Surgical Outcomes of Esophageal Replacement by Colonic Conduit in the Last 5 Years in Pediatric Surgery Department

Abstract

SUMMARY D espite of variety of techniques to preserve the esophagus, occasionally children with long gap esophageal atresia and severe caustic esophageal stricture require esophageal replacement. Kelling and Lundblad in the early 1900's were the first to use colon for esophageal substitution in patients with esophageal atresia, more than two decades before the first primary repair of the anomaly was successful. Substernal colon interposition for esophageal replacement in children was first described by Dale and Sherman in 1955.In 1957, Sherman and Waterston presented a technique of interposing a segment of isolated colon into the left chest for children with esophageal atresia and reviewed the world experience with colon replacement of the esophagus. Many children in developing countries continue to sustain caustic esophageal injures. The first line of treatment is dilatation, unless contraindicated, where 60% to 80% success rate is expected. In cases of failure, esophageal replacement is the only hope for achieving normal swallowing. Over the last decades, thousands of esophageal replacement surgeries were done in the Pediatric Surgery Department at Ain-Shams University. Retro-sternal colon replacement and trans-hiatal esophagectomy with posterior mediastinal colon replacement were the most 2 adopted techniques done. In our study we compare indications and complications of 29 patients operated in the previous 5 years, to experinces of others. Comparing our results and outcome helps us to improve our techniques and decrease complications. We concluded that iso-peristaltic left colon segment based on the upper left colic vessels is the best method of esophageal replacement for esophageal atresia and benign caustic esophageal strictures in children. A sufficient length is available to replace the whole esophagus and even the lower pharynx if needed due to long marginal artery. The blood supply from the left colic vessels is robust and rarely prone to anatomic variation and if there is double blood supply is used. While using the middle colic will make the graft shorter and more fixed making esophgeo-colic anastomosis very difficult. The close relation between the marginal vessels and the border of the viscus results in a straight conduit with little redundancy or tendency to kinking. The colon has proved to be relatively acid resistant, and significant ulceration in the interposed segment is unusual, but still we have reflux is a major complication which needs to be investigated in the future.