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Paediatric Surgery, Shaikh Zayed Hospital, Lahore
Corrosive Intake & Esophageal Replacement
Contents
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Corrosive Intake
Contents
Esophageal Perforation
The esophagus doesnt have a serosal layer so more chances of mediastinitis
Pharyngeal perforation
Respiratory distress, excessive salivation, difficulty passing NG.
Hydropneumothorax in esophageal perforation
Right sided --> mid esophageal injury
Left sided --> distal esophageal injury
X ray findings
Pneumomediastinum
WIdening of mediastinum
Hydropneumothorax
Pleural effusion
Esophagogram: Study of choice.
Chest CT with contrast:
Esophageal thickening
Esophageal pleural fistula
Pleural effusion
mediastinal collection
Medical:
Keep NPO
Source control: Chest tube (drain of collections)
Augmenting host defences with antimicrobials
Nutritional Support: NG under flouroscopic guidance
Contained leak with minimal mediastinal contamination
Conservative
Cervical esophageal perforations if small and contained can be treated by either or drainage alone.
Indication of surgery
Failed medical management
Massive intrapleural or retropharyngeal leak or persistent leak
Preop:
Maintanence of oxygen saturation
Two IV lines
Volume resuscitation
Blood products should be available
Steps
Cervical:
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Left cervical incision: A transverse incision is made on the left side of the neck 1 cm above and parallel to the medial third of the clavicle
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Open the platysma, if needed ligate the anterior jugular vein.
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SCM and carotid sheaths are retracted laterally (The common carotid artery lies medial to the internal jugular vein.)
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Thyroid and trachea retracted medially
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Blunt dissection to the prevertebral space
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Exposure can then be extended superiorly and inferiorly to expose the area
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Following repair a closed suction drain is placed
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Take care of the RLN that is in the tracheoesophageal groove
Mid esophageal injury
RIght posterolateral thoracotomy in 4th or 5th intercostal space
Distal esophagus
Left thoracotomy in the 6th or 7th intercostal space
Intraabdominal
High laparotomy or low left thoracotomy
Thoracic approach
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Open perietal pleura longitudinally to expose the perforation
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devitalised tissue should be debrided
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Chest and mediastinum should be irrigated and widely drained with multiple drains.
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If possible: primary repair with autologous coverage (pleural flap, intercostal muscle flap or omentum is preferred)
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Debride muscle and repair with absorbable sutures
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If primary repair not possible: significant inflammation or greater extent or injury or delayed injury then esophageal T tube can be inserted and creating the perforation into a controlled esophagocutaneous fistula
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If there is severe esophageal damage or necrosis (in case of chemical damage), it may require esophagectomy or cervical esophagostomy
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If perforation in cases of distal obstruction or achlasia: esophagomyotomy on the opposite site of perforation.
Post operative care
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Monitor drain output
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Esophagogram should be obtained 7-10 days after the initial surgical approach
Follow up
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OPD followup for at least 6 months to monitor for stricture or fistula.
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Call after 1 week for wound healing, weight, nutrition, swallowing ability and respiratory status
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Then biweekly for nutritional followup: small frequent meals, high protein, high calorie diet on prop up position.
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Monitor for symptoms, if symptomatic then go for contrast/endoscopy
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PPIs, prokinetics or supplements can be given.
Gastric transposition
Principles
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Mobilize the stomach sufficiently for a tension-free reach.
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Remove or exclude the diseased esophagus safely.
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Choose the safest and shortest route for transposition.
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Avoid twisting or kinking of the stomach conduit.
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Create a well-perfused, tension-free anastomosis.
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Ensure unobstructed gastric drainage and emptying.
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Protect the airway, recurrent laryngeal nerves, and mediastinal structures.
Gastric transposition
Position: Supine
Upper midline or left subcostal abdominal incision.
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The initial feeding gastrostomy should ideally have been sited on the anterior surface of the body of the stomach, well away from the greater curvature, in order to preserve the vascular arcades of the gastroepiploic vessels
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Mobilise the stomach from the left lobe of the liver
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Mobilise the greater curvature by dividing the gastrocolic omentum and short gastric vessels Ligate them well away from the stomatch wall to preserve the vascular arcades of right gastroepiploic vessels and preventing damage to spleen
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Free the lesser curvature by dividing the lesser omentum. The right gastric artery is preserved here. The left gastric vessels are ligated and divided close to the stomach.
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The lower esophagus is exposed by dividing the phrenoesophageal ligament and margins of the esophageal hiatus in the diaphram are identified.
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The inevitably short, blind-ending lower esophageal stump is dissected out of the posterior mediastinum by a combination of blunt and sharp dissection through the diaphragmatic hiatus. The anterior and posterior vagal nerves are divided during this part of the procedure. The body and fundus of the stomach are now free from all the attachements and can be delieved into the wound.
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The esophagus is transected at the gastroesophageal junction and the defect closed in two layers with 4/0 polyglycolic acid sutures.
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The second part of the duodenum may be Kocherized to obtain maximum mobility of the pylorus.
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The highest part of the fundus of the stomach is identified and stay sutures of different material are inserted to the left and the right of the area selected for the anastomosis. These sutures help to avoid torsion
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A short Heinecke–Mikulicz pyloroplasty is performed, the transverse incision being closed horizontally with interrupted fine polyglycolic acid sutures.
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Attention is now turned to the neck, where the previously constructed cervical esophagostomy (preferably performed on the left side) is mobilized via a 3–4 cm transverse incision, taking care not to damage the muscular coat of the esophagus. The recurrent laryngeal nerve coursing upwards on the posterolateral surface of the trachea is identified and preserved. It is important to mobilize at least 1–1.5 cm full-thickness esophagus to allow a satisfactory anastomosis to take place.
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A plane of dissection between the membranous posterior surface of the trachea and the prevertebral fascia is established, and a tunnel is created into the superior mediastinum by blunt dissection immediately in the midline.
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A similar tunnel is fashioned from below in the line of the normal esophageal route, by means of blunt dissection through the esophageal hiatus in the posterior mediastinal space posterior to the heart and anterior to the prevertebral fascia
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When continuity of the superior and inferior posterior mediastinal tunnels has been established, the space to be occupied by the stomach is developed into a tunnel of two to three fingers’ breadth (There will be occasions when fashioning of the posterior mediastinal tunnel by blind dissection is impossible or hazardous due to inflammation, fibrosis from previous surgery, or adhesions following previous perforation or caustic ingestion. Under these circumstances, it is necessary to perform a lateral thoracotomy and for the dissection to be carried out under direction vision)
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.A wide-caliber nasogastric tube is passed through the posterior mediastinal tunnel from the cervical incision to appear via the esophageal hiatus into the abdominal wound. The two stay sutures on the fundus of the stomach are tied to the tube, which is then gently withdrawn, pulling the stomach up through the esophageal hiatus and the posterior mediastinal tunnel into the cervical incision.
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Orientation of the fundus is checked by realigning the stay sutures in their correct position to avoid torsion of the stomach in the mediastinum.
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The transected end of the cervical esophagus is now anastomosed to the highest part of the stomach using a full-thickness single layer of interrupted 4/0 polyglycolic acid sutures.
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A 10–12 Fr transanastomotic nasogastric tube is inserted Figure No. 23 into the intrathoracic stomach before completing the 7a _ anterior layer of the anastomosis.
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A soft rubber drain may be placed at the site of the anastomosis in the neck and the wound is closed in layers.
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The margins of the diaphragmatic hiatus are sutured to the antrum of the stomach with a few interrupted sutures
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A fine-bore feeding jejunostomy has been found to be of considerable value in providing enteral nutrition in the first few weeks following gastric transposition
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The gastroesophageal anastomosis is shown in the cervical region with the nasogastric tube passing into the intrathoracic stomach. The pyloroplasty is below the diaphragm and a feeding jejunostomy tube is inserted for postoperative feeding.
Colon interposition
Bowel Preperation
During gastrostomy (for esophageal atresia or caustic injury), the middle colonic artery may be ligated to increase the vascularity of the colon by increasing blood flow through the marginal vessels. Prior to esophageal replacement, the child is admitted and clear liquids are given for 24 hours preoperatively.
Polyethylene glycol electrolyte solution is given at a rate of 25–40 mL/kg per hour until stools are clear. Intestinal antiseptics are given orally 3 days before surgery with neomycin and erythromycin. On the day of surgery, intravenous cephalosporin and metronidazole are added.
Principles
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Choose a well-vascularized colon segment
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Preserve the marginal artery
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Avoid twisting of the mesentery
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Ensure tension-free anastomosis
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Usually use posterior mediastinal route
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Usually perform cervical esophagocolic anastomosis
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Add feeding jejunostomy
Steps
Position: Supine
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A midline incision is made and the colon is examined. Vascular supply to the colon dictates the segments to be transposed into the chest.
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For left colon: Small vascular clamps are placed on the middle colic artery, if not previously ligated, to evaluate the graft perfusion before dividing the vessels. At the same time, intestinal clamps are placed at the two extremities of the graft to stop the transmural vascularization. The perfusion of the proposed graft by the residual blood supply is assessed after 10 minutes and if adequate, the clamped vessels are divided centrally at their origin
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The colon is then divided at the appropriate length and measured by tape going through the mesentery of the transverse colon. An alternative, where the left colon is not available, is to use the right colon, cecum and a section of the distal ileum, based on the ileocolic vessels, passed retrosternally isoperistaltically into the neck, with the ileum anastomosed to the cervical esophagus.
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the cervical esophagus is approached via an oblique or transverse right neck incision. The neck vessels are retracted and the proximal esophagus is mobilized within the thoracic inlet
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Once the colon graft is mobilized, the distal esophageal stump is resected, if possible, at the stomach with a linear stapling device to avoid reflux in the stump.
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Colonic interposition is passed behind the stomach and pulled through the chest. The graft is placed in the posterior mediastinum in the esophageal bed. This is the preferred route as it is the shortest distance to the cervical region and results in less dysphagia and reflux and improved graft function. In cases with severe scarring in the native esophageal bed, the graft is placed retrosternally.
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The proximal anastomosis between esophagus and colon is created in the neck with a single layer of absorbable sutures and colon is fixated to the neck muscle.
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The gastrocolic anastomosis is performed at the anterior gastric wall below the fundus which limits gastrocolonic reflux compared with cardiac positioning. The anastomosis is partially wrapped with stomach. Pyloroplasty is created and temporary gastostomy is left for gastric decompression and transition to oral feeds.
