ABSTRACT
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)
Subject(s)
Humans , Infant , Child, Preschool , Child , Adolescent , Anastomosis, Surgical/methods , Esophagectomy/methods , Esophageal Atresia/surgery , Esophageal Atresia/chemically induced , Esophagoplasty/methods , Postoperative Complications , Comparative Study , Prospective Studies , Retrospective Studies , Longitudinal Studies , Treatment OutcomeABSTRACT
BACKGROUND/PURPOSE: The treatment of children with esophageal strictures and involvement of the hypopharynx caused by caustic substance ingestion continues to be challenging. The aims of the present study are to describe the peculiarities of the technique of complete esophageal substitution for the treatment of children with severe caustic strictures (pharyngocoloplasties) and to compare the results to those of classical esophagocoloplasty with thoracic and abdominal esophageal substitution in another group of children. METHODS: A total of 258 children underwent colon interposition for esophageal replacement. Among these patients, 19 had complex esophageal caustic strictures involving the high level of the esophagus and hypopharynx without response to endoscopic dilatations. This group was compared with another group who required partial esophagocoloplasty with intact hypopharynx and high esophagus (239 patients). For the pharyngocoloplasty procedure, the transverse and great parts of the right colon were the segments selected for interposition and were maintained by a double vascular pedicle based on the left colic vessels and the marginal paracolic arcade via the sigmoid vessels. RESULTS: In the pharyngocoloplasty group, 9 patients (47.4%) presented with cervical anastomosis stenosis with episodes of aspiration pneumonia, although good responses to endoscopic dilatation treatments were observed. All patients survived. In the esophagocoloplasty group, the main complications were cervical leaking (18.0%) and stenosis (16.7%). Statistical comparisons revealed that the pharyngocoloplasty patients exhibited a lower incidence of cervical leakage and increased incidences of cervical stenosis and aspiration pneumonia, although all patients could swallow normally. CONCLUSION: Pharyngocoloplasty with complete esophageal substitution is a safe and effective procedure for the treatment of esophageal caustic strictures with severe stenoses reaching the hypopharynx that are refractory to previous endoscopic treatment. LEVEL OF EVIDENCE: II.
Subject(s)
Burns, Chemical/surgery , Caustics/toxicity , Colon/transplantation , Esophageal Stenosis/surgery , Esophagoplasty/methods , Esophagus/surgery , Pharynx/surgery , Burns, Chemical/complications , Child , Child, Preschool , Constriction, Pathologic/surgery , Dilatation , Esophageal Stenosis/chemically induced , Esophagoplasty/adverse effects , Esophagus/injuries , Female , Humans , Hypopharynx/injuries , Hypopharynx/surgery , Male , Postoperative Complications , Retrospective Studies , Vocal Cords/injuriesABSTRACT
Esophagocoloplasty is a commonly performed procedure for esophageal replacement in children. Traditionally, mechanical bowel preparation (MBP) is performed before this operation. However, this practice has been questioned, initially in adults and now in children. The aim of this study was to evaluate the influence of MBP on esophagocoloplasty in a series of children. Data collected from 164 patients who underwent esophagocoloplasty in the Pediatric Surgery Division, University of São Paulo Medical School, from February 1978 to July 2011 were reviewed for postoperative complications. In 134 patients, at least one kind of MBP was performed before the surgery (PREP group). MBP was omitted in 30 patients (NO-PREP group). There was no statistical difference between the groups in the rates of evisceration, colocolic, or cologastric anastomotic dehiscence and death. However, in the NO-PREP group, the incidence of cervical leakage (6.6%) was significantly decreased in comparison with the classical PREP group (25.3%) (P= 0.03). The results of this study suggest that the omission of MBP has a positive impact on the incidence of postoperative complications in esophagocoloplasty.