Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia.

The majority of esophageal procedures performed in infants and children are done for congenital esophageal atresia or acquired caustic strictures. With the former, the vast majority (92–97%) can be corrected without difficulty by primary esophagoesophagostomy. 1,2 Successful esophageal anastomoses may even be performed in those few with “long gap” esophageal atresia, defined as a distance of more than 3 cm between the proximal and distal esophageal remnants, with use of circular myotomies, serial preoperative proximal and distal pouch dilation, and other lengthening techniques. 3–7 Preservation of the native esophagus is desirable and can be achieved in most cases. However, some patients with long gap esophageal atresia will require esophageal replacement. In addition, a number of those patients who are managed with primary repair will require an esophageal substitution as a result of complications of the primary procedure or development of refractory gastroesophageal reflux, persistent stricture, and/or esophageal dysfunction. In those patients, preservation of the esophagus may be futile. Caustic injuries represent the second most common reason for esophageal replacement in children. Despite enhanced public education, safer packaging, and reduction in the concentration of sodium hydroxide in the most commonly used drain cleaner fluids, caustic injuries to the esophagus continue, especially in the less developed parts of the world, though at a lower rate; the result is the formation of strictures, which can usually be managed with serial dilation. 8 However, 59% of severe caustic injuries will result in long and sometimes multiple strictures that are refractory to serial dilation. 9 The only option in these patients for restoration of esophagogastric continuity is esophageal replacement. Alternatives for esophageal replacement in infants and children in the past have included a right or left colon interposition, formation of a gastric tube, and a jejunal interposition. All of these have advantages and disadvantages related to short- and long-term complications (Table 1). In 1980, Atwell et al described the use of the stomach as a replacement for the esophagus in six children, all but one of whom were newborns with congenital atresia of the esophagus. 10,11 This was followed in 1987 with a review by Spitz et al, from the United Kingdom, of gastric transpositions performed in 34 infants, 32 of whom had esophageal atresia. 12 Graft survival was 100% and outcome was excellent in 81% of the surviving patients. However, adoption of this technique in the United States has been slow, with few pediatric surgeons performing the procedure. Table 1. SUMMARY OF LITERATURE DATA In 1985, we switched from using colon interpositions to gastric transpositions for esophageal replacement in infants and children. Over the last 17 years we have performed 21 of these procedures at the C.S. Mott Children’s Hospital and have been involved in an additional 20 performed at other centers. The purpose of this report is to review our experience with these 41 gastric transpositions and to assess the advantages and disadvantages of this approach compared with alternative conduits.