Experience with distal circular myotomy for long-gap esophageal atresia

Experience With Distal Circular Myotomy Long-Gap Esophageal Atresia By Jin-Yao

Lai, Jin-Cherng

Sheu, Pei-Yeh Chang, Ming-Lun Yeh, Chi-Yang Taipei, Taiwan, Republic of China

l From 1980 to 1994, the authors treated 65 cases of esophageal atresia (with or without tracheoesophageal fistula). Among these patients, 15 (23%) underwent pure proximal circular myotomies and five (8%) underwent both proximal and distal circular myotomies. Of the latter five cases, three were Gross type C and two were Gross type A. The gap ranged from 4.5 cm to 6.5 cm (mean, 5 cm). Surgical complications in these five patients included two anastomotic leaks (40%). one anastomotic stricture (20%). and four gastroesophageal refluxes (80%). Three patients eventually underwent fundoplication as an antireflux procedure. Mucosal outpouching was noted in all cases. The myotomy did not adversely affect the esophageal peristalsis and motility on the esophagogram. Esophageal function was similar to that of other children who had esophageal atresia without myotomy. All patients could eat food typical for their age. This limited experience suggests that distal circular myotomy might be a safe adjuvant procedure to achieve primary anastomosis in long-gap esophageal atresia. Copyright o 1996 by W.B. Saunders Company

INDEX

WORDS:

Esophageal

atresia,

circular

Chang,

for and Chiu-Chiang

Chen

(mean, 2,703 g). Three infants had EA with distal tracheoesophageal fistula (Gross type C), and two had pure esophageal atresia (Gross type A). One patient had an associated duodenal atresia. All five patients had a one-layer end-to-end anastomosis performed through a right-sided retropleural approach. For patients with Gross type C, fistula ligation and atresia repair were performed during the first day of life. For those with Gross type A, gastrostomy was performed initially, followed by bougienage. Repair of atresia was performed at 2 months of age. Two patients required one proximal and one distal myotomy; and the other three required two proximal and one distal myotomies. The bridge gaps were measured at 4.5 cm to 6.5 cm (average, 5 cm) during surgery. The proximal myotomy was performed as described by Livaditis et al.“’ The distal circular myotomy was made 0.5 cm to 1 cm from the tip of the lower pouch. Minimal dissection of the distal segment to avoid compromising blood supply is mandatory. The follow-up period ranged from 8 months to 8 years (mean, 3 years). The current status of each patient was evaluated by the following parameters: subjective swallowing function, current weight percentile, additional esophageal bougienage, additional esophageal surgery, and esophagogram.

myotomy.

RESULTS

I

N THE TREATMENT of esophageal atresia (EA), long-gap EA is still a challenging problem. Because of difficulty in primary repair, an interposition graft of colon or stomach has been used.‘,* However, follow-up studies have shown many problems.lT3 In our opinion, nature esophagus is still the best substitute for esophageal atresia. To cope with the severe tension during primary repair, esophageal bougienage or proximal circular myotomy is used most frequently.4-s Proximal circular myotomy (Livaditis’ procedure) may safely decrease the tension between the two anastomotic ends. Unfortunately, neither proximal myotomy nor bougienage can adequately reduce the tension in all cases of long-gap EA.g We present five cases of combined proximal and distal circular myotomies to stress the value of distal myotomy in the treatment of long-gap EA. MATERIALS

AND METHODS

Between January 1980 and July 1995, 65 patients with esophageal atresia were treated at Mackay Memorial Hospital, Taipei, Taiwan. Twenty of these patients (31%) required proximal circular myotomies. Among these patients, five (8%) underwent both proximal and distal circular myotomies. Table 1 summarizes the clinical data of these five patients. The gestational ages of these infants ranged from 32 to 41 weeks (mean, 37.4 weeks), and birth weight ranged from 1,600 to 3,300 g

Journal

of Pediatric

Surgery,

Vol31,

No 11 (November),

1996: pp 1503-l 508

There were two early surgical complications in two patients. Case one and five had an anastomotic leak. There was no mucosal tear during myotomy. Anastomotic leaks were shown by the postoperative esophagogram. The site of the leak was separate from the myotomy site. The leaks were sealed with conservative treatment. Gastroesophageal reflux (GER) developed as a late complication in four of the five patients. One patient responded to nonsurgical treatment. Three patients eventually required antireflux procedures (Nissen or Thal fundoplication). In one of the three patients, both anastomotic stricture and gastroesophageal reflux developed, which required bougienage. After fundoplication, this patient no longer required dilatation and has been well for 5 years (Table 2).

From the Division of Pedtatnc Surgery, Mackay Memonal Hosprtal, Taipet, Taiwan, R.O. C. Dr J.-Y. Lar is currently a surgtcal fellow in the Department of Surgery, Chang Gung Children’s Hospital, Taoyuan, Tarwan, R.O.C. Address reprint requests to Jin-Chemg Sheu, MD, Division of Pediatric Surgery, Mackay Memorial Hospctal, No. 92, Section 2, Chung-Shan North Rd, Taipei, Taiwan, R.0 C. Copyright o 1996 by U! B. Saunders Company 0022-3468/96l3111-0008$03.00/0

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LAI ET AL

Table Gestational

Patent

Sex

1 2

M

40

M

3 4 5

F

32 36 38 41

M

M

Age (wk)

NOTE. The numbers m the parentheses Abbreviatrons: P, proximal myotomy;

1. Clinical

Brth Body Weight (g)

Gross Type

Gap (cm)

3,056

A

1,600 2,660

C C

5 4.5

3,300 2,900

C A

indicate the numbers D, distal myotomy.

of myotomles

Postoperative esophagograms showed that all five patients had mucosal ballooning at the myotomy sites (Figs l-4). Peristalsis and motility of the esophagus did not appear to be impaired by the myotomies as Table Leak

GER

2. Results

Myotomes

in)

PP).D(l)

-

P (1). D (1)

4.5 4.5 6.5

Duodenal

atresia

P (1). 0 (1) P (2).D (1) P 12). D (1)

-

performed.

Current Weight PercentlIe

1

-

+

+

10th

2

-

-

+

25-50th 25th

-

-

t

Anomaly

of the Myotomies

Mucosal Tear

+ -

Assoaated

compared with the EA patients who received primary repair without myotomy. The current body weights range from the 10th to 50th percentile. All patients are now able to swallow

Pallent

3 4 5

Anastomotlc

Data

Addltlonal

Nissen

25th 10th

Esophageal Surgery

fundoplication -

Follow-Up

Duration (yr)

8 6

That fundoplication -

1 1

Thal fundoplicatlon

9mo

.;A: Fig 1. Case distal myotomy

1. (A) Esophagogram performed 5 years after esophageal site (arrow). (B) The same patient at 8 years old.

myotomy.

Note

the 1wo

proximal

myotomy

sites v (arrowheads)

end the

CIRCULAR

MYOTOMY

FOR LONG-GAP

ESOPHAGEAL

ATRESIA

Fig 2. Case 2. (A) Esophagogram performed 2 months after operation. of the distal myotomy (arrow). (B) The same patient at 5 years of age.

liquid or solid food typical for their age. There has been no foreign body retention, aspiration pneumonia, or tracheomalacia. Presently, none of the patients needs esophageal bougienage. Their families are satisfied with the results.

DISCUSSION

In the management of long-gap esophageal atresia, the optimal goal is to achieve a primary esophageal anastomosis. Various esohophageal elongation procedures have been proposed to bridge the gap and relieve anastomotic tension. Bougienage with delayed primary repair and proximal circular myotomies are the most popular techniques. The blood supply of the proximal pouch arises from the thyrocervical trunk and runs downward in the submucosal layer. l l Therefore, extensive mobilization of the upper pouch and proximal circular myotomy are safe.5-7 Dissection of the lower esophageal segment often results in ischemia. This may be caused by insufficient vascular anastomoses between the various aortic, pericardial, and intercostal branches, and

Note

the outpouching

of the proximal

myotomy

(open

arrow)

and that

those arising from the left gastric and left inferior phrenic arteries. Therefore, even in cases of attempted anastomosis, distal circular myotomy rarely is recommended for fear of ischemia.” Anastomotic complications are important causes of postoperative morbidity. The incidence of anastomotic leak varies from 4% to 36%.‘?-” Among the group of long-gap EA, the incidence varies even more widely, from 0% to 100% in some series.17-‘y In the present report, both patients with Gross type A experienced anastomotic leak. We attribute the leak to the high anastomotic tension (bridging gaps of 5 and 6.5 cm, respectively). The incidence of stricture ranges from 8% to 49%13J6 and is higher than 50% in the long-gap group.19 In this series, stricture developed in only one of five patients. The incidence of anastomotic leak and stricture is not increased by distal myotomy in our long-gap EA patients as compared with other series. Another consequence of excessive anastomotic tension is an increased incidence of GER. The incidence of GER in EA is about 60% and is even higher in the long-gap group.‘,‘” GER developed in four of our five patients (80%). and three of

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,__,,,,,.,

--

-

,, ,.,.,, 1811111

Fig 3. Case 3. (A) Gross type C EA with duodenal atresia. Note the nasogastric tube without bowel gas indicates duodenal atresia. (B) Two months after Thal fundoplication. myotomy site (open arrow) and the distal myotomy site (arrow).

them (60%) required fundoplication. Both of the incidences are a little higher than in other series. Mucosal outpouching is the most common abnormality on the esophagogram following circular myotomy. 20,21In our series, it was seen in every case (100%). Neither esophageal obstruction nor foreign body retention was noted in our series. Janik et a120 and Schneeberger et a121have reported that proximal myotomy did not adversely affect esophageal function. The esophageal motility and swallowing are similar to those of other children who had EA repair without myotomy. In the series reported by Sumimoto et a1,22distal circular myotomy alone (one case) did not interfere with the esophageal function. Distal myotomy behaved as the proximal myotomy both on the esophagogram and manometrical studies. Our limited clinical experience suggests that distal circular myotomy does not increase the incidence of leak, nor does it compromise esophageal motility. In long-gap EA, if anastomotic tension persists, even after extensive mobilization of the proximal pouch and proxi-

recoiled There

at about T3 level. The dilated are two mucosal outpouchings:

gastric bubble the proximal

mal myotomies, distal myotomy is worth trying to ensure the success of esophageal anastomosis. ADDENDUM

Since this paper was submitted, another patient of Gross type A EA underwent two proximal and one distal myotomies to achieve a primary anastomosis. A 1,920-g boy was born by cesarean section at 36 weeks’ gestation to a 29-year-old mother. Routine prenatal ultrasound showed poiyhydramnios. After birth, cardiac ultrasound demonstrated a patent ductus arteriosus and tricuspid regurgitation. His eldest brother, now 8 years old, was a victim of congenital esophageal stenosis and had corrective surgery performed soon after birth at another hospital. Primary repair in this patient was performed at 2 weeks of age without preliminary gastrostomy. The bridging gap was measured as 5 cm during the operation. The postoperative course was smooth without any surgical complications, including anastomotic leakage and stricture.

CIRCULAR

MYOTOMY

FOR LONG-GAP

ESOPHAGEAL

ATRESIA

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.,I:.*: ,:-

Fig 4. Case 6. (A) Gross type A EA. The bridging gap is 6.6 cm. Note the proximal blind pouch is located T., level after bouginage for 2 months. (6) Esophagogram performed seven months after operation. Note the ballooning of the two proximal myotomies fopen arrow) and the outpouching of the distal myotomy (arrow). (C) Esophagogram performed 11 months after EA repair and 3 months after Thal fundoplication.

LAI ET AL

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