RESUMEN

Introduction: Esophageal atresia (EA) is a congenital defect that causes esophageal discontinuity, often with an associated tracheo-esophageal fistula (TEF) in 70%-90% of cases. When the distance between esophageal ends precludes primary anastomosis, it results in long gap esophageal atresia (LGEA), complicating the surgical management. This study retrospectively reviewed LGEA cases from the past decade, treated with the goal of preserving the native esophagus, comparing surgical techniques and outcomes with current literature. Materials and methods: The data of patients treated for LGEA between 2013 and 2024 were collected from medical charts, focusing on patients treated with the preservation of their native esophagus. Results: Ten patients were enrolled for this study. All of them had a gap between the esophageal ends equal to or greater than three vertebral bodies. Four patients (40%) underwent a delayed primary anastomosis (DPA) procedure, while the remaining six (60%) underwent a traction staged repair. All patients were treated with open surgery. The follow-up period extended from 3 months to 10 years. Conclusion: Preserving the native esophagus in patients with LGEA is a challenging but feasible goal, with delayed primary anastomosis and traction techniques playing key roles. We advocate for the preservation of the native esophagus as the preferred approach for ensuring a high quality of life for patients, as it helps to avoid severe long-term complications associated with esophageal substitution.

Asunto(s)

RESUMEN

PURPOSE: Emergency surgery can save patients' lives in cases of severe caustic injury. However, the long-term outcomes are not well understood. METHODS: Patients who underwent emergency organ resection for severe corrosive acid injury were included. Subsequently, digestive tract reconstruction was performed to fit patients. Long-term outcomes were analyzed. RESULTS: Fifty patients underwent emergency digestive tract resection. The operative mortality rate was 6% (of 3/50). One of the 50 patients underwent successful immediate reconstruction. Of the 46 survivors with digestive tract discontinuity, 32 (70%) underwent subsequent reconstructive surgery, 10 (22%) died while awaiting reconstruction due to deterioration in their psychiatric and nutritional status, and 4 (9%) were unfit for reconstructive surgery. No operative mortality occurred during reconstruction. Among the 32 patients who underwent reconstruction, 30 (94%) achieved nutritional autonomy. Nutritional independence was achieved in 62% of the patients (31/50). At a median duration of 58 months, the median survival time of the 50 patients was 158 months. Patients who underwent reconstruction had a significantly better overall survival than those who did not (p < 0.0001). CONCLUSIONS: Emergency surgery remains the standard treatment for corrosive ingestion of complicated digestive tract injuries. However, only 60% of survivors can undergo subsequent digestive reconstruction and achieve long-term nutritional autonomy and a survival outcome.

RESUMEN

Introduction: Accidental caustic burns of the esophagus in children represent a significant global health challenge, often necessitating esophageal reconstruction. The aim of this study is to compare the efficacy and morbidity related to esophagus replacement with colonic and gastric tube transplants in a pediatric population followed for caustic stenosis. Methods: This retrospective study was conducted at a tertiary pediatric surgery unit for children treated from January 1989 to December 2022. We compared colonic and gastric tube esophageal replacement. Short term (within 30 days) and mid-term outcomes and complications were reviewed. Statistical evaluation was considered using a Chi-square test for categorical data analysis. Results: A total of 124 children with caustic esophageal burns were included. Among them, 23 (18.5%) had a gastric tube transplant for esophagus replacement and 101 (81.5%) a colonic transplant. During surgical intervention, we found a significantly higher risk of complications when using a colonic transplant (34%, p < 0.001). There was no significant statistical difference in postoperative short term and mid-term complications between the two techniques. Twenty-six (26%) of the children required a reoperation, with a higher risk in the gastric tube transplant group (p < 0.001). Endoscopic dilatation after surgery was also performed on a higher number of children who had received a gastric tube transplant (p = 0.005). Overall, 97.6% recovered full normal oral feeding. Conclusions: We found that colonic and gastric tube replacement are both good options for pediatric esophageal replacement after a caustic injury and show effectiveness over time. Gastric tube transplants carried a slightly higher risk of reoperations and a higher number of dilatations post-surgery. However, our groups are not really comparable, due to the much higher number of colonic transplants. Both surgical options have to be considered during surgery, and the choice depends on the anatomy of the patient. Our future research will focus on assessing long term quality of life and the potential risk of neoplastic complications.

RESUMEN

A uniquely challenging subset of infants diagnosed with esophageal atresia (EA) are those born with long-gap EA (LGEA). The common unifying feature in infants with LGEA is that the proximal and distal segments of the esophagus are too far apart to enable primary anastomosis via a single operation in the newborn period. Although any type of EA can technically result in a long gap, the Gross type A variant occurs in 8% of all EA cases and is most commonly associated with LGEA. In this review, we provide an evidence-based approach to the current challenges and management strategies employed in LGEA. There are fortunately a range of available surgical techniques for LGEA repair, including delayed primary repair, staged repair based on longitudinal traction strategies to lengthen both ends (e.g., Foker procedure, internal traction), and esophageal replacement using other portions of the gastrointestinal tract. The literature on the management of LGEA has long been dominated by single-center retrospective reviews, but the field has recently witnessed increased multi-center collaboration that has helped to increase our understanding on how to best manage this challenging patient population. Delayed primary repair is strongly preferred as the initial approach in management of LGEA in the United States as well as several European countries and is supported by the American Pediatric Surgery Association recommendations. Should esophageal replacement be required in cases where salvaging the native thoracic esophagus is not possible, gastric conduits are the preferred approach, based on the relative simplicity of the operation, low postoperative morbidity, and long-term durability. Long-term followup for monitoring of swallowing function, nutritional status, aspiration/respiratory illnesses, gastroesophageal reflux, and associated comorbidities is essential in the comprehensive care of these complex patients.

RESUMEN

Introduction: Esophageal replacement surgery in children is sometimes necessary for long-gap esophageal atresia. Ileocolic esophagoplasty in the retrosternal space can serve as a good alternative technique in case of hostile posterior mediastinum. We present two cases of successful ileocolic transposition performed at 6 months of age. Methods: Esophageal replacement was performed through a midline laparotomy incision associated with a left cervical approach. The ileocolic transplant was pediculized on the right superior colic artery after ligating the right colic and ileocolic vessels. A retrosternal tunnel was created, and the ileocolic transplant pulled through it to reach the cervical region. Proximally, esophageal-ileal anastomosis and, distally, colonic-gastric anastomosis were performed. Ileocolic continuity was repaired. Results: There were no early postoperative complications. In both cases, the patients presented oral feeding difficulties during the first 6 postoperative months. Thereafter, full oral feeding was achieved, and both patients were clinically asymptomatic during the following 18 and 20 years, respectively, with satisfactory oral radiological assessments, showing no redundancy or inappropriate growth of the graft and no anastomotic stricture. Currently, these patients do not complain of dysphagia, pathological reflux, or respiratory symptoms. Conclusion: When native esophagus preservation in long-gap esophageal atresia is estimated unfeasible, ileocolic transposition in the retrosternal space might be considered a good and safe option, particularly in those difficult cases after multiple previous surgical attempts and mediastinitis. This technique is putatively associated with a beneficial anti-reflux effect, thanks to the presence of the ileocecal valve, in preventing cervical peptic esophagitis. Long-term follow-up confirms that the transposed colon in the retrosternal space did not suffer any abnormal modification in size and growth.

RESUMEN

BACKGROUND: Esophageal replacement (ER) with gastric pull-up (GPU) or jejunal interposition (JI) used to be the standard treatment for long-gap esophageal atresia (LGEA). Changes of the ER grafts on a macro- and microscopic level however, are unknown. AIM: To evaluate long-term clinical symptoms and anatomical and mucosal changes in adolescents and adults after ER for LGEA. METHODS: A cohort study was conducted including all LGEA patients ≥ 16 years who had undergone GPU or JI between 1985-2003 at two tertiary referral centers in the Netherlands. Patients underwent clinical assessment, contrast study and endoscopy with biopsy. Data was collected prospectively. Group differences between JI and GPU patients, and associations between different outcome measures were assessed using the Fisher's exact test for bivariate variables and the Mann-Whitney U-test for continuous variables. Differences with a P-value < 0.05 were considered statistically significant. RESULTS: Nine GPU patients and eleven JI patients were included. Median age at follow-up was 21.5 years and 24.4 years, respectively. Reflux was reported in six GPU patients (67%) vs four JI patients (36%) (P = 0.37). Dysphagia symptoms were reported in 64% of JI patients, compared to 22% of GPU patients (P = 0.09). Contrast studies showed dilatation of the jejunal graft in six patients (55%) and graft lengthening in four of these six patients. Endoscopy revealed columnar-lined esophagus in three GPU patients (33%) and intestinal metaplasia was histologically confirmed in two patients (22%). No association was found between reflux symptoms and macroscopic anomalies or intestinal metaplasia. Three GPU patients (33%) experienced severe feeding problems vs none in the JI group. The median body mass index of JI patients was 20.9 kg/m2 vs 19.5 kg/m2 in GPU patients (P = 0.08). CONCLUSION: The majority of GPU patients had reflux and intestinal metaplasia in 22%. The majority of JI patients had dysphagia and a dilated graft. Follow-up after ER for LGEA is essential.

RESUMEN

AIM: A retrospective study was performed to evaluate the role of distance between upper and lower esophageal pouches and pouch lengths to predict delayed primary repair (DPR) in patients with isolated esophageal atresia (EA). METHODS: Patients with isolated EA were evaluated for demographic features, associated anomalies, surgical options, and complications. The babygrams obtained for evaluating gap assessment were examined for the distance between pouches and pouch lengths. Patients were divided into two groups: DPR and esophageal replacement (ER). RESULTS: Fourteen cases with a mean age of 4.1 ± 1.9 years (1-9 years) were included. Female to male ratio was 6:8. There was no significant difference between DPR and ER groups for pouch lengths. The median distance between two pouches were significantly higher in ER group [50 mm (29.4-83.6) vs 18.8 mm (3.4-34.5) (p < 0.05)]. The distance between two pouches and pouch lengths were similar in patients with and without anastomotic strictures (p > 0.05). CONCLUSION: Both upper and lower pouch lengths were shorter in ER group compared to DPR group. However, pouch lengths cannot be considered as a single criterion to predict the need for ER. Large cohort of patients are needed to define the cut-off values for shortest pouch length to achieve a DPR.

Asunto(s)

RESUMEN

INTRODUCTION: Corrosive ingestion forms serious problem, with various outcomes depending on the time of diagnosis and treatment. We report here a case with rare and dangerous complications. PRESENTATION OF CASE: A two-year-old girl came to our hospital, complaining of solids' dysphagia. Retrieving her medical history showed that she had ingested a corrosive liquid accidentally. Without knowing the nature of the ingested agent, the local doctor removed it, using nasal gastric tube. This procedure induced vomiting, which in turn led to more damage. She stayed in the area's hospital for 40 days with just supportive treatment. The radiological investigations suggested severe stenosis. The dilation was done, but the patient did not respond after three months of treatment. Therefore, a gastrostomy was done. The esophagus replacement was inevitable, but the parents refused the surgical approach. Three months later, she returned to our hospital complaining of a productive cough. The radiological investigations suggested destruction in the left lung with a high suspicion of tracheoesophageal fistula. The treatment was through a surgical approach by removing the damaged lung tissue and closing the tracheoesophageal fistula. The patient got better after a month of the surgery, which allowed us to replace the esophagus and close the tracheoesophageal fistula. DISCUSSION: corrosive treatment varies a lot, depending on the patient's situation. Accurate treatment prevents severe and unexpected complications. CONCLUSION: More stringent instructions should be enacted among medical providers, corrosive agents' producers, and the public to be more careful when dealing with corrosive chemicals.

RESUMEN

Caustic or corrosive substance ingestion that results in severe esophageal and gastric lacerations frequently requires surgical management. The most common sequelae after an upper gastrointestinal tract caustic injury include non-responding luminal strictures, which are subject to esophageal replacement. Late corrective surgery may include esophagectomy with gastric pull-up and jejunal or colonic interpositions. Although long-segment esophageal reconstruction with jejunum is technically feasible and has demonstrated good outcomes, the complexity of the surgery has precluded the widespread use of this procedure in low- and middle-income countries. This document summarizes the most relevant aspects of caustic ingestion surgical management and describes the first Latin American experience in the reconstruction of an esophageal-gastric caustic injury using a pedicled jejunal interposition, as a viable and functional option in mid- and lower-income countries with well-established Thoracic Surgery departments and microsurgery access.

RESUMEN

BACKGROUND: Reflux 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. METHODS: All 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. RESULTS: Eleven 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. CONCLUSIONS: The 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 EVIDENCE: IV.

Asunto(s)

RESUMEN

Dysphagia occurs temporarily or permanently following esophageal replacement in at least half of the cases. Swallowing disorder, in addition to severe decline in the quality of life, can lead to a deterioration of the general condition, which may lead to death if left untreated. For this reason, their early detection and treatment are a matter of importance. Between 1993 and 2012, 540 esophageal resections were performed due to malignant tumors at the Department of Surgery, Medical Center of the University of Pécs. Stomach was used for replacement in 445 cases, colon in 38 cases, and jejunum in 57 cases. The anastomosis with a stomach replacement was located to the neck in 275 cases and to the thorax in 170 cases. The colon was pulled up to the neck in each case. There were 29 cases of free jejunal replacements located to the neck and 28 cases with a Roux loop reconstruction located to the thorax. Based on the literature data and own experience, the following were found to be the causes of dysphagia in the order of frequency: anastomotic stenosis, conduit obstruction, peptic and ischemic stricture, foreign body, local recurrence, functional causes, new malignant tumor in the esophageal remnant, and malignant tumor in the organ used for replacement. Causes may overlap each other, and their treatment may be conservative or surgical. The causes of many dysphagic complications might be prevented by improving the anastomosis technique, by better preservation the blood supply of the substitute organ, by consistently applying a functional approach, and by regular follow-up.

Asunto(s)

RESUMEN

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.

Asunto(s)

RESUMEN

Purpose: The classical colon substitution procedure is open surgery. Still, technological developments could allow a minimally invasive procedure that might improve patient outcomes. To present the efficacy and safety of esophagocolonic OrVil anastomosis after minimally invasive esophagectomy. Methods: This retrospective study included 10 patients with esophageal cancer treated with OrVil anastomosis (OA) between August 2017 and May 2021 at Department of Thoracic Surgery, Nanjing Lishui People's Hospital, Zhongda Hospital Lishui Branch, Southeast University, Nanjing, China and the Fourth Associated Hospital of Anhui Medical University. The patient's characteristic information and related perioperative indexes were collected from the hospital's electronic medical record system and the patients were followed up. Results: The mean operative time and median intraoperative blood loss were 530 ± 88 minutes and 200 (range: 100-300) mL, respectively. A median of 26 (range: 13-30) lymph nodes was dissected per patient. The median total duration of hospitalization and postoperative hospitalization was 32 (range: 24-64) and 15 (range: 12-42) days, respectively. Seven (70%) patients had postoperative pulmonary infections. Two (20%) patients had postoperative respiratory failure. No esophagocolonic anastomotic leakage was observed in all cases. One patient was complicated with postoperative colonicoduodenal anastomotic leakage after the operation and was cured. However, 1 (10%) of the remaining 9 patients died from colonicolonic anastomotic leakage during hospitalization. The living 9 cases were followed up, and the median overall survival time was 36 months. Conclusion: Colonic interposition for esophageal cancer is effective and safe using the minimally invasive OA technique.

Asunto(s)

RESUMEN

AIM: The main indications for an esophageal replacement (ER) are unresolved complex esophageal atresia (EA) and caustic strictures (CS). The use of different organs for replacement has been described. When the stomach is chosen, there are two ways to do a gastric pull-up: a partial (PGP) or a total pull-up (TGP). Few studies have been published comparing the different techniques. The aim of this study was to compare the outcomes of patients who underwent ER by PGP or by TGT. METHODS: The medical records of all patients who underwent gastric pull-up for ER in the last 18 years at the National Pediatric Hospital Prof. Dr. Juan P. Garrahan were reviewed. The study is comparative, retro-prospective and longitudinal. Patients were divided in two groups according to the ER technique (PGP or TGP). We compared the following outcomes: duration of the operation, days of hospitalization in the intensive care unit (ICU), days of total hospitalization, time to initiation of oral feedings and rate of anastomosis dehiscence, incidence of anastomotic stenosis, need for re-operations, incidence of gastroesophageal reflux disease (GERD), incidence of tracheo-esophageal fistulas (TEF), incidence of dumping syndrome, incidence of gastric necrosis and mortality. RESULTS: There were 92 patients included in the study: 70 in the PGP group (76%) and 26 in the TGP group (24%). The two groups were demographically equivalent. Patients in the TGP group had a statistically significant lower incidence of anastomotic dehiscence (22,7% versus 54,3%; p = 0.01) and dumping syndrome (13,6% versus 37,1%; p = 0.038). Patients in the TGP had lower incidence of anastomotic stenosis, although the difference was not statistically significant. There were no statistically significant differences between the groups in terms of duration of the operation, postoperative days in the ICU, time to oral feedings, GERD, TEF or overall hospital stay. There were no cases of gastric necrosis. There were 3 deaths in the PGP group and one in the TGP group. CONCLUSIONS: We observed benefits in the TGP group versus the PGP approach in terms of anastomotic dehiscence and dumping syndrome, as well as a trend toward a lower incidence of anastomotic stenosis. Based on this experience, we recommend the TGP approach for patients who need an esophageal replacement by a gastric pull-up. LEVELS OF EVIDENCE: According to the Journal of Pediatric Surgery this research corresponds to type of study level III for retrospective comparative study.

Asunto(s)

RESUMEN

BACKGROUND DATA: EA is the most frequent congenital esophageal malformation. Long gap EA remains a therapeutic challenge for pediatric surgeons. A case case-control prospective study from a multi-institutional national French data base was performed to assess the outcome, at age of 1 and 6 years, of long gap esophageal atresia (EA) compared with non-long gap EA/tracheo-esophageal fistula (TEF). The secondary aim was to assess whether initial treatment (delayed primary anastomosis of native esophagus vs. esophageal replacement) influenced mortality and morbidity at ages 1 and 6 years. METHODS: A multicentric population-based prospective study was performed and included all patients who underwent EA surgery in France from January 1, 2008 to December 31, 2010. A comparative study was performed with non-long gap EA/TEF patients. Morbidity at birth, 1 year, and 6 years was assessed. RESULTS: Thirty-one patients with long gap EA were compared with 62 non-long gap EA/TEF patients. At age 1 year, the long gap EA group had longer parenteral nutrition support and longer hospital stay and were significantly more likely to have complications both early post-operatively and before age 1 year compared with the non-long gap EA/TEF group. At 6 years, digestive complications were more frequent in long gap compared to non-long gap EA/TEF patients. Tracheomalacia was the only respiratory complication that differed between the groups. Spine deformation was less frequent in the long gap group. There were no differences between conservative and replacement groups at ages 1 and 6 years except feeding difficulties that were more common in the native esophagus group. CONCLUSIONS: Long gap strongly influenced digestive morbidity at age 6 years.

Asunto(s)

RESUMEN

PURPOSE: The choice of Esophageal replacement (ER) depends on surgeons' preference and patients' anatomical condition. A cross-sectional study was done to compare the long-term outcomes of two methods of ER, Gastric transposition (GT) and Colonic interposition (CI). METHODS: Children who had undergone ER from January 1997 to December 2017 with a minimum of two-year post-ER follow-up were evaluated by anthropometry, hepatobiliary scintigraphy, gastroesophageal reflux study, gastric emptying test, pulmonary function test and blood tests. RESULTS: Twenty-six (Male:female=17:9) children were recruited. The median age at ER was 13 months (interquartile range 9-40 months) and mean follow-up post-ER was 116.7 ± 76.4 months (range 24-247 months). GT:CI was done in 15(57.7%):11(42.3%) cases. A greater number of abnormal oral contrast studies (p = 0.02) and re-operations (p = 0.05) were documented as baseline characteristics with CI group. The presence of gastroesophageal reflux 9/23(39.1%), duodenogastric reflux 6/24(25%), delayed gastric emptying 6/25(24%), abnormal pulmonary function test 14/22(63.6%) were documented during the study period. However, there was no significant(p>0.05) difference in nutritional, developmental and functional outcomes of both operative methods of ER in the study. CONCLUSION: Assessment of nutritional, developmental and functional parameters in children after ER reveals good long-term results. There was no significant difference in CI and GT. LEVEL OF EVIDENCE: Comparative study; II.

Asunto(s)

RESUMEN

Resumen Objetivo: Describir resultados de la cirugía de sustitución esofágica con tubo gástrico invertido, vía ascenso retroesternal en dos hospitales pediátricos durante el período marzo 2015 a marzo 2018. Materiales y Método: Un estudio observacional, transversal, con recolección de datos retrospectivo, donde se incluyeron todos los expedientes de pacientes que presentaban patología del esófago por causa adquirida o congénita que fueron operados de sustitución esofágica con tubo gástrico invertido en dos hospitales pediátricos durante 3 años. Resultados: Encontramos 29 niños sometidos a sustitución esofágica, de los cuales 27 cumplieron criterios de inclusión. La edad comprendida entre 2 y 17 años. El 63% corresponde al sexo femenino. La causa más frecuente de sustitución esofágica es por estenosis esofágica por ingesta caustica (92,59%). El 70% presentó algún tipo de complicación luego de la cirugía. La fístula esofagocutánea es la complicación principal con 33,33%. La permanencia en la unidad de cuidados intensivos es menor de 24 horas en un 74% de los niños. Se inicia la vía oral en casi la mitad de casos entre los 10-12 días de posquirúrgico, la estancia hospitalaria es en promedio 18,5 días. La mortalidad es 3,7%. Conclusión: La sustitución esofágica por tubo gástrico invertido vía ascenso retroesternal, es una técnica comparable en resultados a la interposición de colón. Para los autores, el estómago es un órgano ideal para realizar la reconstrucción esofágica, y sus complicaciones son manejables.

Aim: To describe the results of esophageal replacement surgery with an inverted gastric tube via retrosternal ascent in two pediatric hospitals during the period March 2015 to March 2018. Materials and Method: an observational, cross-sectional study with retrospective data collection that included all the records of patients with esophageal discontinuity due to acquired or congenital causes who underwent esophageal replacement surgery with an inverted gastric tube in two pediatric hospitals for 3 years. Results: We found 29 children undergoing esophageal replacement, of which 27 met inclusion criteria. The age between 2 to 17 years. 63% corresponds to the female sex. The most frequent cause of esophageal replacement is esophageal stricture due to caustic ingestion (92.59%). 70% presented some type of complication after surgery. The esophagocutaneous fistula is the main complication with 33.33%. The stay in the intensive care unit is less than 24 hours in 74% of children. The oral route is started in almost half of cases between 10-12 days after surgery; the hospital stay is on average 18.5 days. Mortality is 3.70%. Conclusión: The esophageal substitution by inverted gastric tube via retrosternal ascent is a technique comparable in results to the interposition of the colon. For the authors, the stomach is an ideal organ to perform esophageal reconstruction, and its complications are manageable.

Asunto(s)

RESUMEN

Introducción: existen dos rutas para realizar el reemplazo de esófago (RE), la retroesternal (RRE) y la mediastinal posterior (RMP). El objetivo del estudio es comparar los pacientes que recibieron un ascenso gástrico parcial empleando estas dos rutas. Material y métodos: Se revisaron las historias clínicas de 51 pacientes con ascenso gástrico parcial, en 27 años en el Hospital Garrahan. Se utilizó la vía RRE en 25 casos y la RMP en 26. Fueron comparados los datos epidemiológicos de los grupos y las variables para valorar la dificultad del acto quirúrgico, evolución inmediata y alejada. El estudio es comparativo, retro-prospectivo y longitudinal. Resultados: las características generales de los pacientes fueron similares. Los que recibieron el ascenso gástrico por vía RMP presentaron una menor incidencia de dehiscencia (p=0,017), de enfermedad por reflujo gastroesofágico (ERGE) (p=0,001) y de dumping (p=0,0001). No hubo diferencias estadísticamente significativas entre los dos grupos al comparar la duración del procedimiento, días de internación total y en Unidad de Cuidados Intensivos (UCI), días de permanencia en asistencia respiratoria mecánica (ARM), inicio de alimentación oral y estenosis de la anastomosis. Se observó una tendencia clínicamente relevante, que no alcanzó significancia estadística en las complicaciones intraquirúrgicas y número de dilataciones postoperatorias. No hubo necrosis del ascenso. Fallecieron 2 pacientes. Conclusiones: considerando la menor incidencia de dehiscencia, ERGE y dumping reemplazados por RMP, elegimos a ésta como nuestra primera opción para el reemplazo esofágico en la infancia (AU)

Introduction: The two routes for esophageal replacement (ER) are retrosternal (RRE) and posterior mediastinal (PMR). The aim of the study was to compare patients who received a partial gastric pull-up using either of these two routes. Material and methods: The clinical records of 51 patients who underwent partial gastric pull-up over 27 years at the Garrahan Hospital were reviewed. The RRE route was used in 25 and the RMP in 26 cases. The epidemiological data of the groups and the variables to evaluate the complexity of the surgical procedure, and shortand long-term outcome were compared. A comparative, retroprospective, and longitudinal study was conducted. Results: the general characteristics of the patients were similar. Those who underwent gastric pull-up via PMR had a lower incidence of dehiscence (p=0.017), gastroesophageal reflux disease (GERD) (p=0.001), and dumping (p=0.0001). No statistically significant differences were found between the two groups when comparing the duration of the procedure, days of total hospital and intensive care unit (ICU) stay, days on mechanical ventilation (MV), initiation of oral feeding and stenosis of the anastomosis. A clinically relevant trend, which did not reach statistical significance, was observed in intraoperative complications and number of postoperative dilatations. There was no necrosis of the pull-up. Two patients died. Conclusions: considering the lower incidence of dehiscence, GERD, and dumping associated with PMR, this was our first choice for esophageal replacement in infancy (AU)

Asunto(s)

RESUMEN

INTRODUCTION: Preoperative gastric ischemic conditioning (IC) improves the outcome of esophageal replacement gastroplasty and is associated with low morbidity. However, when the stomach cannot be used for esophageal replacement, a colonic replacement is required. The study aim was to assess the viability of right colon and terminal ileum IC in a rat model and the histological damage/recovery sequence and determine if neovascularization is a potential adaptive mechanism. METHODS: The study was conducted in Rattus norvegicus with ileocolic vascular ligation. Seven groups of animals were established (6 rats per group) with groups defined by the date of their post-IC euthanasia (+1, +3, +6, +10, +15, and +21 days). Comparisons were made with a sham group. Viability of the model was defined as <10% of transmural necrosis. The evaluation of histological damage used the Chiu score in hematoxylin and eosin sections of paraffin-embedded specimens with CD31 immunohistochemical assessment of neovascularization by the median of submucosal vessel counts in 5 high-magnification fields. RESULTS: Transmural colon necrosis occurred in 1/36 animals (2.78%) with no animal demonstrating transmural ileal necrosis. The maximum damage was observed in the colon on +1 day post-IC (average Chiu score 1.67, p = 0.015), whereas in the ileum, it was on days +1, +3, and +6 (average Chiu score 1.5, 1.3, and 1.17; p = 0.015, 0.002, and 0.015, respectively). In the +21-day group, histological recovery was complete in the colon in 4 (66.7%) of the 6 animals and in the ileum in 5 (83.3%) of 6 animals. There were no significant differences in quantitative neovascularization in any of the groups when compared with the sham group or when comparisons were made between groups. CONCLUSIONS: The tested animal model for IC of the colon and terminal ileum appeared to be feasible. Histological damage was maximal between the 1st and 3rd day following IC, but by day 21, recovery was complete in two-thirds of the rats. There was no evidence in this preliminary IC model that would suggest neovascularization as an adaptive mechanism.

Asunto(s)