Journal of Pediatric Surgery JULY 1991
VOL 26, NO 7
Ileocolic
Replacement of Esophagus in Children Esophageal Stricture
With
By Mao-Tang Han Tianjin, People’s Republic of China 0 Between 1970 and 1988, 12 restrosternal esophageal substitutions using an ileocolic interposition were performed. The ages of the 12 children ranged from 2 to 8 years. In 11 children the esophageal strictures were secondary to ingestion of caustic liquid. All patients had failed esophageal dilation therapy. One death occurred on the 7th postoperative day following an episode of cardiac arrest at surgery. Early postoperative complications included three cervical ileoesophageal anastomotic leaks, which healed spontaneously. One patient had gastrointestinal bleeding 10 years postoperatively. This was controlled by antacid therapy without recurrence. Redundancy of the interpositioned ileocolic segment was observed in three children. All 11 surviving patients can eat a normal diet and have normal growth and development. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
Esophageal replacement.
E
SOPHAGEAL stricture due to the accidental swallowing of corrosive liquid has been the most frequent cause of severe esophageal stricture in children. Early successful use of the colon for esophageal replacement in a child for stricture from lye ingestion was reported in 1921 by Lundblad.’ In 1954 Waterston’ described his first successful colon esophageal replacement by the intrathoracic route. In 1957, Sherman and Waterston reported the substernal colon interposition for esophagus in infants and children. Subsequently, the use of the colon as a substitute for esophagus in children has become a well-established surgical procedure. From June 1970 to May 1988 at the Children’s Hospital of Tianjin, China, 12 children underwent esophageal replacement for stricture. The latest follow-up was made in 1989 and forms the basis of this report. MATERIALS AND METHODS The age of the 12 children (8 boys and 4 girls) at the time of esophageal replacement ranged from 2 to 6 years. In 11 children the stricture was secondary to ingestion of caustic liquid. One child JournalofPediatric Surgery, Vol26, No 7 (July), 1991: pp 755-757
had congenital esophageal stricture. In all 12 the stricture had been resistant to dilatation therapy. The duration of dilation therapy varied between 3 and 18 months. Ten patients had had gastrostomy to facilitate retrograde dilation of the esophagus and to provide nutrition. Four patients had undergone a left-sided cervical esophagostomy, 2 of these for control of empyema that resulted from perforation of the esophagus during repeat dilation therapy by the otolaryngology department.
Surgical Procedure All 12 patients underwent a one-stage procedure. In each patient a retrosternal segment consisting of the terminal ileum and right colon was used. The blood supply of the ileocolic segment was from the middle colic artery and the marginal arcades. With the patient in the supine position, the patient’s head was turned to the right and the neck was extended posteriorly. Adequate exposure of the suprasternal notch and left side of the neck was obtained. Skin preparations and draping included the entire abdomen, check, and left cervical regions. This permits thoracotomy or insertion of a chest tube for drainage of a pneumothorax if it occurs during dissection of the retrosternal tunnel. The abdominal cavity was entered via a midline incision, the viscera were exposed, and the blood supply of the colon and the terminal ileus was evaluated. The blood vessels were occluded for 3 minutes of observation to avoid ischemic necrosis of the bowel. A length of right colon and terminal ileum sufficient to reach the neck of the patient was measured. The appropriate blood vessels were then ligated and the right colon, with a segment of terminal ileus, was divided. The appendix was excised in conventional fashion. The transplant segment and its vascular pedicle was passed through the gastrohepatic ligament posterior to the stomach. The cologastrostomy was made on the anterior wall of the antrum. An incision was made along the anterior margin of the left sternomastoid muscle. The ileal end of the transplant segment was brought up to the neck through the substernal tunnel, and an esophagoileal
From the Department of Surgery, Tianjin Children’s Hospital, Tianjin, People S Republic of China. Presented at the 23rd Annual Meeting of the Pacific Association of Pediatric Surgeons, Kona, Hawaii, June 3-61990. Address reprint requests to Mao-Tang Han, MD, Department of Surgery, Tianjin Children’s Hospital, Tianjin, People’s Republic of China. Copyright 0 1991 by W.B. Saunders Company 0022-3468/91/2607-0001$03.00/0 755
756
MAO-TANG
anastomosis was established with two layers of interrupted sutures using 4-O silk suture. A rubber drain was used routinely in the cervical incision. The continuity of the intestinal tract was reestablished by an ileocolic anastomosis. RESULTS
Eleven of the 12 children were eating well at discharge. There was an operative death early in this series in a 2-year-old child resulting from cardiac arrest during surgery and death due to respiratory failure on the 7th postoperative day due to respiratory failure. This death was preventable. Complications
In 3 children a small leak occurred from the cervical anastomosis. The children continued eating. Careful attention was given to ensure adequate drainage. Within 2 weeks the leak healed spontaneously. No stricture resulted. In another child, a slight stricture developed at the site of cervical anastomosis. The stricture responded to dilation therapy. Two children had early transient dysphagia. Both underwent esophagoscopy, and only edema around the site of anastomosis was found. A liquid diet was given for a few days, and the dysphagia disappeared. In one child, a small bowel obstruction due to postoperative adhesion band formation developed. It was treated by enterolysis. One child suffered massive gastrointestinal bleeding 10 years after the colon interposition. The bleeding resolved with antacid therapy. The child has remained well without recurrence. Follow- Up
The latest follow-up in February 1989, which ranged from 2 to 19 years after surgery, showed that the growth and development of these patients was satisfactory. All could eat a regular diet without difficulty. Two had dysphagia when eating large meals. Barium swallow study showed that liquid barium passed into the stomach promptly when the patient was in the standing position. No obstruction was observed at the ileocecal valve or at the site of the anastomoses. In two patients, redundancy of the colon and a temporary air-fluid level after meal was noted in the transplanted action. However, there were no clinical symptoms. DISCUSSION
In North China, liquid lye (sodium hydroxide) is commonly used as a wall painting material. Because the liquid form of lye is odorless and colorless, it may be swallowed accidentally. Of the 12 children in the present series, 11 had swallowed lye. In every case,
HAN
the corrosive material was in contact with the esophageal mucosa for only a few seconds. A deep extensive irregular circular injury was produced. Although in the present series early management was prompt and dilation combined with steroid therapy was aggressive, the esophageal stricture was irreversible. Varied surgical procedures have been used for the treatment of the undilatable esophageal stricture4-‘; these have included the use of small intestine, skin tube, and gastric tube made by gastric flap from the great curvature, as well as the use of colon. In the present series, the right colon with a segment of terminal ileum was preferred for esophageal substitution. The ileocolic segment was placed in the retrosternal tunnel in an isoperistaltic position and the colon was anastomosed to the stomach. Although studies by others*~” showed no functional difference between the isoperistaltic or antiperistaltic position, the colon has proven to be more acid resistant and promptly clears any reflux acid. Interpositioning the segment in an isoperistaltic position reduces the incidence of peptic colitis and ulcer formation.‘.” An additional advantage of the isoperistaltic interposition is the similar caliber of the terminal ileum and the proximal esophagus, which facilitates the anastomosis and makes it easier to obtain segment of ample length. The blood supply of the middle colonic artery and its branches has been sufficient for transplant. Three routes of the interposed segment have been recommended: subcutaneous, transthoracic, and retrosternal. In children it is important to protect the transplanted segment from trauma, and the retrosternal route provides ideal protection. Additional advantages of the retrosternal route include avoiding thoracotomy and its accompanying potential complications and dangers of pleural cavity contamination if ischemic necrosis of the transplanted segment occurs. The colon is relatively acid-resistant and ulcer in the interposed colon is uncommon. However, in the present series, one child had gastrointestinal bleeding 10 years after the operation, although the bleeding has responded to antacid therapy. The bleeding in this child was probably from a peptic ulcer; however, the exact site of hemorrhage remained unknown even after barium study. The children who had cervical esophagostomy had the symptoms of temporary dysphagia when they started eating by mouth after operation. No stricture was identified on barium study or esophagoscopy. Both children were younger than the average in this series and both had longer periods of dilation therapy. Their inexperience in swallowing may have been
ILEOCOLIC
REPLACEMENT
757
OF ESOPHAGUS
a factor13 because both children had received feedings by gastrostomy for almost half of their lives. When feeding by gastrostomy is used, children appeared to lose their natural ability and interest in chewing and swallowing food.” Training in swallowing probably should be started when a cervical terminal esophagostomy is performed. Also, eating by mouth may benefit the normal digestive secretions. For severe caustic esophageal strictures, forcible dilation is difficult and hazardous because of the increased risk of perforations. Commonly, a stringlike lumen is present after long periods of dilation. The esophagus in these children is often abnormal both in function and histological appearance. Under these circumstances, even normal food may be a chronic stimulus to the formation of esophageal scar tissue. As reported in the literature, the danger of esophageal cancer developing in patients with lye stricture
is many times greater than that in normal persons.‘4.1s This increased risk is particularly important to consider in children because of their longer life expectancy. For children who have severely damaged esophageal strictures, a substitution procedure is indicated, and a good result can be obtained. Long-term satisfactory results are observed in the present series of patients. The growth and development of the children was normal. The bowel grows with the child and the long-term functional results have been good. They learned to chew their food carefully, to eat slowly without taking large bites, and to swallow carefully. Gradually, they learn to care for themselves. The 11 patients in this series who survived have maintained normal height and weight. Some of the children were underweight before surgery, but after the conduit was established their weights quickly returned to normal.
REFERENCES 1. Lundblad 0: Uber antethorakale osophagoplastik. Acta Chir Stand 53535.1921 2. Waterston DJ: Esophageal atresia, in Gairdner D (ed): Recent Advances in Paediatrics. London, England, Churchill, 1954, pp 151-157 3. Sherman CD, Waterson DJ: Oesophageal reconstruction in children using colon. Arch Dis Child 32:11-16, 1957 4. Rous C: L oesopho-jejuno-gastromose, nouvelle operation pour retrocissement infranchissable de L oesophage. Semaine Med 27:37, 1907 5. Ochsner A, Owens N: Anterothoracic esophagoplasty for impermeable stricture of the esophagus. Ann Surg 100:1055-1091, 1954 6. Burrington JD, Stephens CA: Esophageal replacement with a gastric tube in infant and children. J Pediatr Surg 3:246-252.1968 7. Ein SH, Shandling B, Simpson JS, et al: Fourteen years of gastric tube. J Pediatr Surg 13:638-641, 1978 8. Sieber AM, Sieber WK: Colon transplants as esophageal replacement: cineradiographic and manometric evaluation in children. Ann Surg 168:116-122, 1968
9. Shiller M, Fryo TR, Boles ET Jr: Evaluation of colonic replacement of the esophagus in children. J Pediatr Surg 6:753-760, 1971 10. Hendren WH, Hendren WG: Colon interposition for esophagus in children. J Pediatr Surg 20:829-839,1985 11. German JC, Waterston DJ: Colon interposition for the replacement of the esophagus in children. J Pediatr Surg 11:227234, 1976 12. Jones EL, Booth DJ, Cameron JL, et al: Functional evaluation of esophageal reconstructions. Ann Thorac Surg 12:331-336, 1971 13. Campbell JR, Webber BR, Harrison MW, et al: Esophageal replacement in infants and children by colon interposition. Am J Surg 144:29-34,1982 14. Joske RA, Bendict EB: The role of benign esophageal obstruction in the development of carcinoma of the esophagus. Gastroenterology 36:749-755,1959 15. Kiviranta UK: Corrosion carcinoma of the esophagus. Acto Otolaryngol Stockh 42:89-95,1952
VOL 26, NO 7
Ileocolic
Replacement of Esophagus in Children Esophageal Stricture
With
By Mao-Tang Han Tianjin, People’s Republic of China 0 Between 1970 and 1988, 12 restrosternal esophageal substitutions using an ileocolic interposition were performed. The ages of the 12 children ranged from 2 to 8 years. In 11 children the esophageal strictures were secondary to ingestion of caustic liquid. All patients had failed esophageal dilation therapy. One death occurred on the 7th postoperative day following an episode of cardiac arrest at surgery. Early postoperative complications included three cervical ileoesophageal anastomotic leaks, which healed spontaneously. One patient had gastrointestinal bleeding 10 years postoperatively. This was controlled by antacid therapy without recurrence. Redundancy of the interpositioned ileocolic segment was observed in three children. All 11 surviving patients can eat a normal diet and have normal growth and development. Copyright o 1991 by W.B. Saunders Company INDEX WORDS:
Esophageal replacement.
E
SOPHAGEAL stricture due to the accidental swallowing of corrosive liquid has been the most frequent cause of severe esophageal stricture in children. Early successful use of the colon for esophageal replacement in a child for stricture from lye ingestion was reported in 1921 by Lundblad.’ In 1954 Waterston’ described his first successful colon esophageal replacement by the intrathoracic route. In 1957, Sherman and Waterston reported the substernal colon interposition for esophagus in infants and children. Subsequently, the use of the colon as a substitute for esophagus in children has become a well-established surgical procedure. From June 1970 to May 1988 at the Children’s Hospital of Tianjin, China, 12 children underwent esophageal replacement for stricture. The latest follow-up was made in 1989 and forms the basis of this report. MATERIALS AND METHODS The age of the 12 children (8 boys and 4 girls) at the time of esophageal replacement ranged from 2 to 6 years. In 11 children the stricture was secondary to ingestion of caustic liquid. One child JournalofPediatric Surgery, Vol26, No 7 (July), 1991: pp 755-757
had congenital esophageal stricture. In all 12 the stricture had been resistant to dilatation therapy. The duration of dilation therapy varied between 3 and 18 months. Ten patients had had gastrostomy to facilitate retrograde dilation of the esophagus and to provide nutrition. Four patients had undergone a left-sided cervical esophagostomy, 2 of these for control of empyema that resulted from perforation of the esophagus during repeat dilation therapy by the otolaryngology department.
Surgical Procedure All 12 patients underwent a one-stage procedure. In each patient a retrosternal segment consisting of the terminal ileum and right colon was used. The blood supply of the ileocolic segment was from the middle colic artery and the marginal arcades. With the patient in the supine position, the patient’s head was turned to the right and the neck was extended posteriorly. Adequate exposure of the suprasternal notch and left side of the neck was obtained. Skin preparations and draping included the entire abdomen, check, and left cervical regions. This permits thoracotomy or insertion of a chest tube for drainage of a pneumothorax if it occurs during dissection of the retrosternal tunnel. The abdominal cavity was entered via a midline incision, the viscera were exposed, and the blood supply of the colon and the terminal ileus was evaluated. The blood vessels were occluded for 3 minutes of observation to avoid ischemic necrosis of the bowel. A length of right colon and terminal ileum sufficient to reach the neck of the patient was measured. The appropriate blood vessels were then ligated and the right colon, with a segment of terminal ileus, was divided. The appendix was excised in conventional fashion. The transplant segment and its vascular pedicle was passed through the gastrohepatic ligament posterior to the stomach. The cologastrostomy was made on the anterior wall of the antrum. An incision was made along the anterior margin of the left sternomastoid muscle. The ileal end of the transplant segment was brought up to the neck through the substernal tunnel, and an esophagoileal
From the Department of Surgery, Tianjin Children’s Hospital, Tianjin, People S Republic of China. Presented at the 23rd Annual Meeting of the Pacific Association of Pediatric Surgeons, Kona, Hawaii, June 3-61990. Address reprint requests to Mao-Tang Han, MD, Department of Surgery, Tianjin Children’s Hospital, Tianjin, People’s Republic of China. Copyright 0 1991 by W.B. Saunders Company 0022-3468/91/2607-0001$03.00/0 755
756
MAO-TANG
anastomosis was established with two layers of interrupted sutures using 4-O silk suture. A rubber drain was used routinely in the cervical incision. The continuity of the intestinal tract was reestablished by an ileocolic anastomosis. RESULTS
Eleven of the 12 children were eating well at discharge. There was an operative death early in this series in a 2-year-old child resulting from cardiac arrest during surgery and death due to respiratory failure on the 7th postoperative day due to respiratory failure. This death was preventable. Complications
In 3 children a small leak occurred from the cervical anastomosis. The children continued eating. Careful attention was given to ensure adequate drainage. Within 2 weeks the leak healed spontaneously. No stricture resulted. In another child, a slight stricture developed at the site of cervical anastomosis. The stricture responded to dilation therapy. Two children had early transient dysphagia. Both underwent esophagoscopy, and only edema around the site of anastomosis was found. A liquid diet was given for a few days, and the dysphagia disappeared. In one child, a small bowel obstruction due to postoperative adhesion band formation developed. It was treated by enterolysis. One child suffered massive gastrointestinal bleeding 10 years after the colon interposition. The bleeding resolved with antacid therapy. The child has remained well without recurrence. Follow- Up
The latest follow-up in February 1989, which ranged from 2 to 19 years after surgery, showed that the growth and development of these patients was satisfactory. All could eat a regular diet without difficulty. Two had dysphagia when eating large meals. Barium swallow study showed that liquid barium passed into the stomach promptly when the patient was in the standing position. No obstruction was observed at the ileocecal valve or at the site of the anastomoses. In two patients, redundancy of the colon and a temporary air-fluid level after meal was noted in the transplanted action. However, there were no clinical symptoms. DISCUSSION
In North China, liquid lye (sodium hydroxide) is commonly used as a wall painting material. Because the liquid form of lye is odorless and colorless, it may be swallowed accidentally. Of the 12 children in the present series, 11 had swallowed lye. In every case,
HAN
the corrosive material was in contact with the esophageal mucosa for only a few seconds. A deep extensive irregular circular injury was produced. Although in the present series early management was prompt and dilation combined with steroid therapy was aggressive, the esophageal stricture was irreversible. Varied surgical procedures have been used for the treatment of the undilatable esophageal stricture4-‘; these have included the use of small intestine, skin tube, and gastric tube made by gastric flap from the great curvature, as well as the use of colon. In the present series, the right colon with a segment of terminal ileum was preferred for esophageal substitution. The ileocolic segment was placed in the retrosternal tunnel in an isoperistaltic position and the colon was anastomosed to the stomach. Although studies by others*~” showed no functional difference between the isoperistaltic or antiperistaltic position, the colon has proven to be more acid resistant and promptly clears any reflux acid. Interpositioning the segment in an isoperistaltic position reduces the incidence of peptic colitis and ulcer formation.‘.” An additional advantage of the isoperistaltic interposition is the similar caliber of the terminal ileum and the proximal esophagus, which facilitates the anastomosis and makes it easier to obtain segment of ample length. The blood supply of the middle colonic artery and its branches has been sufficient for transplant. Three routes of the interposed segment have been recommended: subcutaneous, transthoracic, and retrosternal. In children it is important to protect the transplanted segment from trauma, and the retrosternal route provides ideal protection. Additional advantages of the retrosternal route include avoiding thoracotomy and its accompanying potential complications and dangers of pleural cavity contamination if ischemic necrosis of the transplanted segment occurs. The colon is relatively acid-resistant and ulcer in the interposed colon is uncommon. However, in the present series, one child had gastrointestinal bleeding 10 years after the operation, although the bleeding has responded to antacid therapy. The bleeding in this child was probably from a peptic ulcer; however, the exact site of hemorrhage remained unknown even after barium study. The children who had cervical esophagostomy had the symptoms of temporary dysphagia when they started eating by mouth after operation. No stricture was identified on barium study or esophagoscopy. Both children were younger than the average in this series and both had longer periods of dilation therapy. Their inexperience in swallowing may have been
ILEOCOLIC
REPLACEMENT
757
OF ESOPHAGUS
a factor13 because both children had received feedings by gastrostomy for almost half of their lives. When feeding by gastrostomy is used, children appeared to lose their natural ability and interest in chewing and swallowing food.” Training in swallowing probably should be started when a cervical terminal esophagostomy is performed. Also, eating by mouth may benefit the normal digestive secretions. For severe caustic esophageal strictures, forcible dilation is difficult and hazardous because of the increased risk of perforations. Commonly, a stringlike lumen is present after long periods of dilation. The esophagus in these children is often abnormal both in function and histological appearance. Under these circumstances, even normal food may be a chronic stimulus to the formation of esophageal scar tissue. As reported in the literature, the danger of esophageal cancer developing in patients with lye stricture
is many times greater than that in normal persons.‘4.1s This increased risk is particularly important to consider in children because of their longer life expectancy. For children who have severely damaged esophageal strictures, a substitution procedure is indicated, and a good result can be obtained. Long-term satisfactory results are observed in the present series of patients. The growth and development of the children was normal. The bowel grows with the child and the long-term functional results have been good. They learned to chew their food carefully, to eat slowly without taking large bites, and to swallow carefully. Gradually, they learn to care for themselves. The 11 patients in this series who survived have maintained normal height and weight. Some of the children were underweight before surgery, but after the conduit was established their weights quickly returned to normal.
REFERENCES 1. Lundblad 0: Uber antethorakale osophagoplastik. Acta Chir Stand 53535.1921 2. Waterston DJ: Esophageal atresia, in Gairdner D (ed): Recent Advances in Paediatrics. London, England, Churchill, 1954, pp 151-157 3. Sherman CD, Waterson DJ: Oesophageal reconstruction in children using colon. Arch Dis Child 32:11-16, 1957 4. Rous C: L oesopho-jejuno-gastromose, nouvelle operation pour retrocissement infranchissable de L oesophage. Semaine Med 27:37, 1907 5. Ochsner A, Owens N: Anterothoracic esophagoplasty for impermeable stricture of the esophagus. Ann Surg 100:1055-1091, 1954 6. Burrington JD, Stephens CA: Esophageal replacement with a gastric tube in infant and children. J Pediatr Surg 3:246-252.1968 7. Ein SH, Shandling B, Simpson JS, et al: Fourteen years of gastric tube. J Pediatr Surg 13:638-641, 1978 8. Sieber AM, Sieber WK: Colon transplants as esophageal replacement: cineradiographic and manometric evaluation in children. Ann Surg 168:116-122, 1968
9. Shiller M, Fryo TR, Boles ET Jr: Evaluation of colonic replacement of the esophagus in children. J Pediatr Surg 6:753-760, 1971 10. Hendren WH, Hendren WG: Colon interposition for esophagus in children. J Pediatr Surg 20:829-839,1985 11. German JC, Waterston DJ: Colon interposition for the replacement of the esophagus in children. J Pediatr Surg 11:227234, 1976 12. Jones EL, Booth DJ, Cameron JL, et al: Functional evaluation of esophageal reconstructions. Ann Thorac Surg 12:331-336, 1971 13. Campbell JR, Webber BR, Harrison MW, et al: Esophageal replacement in infants and children by colon interposition. Am J Surg 144:29-34,1982 14. Joske RA, Bendict EB: The role of benign esophageal obstruction in the development of carcinoma of the esophagus. Gastroenterology 36:749-755,1959 15. Kiviranta UK: Corrosion carcinoma of the esophagus. Acto Otolaryngol Stockh 42:89-95,1952
