Total Esophagogastric Dissociation Research Articles

Pediatric nutritional surgery and its implications: results from a unicentric retrospective analysis

PurposeExisting guidelines provide weak recommendations on the surgical management of nutritional problems in children. The objective was to design a management pathway to address the best nutritional surgery (NS) procedure in a given patient.MethodsRetrospective analysis of children treated at our department from January 2015 to December 2019. The sample was divided into two groups according to presence or absence of neurological impairment (NI). Patients with NI (Group 1) were classified in three subgroups based on presenting symptoms: A-Dysphagia without gastroesophageal reflux (GER); B-GER with or without dysphagia; C-Symptoms associated with a delayed gastric emptying.ResultsA total of 154 patients were included, 111 with NI. One-hundred-twenty-eight patients underwent only one procedure. Complications and mortality were superior in Group 1. In subgroup A, isolated gastrostomy was the first NS in all patients. In subgroup B most of patients were subjected to a Nissen fundoplication, while in 5 cases total esophagogastric dissociation (TEGD) was the first intervention. Considering the entire sample, 92.3% patients who underwent a TEGD did not require further procedures.ConclusionNS encompasses various procedures depending on presenting symptoms and neurological status. A management flowchart for these patients is proposed.

Total esophagogastric dissociation (TEGD) in neurologically impaired children: the floor to parents

Total esophagogastric dissociation (TEGD) was proposed to treat gastroesophageal reflux disease (GERD) both as a rescue in case of fundoplication failure and as first-line surgery in neurologically impaired children (NIC). Aim of the study is to evaluate the impact of TEGD on the quality of life (QoL) of both NIC and their caregivers focusing on the parents’ point of view. A retrospective observational study was conducted on all NIC who underwent TEGD in our center between 2012 and 2022. A questionnaire centered on the parents’ point of view and investigating QoL of NIC and their caregivers was administered to all patients’ parents. Data were compared using Fisher exact test and Mann–Whitney test; a p-value < 0.05 was considered statistically significant. 12 patients were enrolled in the study. Parents reported improvements in weight gain (p = 0.03), sleep disorders, apnea, regurgitation and vomiting (p < 0.01). Caregivers also declared a decrease in number of hospitalizations, particularly related to severe respiratory infections and ab ingestis pneumonia (p = 0.01). We also documented a reduction of caregivers’ worries during food administration (p < 0.01). 50% of parents whose children were subjected to both fundoplication and TEGD would suggest TEGD as first line surgical treatment instead of fundoplication. According to parents’ point of view, TEGD improves significantly NIC QoL and 50% of them would enthusiastically suggest TEGD as first-line surgical approach to GERD in NIC.

Total Esophagogastric and Cologastric Dissociation in Neurologically Normal Children: Systematic Review.

Total esophagogastric dissociation (TEGD) was first described by Bianchi as a definitive procedure for gastroesophageal reflux disease (GERD) in neurologically impaired children. In the last 20 years, different centers extended the indication to neurologically normal (NN) patients with GERD associated with congenital or acquired esophageal anomalies. The aim of this paper is to analyze the role of TEGD in this cluster of patients. A PubMed and Google Scholar search was conducted. All cases of NN children who underwent TEGD for GERD were collected. Patient characteristics and outcomes were analyzed. Complications were classified according to Clavien–Dindo classification. Forty-eight children were identified. In 56.25%, TEGD was the first anti-reflux procedure, while in 43.75% it was performed after failed fundoplications. Mean follow-up was 5.5 years. Mortality related to surgery was 2.08%. All of the survivors improved their condition, with resolution of GERD and weight gain. In addition, 50% of children weaned off enteral nutrition, with 14.6% having their gastrostomy removed, while 41.67% maintained partial enteral supplementation. Respiratory symptoms almost disappeared in 54.17% of patients. This review suggests that TEGD can also be considered for NN children where conventional methods seem insufficient to control reflux and preserve pulmonary function. Nevertheless, long-term follow-up is still required.

Total esophagogastric dissociation (TEGD): Lessons from two decades of experience

BackgroundTotal esophagogastric dissociation (TEGD) has been performed in our institution since 1994, predating its published description by Bianchi in 1997. Originally it was considered a rescue procedure when conventional antireflux surgery failed. Recently TEGD has been considered a viable primary option for the treatment of gastroesophageal reflux disease (GERD) in severely neurological impaired (NI) patients. We describe our institution’s experience of TEGD in this selected cohort of patients. MethodsAn institutional retrospective review was performed detailing our total experience of open TEGD between 1994 and 2015 in severely neurologically impaired (NI) patients. Demographic, complications, and outcome were analyzed. ResultsSixty-six NI patients underwent TEGD between 1994 and 2015 (39 female). Primary TEGD was performed in forty-nine patients (74.2%), while the remainder were rescue procedures following the failure of previous antireflux surgery. In 98% of cases no recurrence of clinically significant reflux was reported. The mean hospital length of stay was 10.2 days. There were sixteen reported complications in twelve patients representing 18.2% of the cohort. One death was attributable to the procedure (1.5%). Median follow-up was 31.6 months (range, 1.3–137.9 months). ConclusionTEGD appears to be a valid surgical option to treat severe GERD in severely neurologically impaired children, both as a primary procedure and as a rescue procedure following failure of anti-reflux surgery. Further studies comparing TEGD versus laparoscopic fundoplication are desirable to understand which of these procedures can be the most effective in this compromised group of patients.Type of study: Retrospective studyLevel of evidence: IV

Gastroesophageal reflux in children with neurological impairment: a systematic review and meta-analysis.

Neurologically impaired children (NIC) suffer severe gastroesophageal reflux (GER) with poor fundoplication outcome. Aims of the study were: (1) to determine the recurrence of GER after fundoplication in NIC; (2) to compare fundoplication versus gastro-jejunal tube feeding insertion (GJ) and fundoplication versus total esophagogastric dissociation (TEGD) in primarily treating GER in NIC. Using defined search strategy, two investigators identified all comparative studies reporting the mentioned procedures to primarily treat GER in NIC. The study was conducted under PRISMA guidelines. The meta-analysis was performed using RevMan 5.3. Data are mean ± SD. Of 3840 titles/abstracts screened, 14 studies on fundoplication (2716 pts.) reported a recurrence/persistence of GER higher in NIC (14.2 ± 8.3%) than in neurologically normal (9.4 ± 5.2%; p = 0.0001), with an increased incidence of re-do fundoplication (12.6 ± 7.0% versus 9.1 ± 4.5%; p < 0.01). Three studies revealed a similar risk of undergoing subsequent fundoplication after GJ (4.9 ± 2.1%) or initial fundoplication (12.0 ± 0.6%; p = ns). Four studies showed a lower recurrence of GER following TEGD (1.4 ± 1.1%) than fundoplication (24.8 ± 1.4%; p = 0.002). NIC are at risk of recurrence/persistence of GER after fundoplication or GJ. TEGD seems more effective to primarily treat GER in NIC. Prospective randomized controlled trials are necessary to establish which is the ideal treatment of GER in NIC.

Indications for total esophagogastric dissociation in children with gastroesophageal reflux disease.

Total esophagogastric dissociation (TED) is used to treat gastroesophageal reflux (GER) after failed fundoplication in neurologically impaired patients. It is now performed for some otherwise healthy patients with severe GER. In this procedure, the gastrointestinal tract is reconstructed in a non-physiological way with a Roux-en-Y esophagojejunal anastomosis and jejuno-jejunostomy. Although TED eliminates almost all GER, some patients experience late complications. In this review, we investigated the long-term outcomes after TED to determine the best indications. In total, 147 neurologically impaired patients and 28 neurologically normal patients were identified. The total rate of complications requiring re-operation was 17.2% in neurologically impaired patients and 32.1% in normal patients, both higher than the rates associated with fundoplication. Although most authors added pyloroplasty when there was a concern of gastric emptying, this sometimes caused bile reflux. Nutritional and metabolic complications, including dumping syndrome and chronic digestive malabsorption, were also reported to occur after TED. TED is an option for the treatment of neurologically impaired patients with recurrent GER after fundoplication or who are at a high risk of recurrence of GER with fundoplication. However, neurologically normal patients who have the ability to obtain nutrition orally should consider options other than TED, as postoperative complications are frequent.

Total esophagogastric dissociation: single center experience

AimFundoplication fails in approximately 20% of children with severe neurodisability. We aimed to evaluate total esophagogastric dissociation (TOGD) as a primary procedure and as a ‘rescue’ procedure for severely neurologically impaired children with significant swallowing discoordination and gastroesophageal reflux disease. MethodsCasenotes of 40 children with severe neurodisability who underwent TOGD between 2005 and 2015 were retrospectively reviewed. Of these, 33 were primary procedures and 7 were ‘rescue’ procedures following failed fundoplication. ResultsMedian age at surgery was 3years 7months (range 1month to 13years 11months). Preoperatively, all children had symptoms of regurgitation, retching or vomiting and 70% of children had an unsafe swallow. There were 5 early complications related to surgery in 4 children requiring surgical intervention. One child died following relaparotomy for esophagojejunal anastomotic breakdown because of multiorgan failure. Gastrostomy feeding was established by a median of 6days (range 2 to 25days) and median hospital stay was 10days (range 4 to 280days). There were 5 late complications. Median follow-up was 13months (range 1month to 8years 4months). All children have had resolution of gastroesophageal reflux. Thirteen percent of children experience bloating or pain on feeding and 26% of children experience retching unrelated to gastroesophageal reflux. There were 8 late deaths unrelated to surgery. ConclusionTOGD should be considered as a primary and definitive procedure in selected severely neurodisabled children who are at higher risk of failure of fundoplication, recurrent aspiration and a reduced quality of life. Level of EvidenceIV.

Long-term and ‘patient-reported’ outcomes of total esophagogastric dissociation versus laparoscopic fundoplication for gastroesophageal reflux disease in the severely neurodisabled child

AimFundoplication has high failure rates in neurodisability: esophagogastric dissociation (TOGD) has been proposed as an alternative. This study aimed to compare the long-term and ‘patient-reported’ outcomes of TOGD and laparoscopic fundoplication (LapFundo). MethodsMatched cohort comparison comprises (i) retrospective analysis from a prospective database and (ii) carer questionnaire survey of symptoms and quality of life (CP-QoL-Child). Children were included if they had severe neurodisability (Gross Motor Function Classification System five) and spasticity. ResultsGroups were similar in terms of previous surgery and comorbidities. The TOGD group was younger (22 vs. 31.5months, p=0.038) with more females (18/23 vs. 11/24, p=0.036). TOGD was more likely to require intensive care: operative time, length of stay and time to full feeds were all longer (p<0.0001). Median follow-up was 6.3 and 5.8years. Rates of complications were comparable. Symptom recurrence (5/24 vs. 1/23, p=0.34) and use of acid-reducing medication (13/24 vs. 4/23, p=0.035) were higher for LapFundo. Carer-reported symptoms and QoL were similar. ConclusionsTOGD had similar efficacy to LapFundo (with suggestion of lower failure), with comparable morbidity and carer-reported outcomes. However, TOGD was more ‘invasive,’ requiring longer periods of rehabilitation. Families should be offered both procedures as part of comprehensive preoperative counseling.

Morbidity and mortality in total esophagogastric dissociation: A systematic review

Background/PurposeTotal esophagogastric dissociation has been described as both a primary and a rescue procedure for patients with severe gastroesophageal reflux. Although most commonly used in the neurologically impaired, it has also been used in those with no neurological impairment. The main objective of this study was to determine morbidity and mortality for this procedure. MethodsAll published cases of esophagogastric dissociation in children were identified. Series were updated where possible by personal communication with the author. Patient characteristics, indications, morbidity, and mortality were analyzed. ResultsOne hundred eighty-one cases were identified. One hundred seventeen were primary operations and 64 were rescue procedures. There were 29 (16.0%) early complications and 28 (15.5%) late complications with 6 (3.3%) deaths related to the procedure of a total of 35 deaths. Twenty-one patients (11.6%) required re-operation in the study periods. ConclusionsEsophagogastric dissociation has an acceptable morbidity and mortality. It is useful as both a primary and a rescue procedure.

Physical outcome and quality of life after total esophagogastric dissociation in children with severe neurodisability and gastroesophageal reflux, from the caregiver's perspective

Background/Purpose The objective of this study is to retrospectively assess the surgical outcome and the quality of life (QOL) from the caregiver's perspective after total esophagogastric dissociation in neurologically impaired (NI) children with gastroesophageal reflux (GOR). Methods Based on O'Neill questionnaire, a QOL questionnaire was designed, which was completed by the caregivers recording the child's well being and caregiver's satisfaction preprocedure, immediately (6 months), and long-term postprocedure (median, 21 months; range, 4-38). Statistical analysis was done using Kruskal-Wallis Test and Dunn's multiple comparisons test. Results Twenty-three children underwent surgery between 2003 and 2008; 19 families participated. Ease of feeding improved significantly both immediately and long term. Statistically significant improvements were also seen in comfort and ability of the child to enjoy life, frequency of medical visits, vomiting, retching, and choking. Postoperatively, caring for the child became easier, and the caregiver's frustration in caring improved statistically, but the caregiver's overall QOL did not improve significantly. Conclusions Total esophagogastric dissociation has huge positive impact on the physical well being of the NI children experiencing GOR. The overall view of the procedure is one of success surpassing all expectations. Therefore, it should be considered alongside other antireflux procedures in NI children.

Prolonged Enteral Feeding Is Often Required to Avoid Long‐term Nutritional and Metabolic Complications After Esophagogastric Dissociation

Total esophagogastric dissociation (TED) was first described in 1997 by Bianchi as a new surgical procedure to treat severe gastroesophageal reflux disease (GERD) in children with neurological impairment. Recently, TED has been proposed in other conditions, such as esophageal atresia, esotracheal cleft, or caustic esophageal lesions. Although the long-term results in terms of GERD control have been previously reported, those regarding the nutritional and metabolic status have never been documented. All patients without neurological impairment with TED between 1999 and 2004 at Robert Debre Hospital and Jeanne de Flandre Hospital, France, were prospectively investigated, paying particular attention to their metabolic and nutritional status (blood concentration of iron and vitamins A, D, E, and B12; lipid malabsorption; and hyperglycemia test) and growth. Seventeen children underwent TED. Six received primary procedures, whereas 11 were operated on because of severe respiratory diseases or failure to thrive. The mean follow-up was 6 years (range 3-8 years). Two children died (12%). Seven children were weaned from enteral nutrition support, but 5 of them had failure to thrive, steatorrhea, and/or malabsorption of vitamin B12 and/or fat-soluble vitamins. Eight patients had dumping syndrome, which was symptomatic in 6 cases. TED is an effective procedure for treatment of GERD. However, nutritional and metabolic complications including dumping syndrome and chronic digestive malabsorption are frequent after TED, especially after enteral nutrition weaning. A long-term follow-up of these patients is thus necessary and prolonged enteral nutrition support is recommended.

Laparoscopic Proximal Roux-en-Y Gastrojejunal Diversion in Children: Preliminary Experience from a Single Center

Neurologically impaired children (NIC) have a high risk of recurrence of gastroesophageal reflux (GER) following fundoplication. A postpyloric feeding tube may be useful when gastric emptying disorders occur; however, dislocation and difficulty in feeding management often require more aggressive procedures. Total esophagogastric dissociation (Bianchi's TEGD) is an alternative to the classic fundoplication procedure, whereas laparoscopic gastric bypass is a frequently performed procedure in morbid obesity, improving gastric outlet. The aim of this paper is to present a preliminary experience on the laparoscopic Roux-en-Y gastrojejunal bypass, associated with Nissen fundoplication and gastrostomy, to treat and prevent GER in NIC with gastric emptying disorders. Eight neurologically impaired children underwent surgical treatment because of feeding problems and pulmonary complications. The procedure included: 1) hiatoplasty, 2) Nissen fundoplication, 3) 20-cm Roux-en-Y gastrojejunal anastomosis and jejuno-jejunal anastomosis, and 4) gastrostomy. All cases were fed on postoperative day 3 without any intraoperative complications. One case developed an obstruction of the distal anastomosis due to adhesion and needed reoperation. Outcome was clinically evaluated with serial upper gastrointestinal contrast studies and endoscopies. Laparoscopic proximal Roux-en-Y gastrojejunal diversion, without gastric resection, is a safe, feasible procedure that improves gastric emptying and reduces the risk of GER recurrence. Yet, long-term results still have to be evaluated.

Laparoscopic total esophagogastric dissociation

The total esophagogastric dissociation (Bianchi's procedure) is used to control the severe gastroesophageal reflux in patients after failure of the fundoplication techniques. The laparoscopic approach can be usefully performed in patients with impaired respiratory function. We report here 2 patients in whom the total esophagogastric dissociation has been entirely performed by laparoscopy. The laparoscopic examination of the proximal esojejunal anastomosis is made feasible using an intestinal clamp placed to avoid the esophageal retraction up into the posterior mediastinum. The principal complication after this surgery is the risk of internal hernia.

Total esophagogastric dissociation in adult neurologically impaired patients with severe gastroesophageal reflux: an alternative approach

Patients with neuromuscular impairment, such as cerebral palsy or myotonic dystrophy, often suffer from oropharyngeal neuromuscular incoordination and severe gastresophageal reflux (GER). In 1997, Bianchi proposed total esophagogastric dissociation (TEGD) as an alternative to fundoplication and gastrostomy to eliminate totally the risk of recurrence of GER in neurologically impaired children. Little information exists about the best management for adult patients with severe neurological impairment in whom recurrent GER develops after failed fundoplication. We present our experience in three adult patients with neurological impairment in whom TEGD with Roux-en-Y esophagojejunostomy and feeding gastrostomy was performed for permanent treatment of GER.

Total esophagogastric dissociation: 10 years' review

Purpose Neurologically impaired children run a 12% to 45% risk of recurrent gastroesophageal reflux (GER) after fundoplication. Elimination of the reflux by “rescue” total esophagogastric dissociation (TEGD) encouraged us to use it also as a “primary” form of antireflux surgery in this group of patients. Methods Twenty-six (14 male, 12 female) patients underwent TEGD between 1994 and 2004, of which 16 were primary and 10 were rescue procedures for failed fundoplication. Results There was no operative mortality and postoperative complications were limited to one subphrenic collection, one esophagojejunal dehiscence, and one small bowel hernia beneath the jejunal Roux loop. Gastrostomy feeding was usually established by 3 to 5 days and the mean hospital stay was 10.2 days (range, 6-18 days). At follow-up of 7 months to 11 years, there was no recurrence of GER. Four late deaths were unrelated to the surgery. The children's nutritional status improved with the mean weight standard deviation score showing a statistically significant increase from −2.63 preoperatively to −0.96 postoperatively (Wilcoxon's signed rank P value ≤.005). Conclusions Total esophagogastric dissociation is a safe definitive solution for GER because it eliminates all risk of recurrent reflux. We therefore feel that TEGD can be used as a primary treatment of choice for severely neurologically impaired patients who are experiencing GER and are completely dependant on tube feeds.

Reflux in esophageal atresia, tracheoesophageal cleft, and esophagocoloplasty: Bianchi's procedure as an alternative approach

Purpose Fundoplication has been used successfully to treat gastroesophageal reflux (GER) in the pediatric population. Although successful in many patients, there is a significant risk of complications and failure, especially in high-risk patients such as those with certain types of associated anomalies, diffuse motility disorders, chronic pulmonary disease, neurological impairment, and young infants. However, the results are poorer with children with severe pathologic lesion associated to reflux: tracheoesophageal cleft, esophagocoloplasty, and esophageal atresia (EA) with severe dysmotricity. In neurologically impaired children with neuromuscular incoordination and GER, Bianchi has proposed total esophagogastric dissociation (TED). The authors report the use of esophagogastric or esocologastric dissociation to control reflux in children with severe GER in other situations, such as EA, burn esophageal lesions having led to coloplasty and severe esotracheal cleft. Methods The authors reviewed the patients operated on for an esogastric or cologastric disconnection between 1997 and 2002. It is a single center retrospective study. The initial diagnosis, previous surgical procedure, postoperative course, and follow-up results were studied. Results Between September 1999 and June 2003, 13 TEDs were performed in 6 boys and 7 girls. The mean age for TED procedure was 35 months (range 14 days to 218 months). Indication for TED was severe persistent reflux in, respectively, 9 cases of EA (7 with coloplasty and 2 with preservation of the native esophagus after atresia repair, associated in 1 case with an esotracheal cleft), 2 cases of esotracheal cleft type III, and 2 cases of esophagocoloplasty for caustic burns. Six patients had undergone previous fundoplications (1-4 procedures) that failed, whereas the remaining patients underwent TED as the primary antireflux procedure. The average follow-up was 26 months (range 1 month to 4 years). There were no complication during the immediate postoperative course. Three children died at 3, 4, and 12 months after the procedure from acute respiratory failure. Respiratory status was improved in 8 children, and recurrent bronchitis was noted in 1 child. Regarding the digestive status, gastrostomy was closed at 18 and 24 months in 2 children, and partial nocturnal enteral nutrition (200 to 900 mL/d) through the gastrostomy remains necessary in the other children. Conclusion Total esophagogastric dissociation procedure improves the respiratory consequences of severe GER, particularly in children for whom other surgical treatments have failed. The long-term safety of this operation remains to be determined especially regarding the consequences of a gastrointestinal Roux-en-Y loop procedure.