Ileal pedicle grafting for esophageal replacement in children

Abstract

Reconstruction of the upper esophagus in small children remains a challenge. Free jejunal interposition as frequently used in adults is much less appropriate in children because of the limited vessel size. The use of a jejunal pedicle graft in children has been described, but gaining enough length may be a problem. A pedicle graft of terminal ileum may be a better option, but this technique has never been described. We report a child with esophageal atresia and distal fistula who had a very short upper esophageal pouch. Primary repair was impossible. The fistula was ligated and a gastrostomy created. A second attempt at anastomosis was not successful either, and a cervical esophagostomy was created. The child was fed by gastrostomy and received sham feeding orally. When the child was 10 months old, the upper esophagus was successfully reconstructed with a pedicle graft of terminal ileum. Postoperatively there was a limited leak of the proximal anastomosis, which healed spontaneously. The distal anastomosis had to be dilated on a few occasions. With a follow-up of 1 year, the child is eating well without gastrostomy supplementation. On imaging, the ileal pedicle graft looks somewhat tortuous but contracts nicely. We feel that ileal pedicle graft reconstruction of the esophagus should be part of the instrumentarium of pediatric surgeons dealing with esophageal reconstruction.

Tissue blood flow to a pedicled jejunal autograft in the dog: A pilot study

“…A pedicled jejunal autograft based on 3 or 4 jejunal arcades has been used successfully to replace portions of the esophagus in people . This technique has been associated with 31% morbidity and 10.5% mortality rates in adult human patients undergoing replacement of the lower esophagus .…”

“…A viable pedicled jejunal autograft, created by ligating up to 3 individual jejunal arteries, has been mostly used for esophageal substitution in humans . In dogs, however, the blood supply of the jejunum has been suggested to be unreliable, and to rely on a short pedicle .…”

Jejunal pedicle grafts for reconstruction of the esophagus in children

“…By doing so, other surgical treatment options are available in case a jejunal interposition is not feasible. In a patient not included in this series, a pedicle ileal graft was used [9]. Prophylactic antibiotics are given and are continued postoperatively until normalization of the C-reactive protein level.…”

Collis–Nissen plastikos metodas esant labai ilgam tarpui tarp stemplės galų

“…Daugiausia problemų iškyla esant ilgam (daugiau nei 2,5 cm) ir labai ilgam (daugiau nei 3,5 cm) tarpui tarp stemplės galų. Tokių naujagimių gydymo algoritmas, kai neįmanoma atlikti pirminės ankstyvosios stemplės plastikos, išlieka diskutuotinas [4,6,10]. Literatūroje yra aprašyta daug stemplės pailginimo būdų prieš atliekant pirminę vėlyvąją stemplės plastiką, taip pat stemplę pakeičiančių operacijų, kai stemplės pailginti visgi nepavyksta.…”

“…Be to, nekrozės išsivystimo tikimybė dėl geros skrandžio kraujotakos yra reta. Nurodoma, kad atliekant kitas operacijas transplanto išemijos atvejų pasitaiko dažniau [10][11][12]. Nors visiems trims ligoniams po vėlyvosios pirminės stemplės plastikos atsirado anastomozės nesandarumas, mediastinitas, sepsis, medicinos literatūroje pateikiami panašūs duomenys [1,2,13].…”