, complications and outcomes were reviewed. ResultsICG/NIRF was used in three patients (2M:1F) at a dose of 0.2 mg/kg. ICG/NIRF imaging helped select the jejunal graft and confirmed perfusion after division of segmental arteries. Perfusion was assessed before and after passing the graft through the diaphragmatic hiatus and before and after making the oesophago-jejunal anastomosis. Intrathoracic assessment at the end of the procedure confirmed good perfusion of mesentery and intrathoracic bowel. In two patients, the reassurance contributed to successful procedures. In the third patient, graft selection was satisfactory, but borderline perfusion on clinical assessment after passing the graft to the chest, confirmed by ICG/NIRF meant the graft was abandoned. ConclusionsICG/NIRF imaging was feasible and augmented our subjective assessment of graft perfusion, giving greater confidence during graft preparation, movement, and anastomosis. In addition, the imaging helped us abandon one graft. This series demonstrates the feasibility and benefit of ICG/NIR use in JI surgery. Further studies are required to optimise ICG use in this setting.

Thoracoscopic-Assisted Esophageal Replacement with a Detached Reversed Gastric Tube Pedicled Graft: Technical Report and Preliminary Outcomes

BackgroundReflux is one of the most common late complications after gastric tube esophageal replacement in children. Herein, we report a novel approach for safely and selectively replacing the caustic strictured thoracic esophagus with a detached reversed gastric tube (d-RGT) pedicled graft with preservation of the cardia and implementation of thoracoscopy for optimizing the mediastinal pull-through process, and its outcomes. MethodsAll children who presented to our facility with an intractable postcorrosive thoracic esophageal stricture through 2020 and 2021 were enrolled in this study. The primary operational steps were thoracoscopic esophagectomy, laparotomy for d-RGT fashioning, and cervicotomy for anastomosis after the thoracoscopically monitored mediastinal pull-through process. ResultsEleven children met the enrollment criteria, and their perioperative characteristics were assessed. The mean operative time was 201 min. The average duration of hospitalization was 5 days. There was no perioperative mortality. A transient cervical fistula was reported for one patient and a cervical side anastomotic stricture in another patient. A third patient developed kinking of the lower end of the d-RGT at the diaphragmatic crura level and this was treated satisfactorily by redoing the abdominal side surgery. After a mean follow-up of 8.5 months, none of the patients experienced reflux, dumping syndrome, or neoconduit redundancy. ConclusionsThe pattern of vascular supply of the d-RGT allowed for its total irrigation. Thoracoscopy assisted in preparing the mediastinal path for a safe and precise pull-through process. The lack of reflux seen on imaging and endoscopy in these children suggests that retaining the cardia may be beneficial. Level of EvidenceIV.

Isoperistaltic gastric tube: a versatile, length-gaining option for esophageal replacement in children and adolescents.

Several substitutes, including gastric transposition, colonic interposition, reverse gastric tube (RGT), etc., have been described for esophageal replacement in children and adolescents. However, the search for the ideal esophageal substitute continues due to adverse events associated with these procedures. This report presents our technique for creating an isoperistaltic gastric tube (IGT). We believe that the IGT is a versatile option for esophageal replacement as it is never length-limiting, and additional length can be gained by making minor adjustments.

Quality of life after esophageal replacement in children

PurposeAssessing quality of life (QoL) after esophageal replacement (ER) for long gap esophageal atresia (LGEA). MethodsAll patients after ER for LGEA with gastric pull-up (GPU n = 9) or jejunum interposition (JI n = 14) at the University Medical Center Groningen and Utrecht (1985–2007) were included. QoL was assessed with 1) gastrointestinal-related QoL using the Gastrointestinal Quality of Life Index (GIQLI)), 2) general QoL (Child Health questionnaire CHF87-BREF (children)/World Health Organization questionnaire WHOQOL-BREF (adults)), and 3) health-related QoL (HRQoL) (TNO AZL TACQoL/TAAQoL). Association of morbidity (heartburn, dysphagia, dyspnea on exertion, recurrent cough) and (HR)QoL was evaluated. ResultsSix patients after GPU (75%) and eight patients after JI (57%) responded to the questionnaires (mean age 15.7, SD 5.9, 12 male, two female). Mean gastrointestinal, general and health-related QoL total scores of the patients were comparable to healthy controls. However, young adults reported a worse physical functioning (p = 0.02) but better social functioning compared to peers (p = 0.01). Morbidity was not associated with significant differences in (HR)QoL. ConclusionsWith the current validated QoL most patients after ER with GPU and JI for LGEA have normal generic and disease specific QoL scores. Postoperative morbidity does not seem to influence (HR)QoL. Type of StudyPrognosis Study. Level of evidenceIII.

30-Day Outcomes Following Esophageal Replacement in Children: A National Surgical Quality Improvement Project Pediatric Analysis

IntroductionThe optimal method of esophageal replacement remains controversial. The aim of this study was to evaluate 30-d outcomes of children in the National Surgical Quality Improvement Project Pediatric (NSQIP-P) database who underwent esophageal replacement from 2012 to 2018. MethodsDemographics, comorbidities, and procedural technique was identified in NSQIP-P and reviewed. Thirty-day outcomes were assessed and stratified by gastric pull-up or tube interposition versus small bowel or colonic interposition. Categorical and continuous variables were assessed by Pearson's chi-square, Fisher's exact, and Wilcoxon rank-sum tests, respectively. Multivariate logistic regression was performed to estimate the effects of procedure technique and clinical risk factors on patient outcomes. ResultsOf the 99 cases of esophageal replacement included, 52 (52.5%) utilized a gastric conduit, whereas 47 (47.5%) involved small bowel/colonic esophageal interposition. Overall risk of complications was 52.5%, the most common of which were perioperative transfusion (30.3%), surgical site infection (11.1%), and sepsis (9.1%). Risk of unplanned reoperation was 17.2%, and risk of mortality was 3.0%. Risk for complications, reoperation, and readmission did not differ significantly between those who underwent gastric esophageal replacement and those who underwent small bowel or colonic interposition. Median operative time was shorter in the gastric esophageal replacement group (5.2 versus 8.1 h, P = 0.009). ConclusionsAmong children in NSQIP-P who underwent esophageal replacement from 2012 to 2018, the risk of 30-d complications, unplanned reoperation, and mortality was relatively frequent and was similar across operative techniques. Opportunities exist to improve preoperative optimization, utilization of blood transfusion services, and infectious complications in the perioperative period irrespective of operative technique. Level of evidenceLevel III, retrospective comparative study.

What is the Best Choice for Esophageal Replacement in Children?

Esophageal replacement surgery is performed in children with either congenital long gap esophageal atresia or acquired esophageal damages such as caustic injury of the esophagus. although the left colon because of less variation in blood supply and suitable diameter in comparison with right colon is the better choice. A secured pedicled colon is mandatory for reducing the sever complications, such as leak and necrosis. Ileocolic conduit is an alternative method of colon interposition which has anti reflux effect and therefore with less complications related to gastroesophageal reflux. When we have a short segment esophageal stricture due to corrosive esophagitis or other causes of esophageal strictures which is refractory to repeated dilatations, it is advisable to perform colon patch esophagoplasty. Gastric transposition can produce a good way for gastrointestinal continuity with a perfect weight gain and oral feeding, therefor it can be a safe choice for esophageal replacement in children. Partial gastric pull-up is an alternative operation for esophageal replacement in children and infants with long gap esophageal atresia. Gastric conduit replacement is another alternative technique for esophageal replacement, in which a gastric tube is created in the abdomen and it is pulled to via thoracic cavity to the neck and is committed by cervical anastomosis. Antral patch esophagoplasty is used for benign and limited esophageal stricture due to gastroesophageal reflux. Usefulness of pedicled jejunum was under optimal results because of technical problems and high rate of necrosis and mortality for decades. Sternocleidomastoid myocutaneous esophagoplasty is a scarce method which is reported by some surgeons for limited cervical esophageal stricture repair. Free microvascular transfer of the reverse ileo-colon flap with ileocaecal valve valvuloplasty is used for reconstruction of a pharyngoesophageal defect, and Patch esophagoplasty by using of degradable bioscaffolds of extracellular matrix have shown good results in preclinical and clinical outcomes to prevent stenosis after endoscopic mucosectomy. We will explain the advantages and disadvantages of these different surgical methods in this review article.

Respiratory function after esophageal replacement in children

BackgroundChildren born with esophageal atresia require an anastomosis between the proximal and distal esophagus. When this distance is too wide (long gap esophageal atresia, LGEA) esophageal replacement strategies have to be deployed. The aim of this study was to assess long-term respiratory morbidity and lung function after esophageal replacement with either stomach (gastric pull-up, GPU) or jejunum (jejunal interposition, JI) for LGEA. MethodsRetrospective cohort study. Patients operated with GPU and JI for LGEA (1985–2007) underwent a semi-structured interview and lung function testing (LFT). ResultsSeven GPU-patients and eight JI-patients were included. Median age was 12years. One patient per group could not perform LFT. Respiratory symptoms were reported by 13/15 patients (7/7 GPU-patients vs 6/8 JI-patients). All LFT items were lower than reference values; 6/13 patients showed restriction and 6/13 obstruction. All six GPU-patients had abnormal TLC and/or FEV1/FVC vs 3/7 after JI. Restriction was noted in 4/6 GPU-patients vs 2/7 JI-patients. ConclusionAfter esophageal replacement for LGEA many children have impaired lung function and respiratory symptoms are common. Lung volumes seem decreased after GPU compared to JI. This may be caused by the intrathoracic stomach which may limit normal lung growth. Respiratory follow-up in adult life is important after esophageal replacement. Level of evidenceIII

Surgical techniques for esophageal replacement in children.

Surgical techniques for esophageal replacement (ER) in children include colon interposition, gastric tube, gastric transposition, and jejunal interposition. This review evaluates the merits and demerits of each. Surgical techniques, complications, and outcome of ER are reviewed over last seven decades. Colon interposition is the time-tested procedure with minimal and less serious complications. Long-term complications include reflux, halitosis, colonic segment dilatation, and anastomotic stricture, sometimes requiring surgical interventions especially for dilatation and reflux. Gastric tube is technically more risky, and associated with early serious complications like prolonged leak in neck or mediastinum, graft necrosis, and ischemia leading to stricture of the tube. Long-term results are good. Gastric transposition is much simpler, can be performed in emergency and in newborns. It involves a single anastomosis in the neck.Post-operative complications include gastric stasis, bile reflux, restricted growth, and decreased pulmonary functional capacity. Jejunal interposition has not been used extensively due to short mesentery but long-term results are good in expert hands. Colon is the most preferred and safest organ for ER. Stomach is a vascular and muscular organ with lower risk of ischemia. Gastric tube is a demanding technique. Jejunum or ileum is alternative for redo cases.

Gastric tube esophagoplasty for pediatric esophageal replacement

BackgroundEsophageal replacement in children is indicated in cases of esophageal atresia with or without fistula, in case of long gap esophageal atresia or failed primary repair. Intractable post corrosive esophageal stricture is considered also a major indication for replacement. MethodsThis is a cohort retrospective study of esophageal replacement cases by gastric tube carried out at the pediatric surgery department at Cairo University between 2011 and 2015. We reported 50 patients (30 boys and 20 girls); the ages ranged from 7months to 9years. Esophageal atresia cases were 27 while caustic esophageal stricture cases were 23. Isoperistaltic gastric tube technique was done in 45 patients while antiperistaltic (reversed) gastric tube technique was done in 5 cases. Retrosternal route was chosen in 38 patients while transhiatal route was chosen in 12 patients. ResultsLeakage and stricture were the most common complications. We had 5 cases of mortality, which were caused mainly by chest related complications. We had excellent to good results during long term follow up in terms of weight gain, swallowing pattern, quality of life, and overall satisfaction ConclusionGastric tube is a satisfactory surgical method for esophageal replacement in children. Level of EvidenceIII.

Gastric transposition as a valid surgical option for esophageal replacement in pediatric patients: experience from three Italian medical centers.

Background: Esophageal replacement in children is an option that is confined to very few situations including long-gap esophageal atresia and esophageal strictures unresponsive to other therapies (peptic or caustic ingestion). The purpose of our work was to describe the experience of gastric transposition in three Italian centers.Methods: This is a retrospective study. The data were extrapolated from a prospective database. We included all patients who had undergone gastric transposition in the last 15 years.Results: In the 15-year period, eight infants and children (3 males and 5 females) underwent gastric transposition for esophageal replacement. Six patients had long-gap esophageal atresia, and two had caustic esophageal stenosis. There were no deaths in the series. Three patients had an early postoperative complication: two had a self-limited salivary fistula at three weeks, and one (a patient with jejunostomy) had a jejunal perforation treated surgically. One late complication, anastomotic stricture, was recorded that required two endoscopic dilatations. The median follow-up was 60 months (range: 18–144 months). At final clinical follow-up, six patients had no eating problems, and two patients had some difficulties with eating (jejunostomy in situ), but they underwent logopedic therapy with improved outcomes. All patients had an increase in body weight and height postoperatively.Conclusion: Our small study reports the clinical experience of three Italian centers in which gastric transposition was performed with excellent results, both in terms of surgical technique (simplicity, reproducibility, complication rate) and clinical follow-up (good oral feeding of young patients, normal social life and regular growth curves).

The use of ileocolic segment for esophageal replacement in children.

Aims:To evaluate and describe the procedure and outcome of ileocolic replacement of esophagus.Materials and Methods:We review 7 children with esophageal injuries, who underwent esophageal replacement using ileocolic segment in Christian Medical College, Vellore, India between 2006 and 2014.Results:The ileocolic segment was used in 7 children with scarred or inadequate esophagus. There were 4 girls and 3 boys, who underwent esophageal replacement using isoperistaltic ileocolic segment in this period. Age at presentation varied from 1 month to 14 years with an average of 4.6 years. The indications for ileocolic replacements were corrosive strictures in 5, failed esophageal atresia repair in one and gastric volvulus related esophageal stricture in another. The average follow-up duration was 37 months. One child with corrosive stricture lost to follow-up and died 2 years later in another center. Other 6 children were free of dysphagia till the last follow-up.Conclusions:Although the ileocolic segment is not commonly used for esophageal substitution, it can be useful in special situations where the substitution needs to reach the high cervical esophagus and also where the stomach is scarred and not suitable for gastric pull-up.

Esophageal replacement in children: Challenges and long-term outcomes.

Replacement of a nonexistent or damaged esophagus continues to pose a significant challenge to pediatric surgeons. Various esophageal replacement grafts and techniques have not produced consistently good outcomes to emulate normal esophagus. Therefore, many techniques are still being practiced and recommended with no clear consensus. We present a concise literature review of the currently used techniques and with discussions on the advantages and anticipated morbidity. There are no randomized controlled pediatric studies to compare different types of esophageal replacements. Management and graft choice are based on geographical and personal predilections rather than on any discernible objective data. The biggest series with long-term outcome are reported for gastric transposition and colonic replacement. Comparison of different studies shows no significant difference in early (graft necrosis and anastomotic leaks) or late complications (strictures, poor feeding, gastro-esophageal reflux, tortuosity of the graft, and Barrett's esophagus). The biggest series seem to have lower complications than small series reflecting the decennials experience in their respective centers. Long-term follow-up is recommended following esophageal replacement for the development of late strictures, excessive tortuosity, and Barrett's changes within the graft. Once child overcomes initial morbidity and establishes oral feeding, long-term consequences and complications of pediatric esophageal replacement should be monitored and managed in adult life.

Long-term follow-up after esophageal replacement in children: 45-Year single-center experience

PurposeWe evaluated the results of esophagocoloplasty (ECP) in children by performing a 45-year retrospective cohort study in a single center. Materials and MethodsWe collected all of the medical charts of patients who underwent ECP at our hospital from January 1969 to January 2014. We reviewed the medical history for each patient and then contacted the patients by phone to obtain responses to a questionnaire. The questionnaire evaluated the following four areas: overall general state, gastrointestinal function, dependence on the Health Sanitary System, and their aesthetic satisfaction. ResultsWe contacted 96 patients, and 72 completed our questionnaire. There were 45 males and 27 female respondents, with a mean age of 34.5years. The mean Karnofsky performance status index was 96.4%. There were excellent scores obtained from 55 patients and fairly good scores from 16 patients. There was 1 patient with a low score, and there were no scores reported below 70%. Most patients (58/72) reported regular bowel habits, and no patients required drugs or other measures to facilitate defecation. Gastroesophageal reflux was present in 51 patients, and 62.8% have bothersome symptoms. Twenty-five patients used pharmacological therapies. Forty-eight patients (66.6%) were satisfied with the aesthetic result of surgery (mean score in a scale from 0 to 5, is 3). ConclusionsECP can be used in children who require esophageal substitution. The resulting long-term QoL is acceptable. However, the aesthetic outcomes remain a problem.

Comparison of transhiatal laparoscopy versus blind closed-chest cervicotomy and laparotomy for esophagectomy in children

BackgroundEsophageal replacement for caustic stenosis in children poses a challenging surgical problem. Blind removal of the injured esophagus without thoracotomy through a left cervical and transhiatal approach followed by an orthotopic esophageal replacement using either the colon or the stomach is a difficult procedure and can be dangerous in children. We performed our first total laparoscopic transhiatal esophagectomy in February 2007. We aim to compare this new technique to the previously applied method of blind closed-chest esophagectomy through a cervicotomy and laparotomy. MethodsWe analyzed the surgery and follow-up of 40 children operated upon for extensive irreversible caustic burns of the esophagus. The first 20 esophageal replacements were performed following a blind dissection of the mediastinum through a cervical incision and a laparotomy for esophagectomy (Group I). The last 20 esophageal replacements were performed after laparoscopic transhiatal dissection in the mediastinum and cervicotomy in the neck for esophagectomy (Group II). All operations were performed under the supervision of the same senior surgeon. ResultsAverage age at the time of surgery was the same in both groups. Total esophagectomy was achieved in 45.0% of cases in Group I versus in 90.0% of cases in Group II. Colon was used in 80.0% of cases in Group I and in 90.0% in Group II. The mean duration of surgery was one hour longer in the laparoscopy group. One vascular injury was reported in the blind laparotomy group. Pneumothorax was more frequent in Group II without significant consequences besides drainage. Average time of extubation was about the same in both groups (1.8days). ConclusionLaparoscopic transhiatal esophagectomy for caustic burns before esophageal replacement in children is safe and effective. It could avoid vascular and bronchial mediastinal injuries as the dissection is performed under direct visual control. The routine use of laparoscopic assistance by a senior surgeon improves the safety of esophageal dissection and reduces life-threatening complications.

Long-Gap Esophageal Atresia: a Meta-Analysis of Jejunal Interposition, Colon Interposition, and Gastric Pull-Up

There is still no consensus about the optimal surgical approach for esophageal replacement in the case of long-gap esophageal atresia (LGEA) or extensive corrosive strictures. The aim of this article was to perform a meta-analysis comparing the most widely used techniques for esophageal replacement in children: jejunal interposition (JI), colon interposition (CI), and gastric pull-up (GPU). Review of the English-language literature published in the past 5 years about esophageal replacement in children was done. The focus was on postoperative survival rate, morbidity (gastrointestinal complications such as anastomotic stenosis/leakage and respiratory complications such as pneumothorax, pneumonia, and atelectasis), and long-term follow-up when available. Among long-term gastrointestinal outcomes were dysphagia, reflux, and dumping; among long-term respiratory outcomes were recurrent pneumonia and recurrent aspiration leading to chronic lung disease. Data were computed by Comprehensive Meta-Analysis software (Version 2.2.064). A total of 15 studies (4 comparative retrospective, 8 retrospective, and 3 prospective) including 470 patients (264 LGEA) were identified; 344 (73%) patients underwent CI, 99 (21%) GPU, and 27 (6%) JI. Among these 15 studies, 9 provided data about long-term follow-up. Proper prospective comparative studies are lacking. GPU and CI appear comparable regarding postoperative mortality, anastomotic complications, and graft loss. On the long-term, GPU seems to be associated with a higher respiratory morbidity but fewer gastrointestinal complications than CI. Based on this article only two series provide data about JI, and they show highly divergent results. JI appears to be a valid replacement technique when performed by experienced centers; however larger numbers are needed to assess the outcomes of this procedure.

Esophageal replacement in children and its long-term consequences

BACKGROUND: In children esophageal replacement is sometimes required when other techniques have failed to restore continuity in esophageal atresia or in a severely damaged esophagus. METHODS: We present here a short description of the currently used techniques and some thoughts on the problems that may arise in adulthood. RESULTS: Of the currently used techniques, gastric pull up is the procedure most commonly used in Europe. Common long-term effects include reflux and peptic ulcers and need to be considered when managing these patients. CONCLUSION: Replacement of an inexistent or damaged esophagus continues to pose a significant challenge to the surgeon. The long-term consequences and complications of esophageal replacement in childhood need to be known by adult surgeons as they will take over care of such patients once they reach adulthood.

Mechanical bowel preparation for esophagocoloplasty in children: is it really necessary?

Esophagocoloplasty is a commonly performed procedure for esophageal replacement in children. Traditionally, mechanical bowel preparation (MBP) is performed before this operation. However, this practice has been questioned, initially in adults and now in children. The aim of this study was to evaluate the influence of MBP on esophagocoloplasty in a series of children. Data collected from 164 patients who underwent esophagocoloplasty in the Pediatric Surgery Division, University of São Paulo Medical School, from February 1978 to July 2011 were reviewed for postoperative complications. In 134 patients, at least one kind of MBP was performed before the surgery (PREP group). MBP was omitted in 30 patients (NO-PREP group). There was no statistical difference between the groups in the rates of evisceration, colocolic, or cologastric anastomotic dehiscence and death. However, in the NO-PREP group, the incidence of cervical leakage (6.6%) was significantly decreased in comparison with the classical PREP group (25.3%) (P= 0.03). The results of this study suggest that the omission of MBP has a positive impact on the incidence of postoperative complications in esophagocoloplasty.

Surgical treatment of esophagogastric dysfunction forty years after reverse gastric tube esophagoplasty for congenital esophageal anomaly

Background In 1968, Burrington first described use of the reverse gastric tube esophagoplasty for esophageal replacement in children with esophageal atresia or acquired stenosis. There are few documented cases of long-term follow-up of these patients. Case Report We describe a 41-year-old female who presented with progressive dysphagia 40 years after reverse gastric tube for a congenital esophageal stenosis as an infant. Repeated endoscopic dilations were unsuccessful in relieving her symptoms, and she subsequently underwent a modified Ivor-Lewis esophagogastrectomy with resection of the reverse gastric tube and reconstruction using her remaining gastric remnant. Conclusions This report describes what we believe to be the longest recorded follow-up after reverse gastric tube esophagoplasty and highlights the potential for long-term complications after surgery for congenital anomalies.

Bloodless esophageal replacement in children with corrosive esophageal strictures: Report of two cases

Esophageal replacement is major procedure with high risk for perioperative allogeneic blood transfusion (ABT), especially in pediatric patients due to nutritive deficiency, anemia, small body weight and blood volume. Autologous blood policy is particularly important in female children. We present treatment strategy with the aim of avoiding ABT, that have been applied in two female pediatric patients with caustic stricture of thoracic esophagus. The patients were 7 and 8 years old, with body weight 34 and 23.5 kg, respectively. Protocol was based on the stimulation of haematopoetic system with erythropoietin, iron therapy and preoperative autologous blood donation (PABD). In the first patient, with a history of previous retrosternal bypass esophagocoloplasty and extraction of necrotic colonic graft, delayed reconstruction--transhiatal subtotal esophagectomy and gastric pull-up with cervical anastomosis were performed. In the second patient, repeated ineffective dilatations of esophageal stricture were reason for retrosternal left colon interposiotion and exclusion of native esophagus. No adverse events were attributed to preoperative blood donation period. No allogenic blood products were used during perioperative period. Both patients had uneventful postoperative course. In specialized institutions for esophageal surgery, PABD with administration of erythropoietin and iron therapy, enable bloodless esophageal replacement, even in children.