Laparoscopic and thoracoscopic gastric pull-up for pure esophageal atresia in early infancy.

In the developing countries, the babies with pure esophageal atresia undergo an esophagostomy and feeding gastrostomy at birth. It assists in early discharge from hospital. Esophageal substitution in these babies around six months is recommended. We report the first laparoscopic and thoracoscopic gastric pull up in early infancy from India.

INTRODUCTION

Esophageal atresia with tracheo-esophageal fistula occurs in approximately 1 in 3000 live births.[1] Pure esophageal atresia constitutes 5-7% of these patients.[2] Whereas, the initial management of this group of babies with esophageal atresia is relatively straightforward, the long term outcome of this specific group has never been reported from our country. The management of these babies requires months of gastrostomy feeds and meticulous maintenance of gastrostomy and esophagostomy site. Local complications and gastroenteritis is common and can be dangerous in some babies preventing many babies from returning back for definitive surgery.

Esophageal substitution with gastric tube, gastric pull up or colonic conduit is done in late infancy.[3-5] Among the available option only gastric pull-up is feasible with an endoscopic approach. This also has been reported from a few western centres.[6-11] We are reporting the first infant from our country; with laparoscopic and thoracoscopic gastric pull-up for esophageal atresia.

CASE REPORT

A newborn, preterm (34 weeks, 1500g), male baby was admitted with pure esophageal atresia as demonstrated with failure of nasogastric intubation, coiling of tube in esophageal pouch and gasless abdomen. Initial workup revealed a solitary functioning kidney and no other associated anomaly. Cervical esophagostomy and feeding gastrostomy were done. The baby was discharged on gastrostomy feeds on 6th day of life.

He was maintained on gastrostomy feed with progressively changing feeds and volume of feeds depending on growth. He continued to grow satisfactorily with monthly monitoring and reached 6 kg at eight months. We discussed the various approaches and possible problems and informed consent was obtained for endoscopic esophageal substitution with gastric pull-up with an option for conversion to open surgery.

Surgical technique

The baby underwent endotracheal intubation and general anaesthesia. The position of the baby was supine and right lateral decubitus. The baby was brought so that the foot end was towards the caudal end of the table. The video screen was arranged at the head end of the table with operating surgeon operating from the foot end of the table and camera control being managed from the left foot end. The right side of the table was used for thoracoscopic surgery. Painting and draping was done in such a way that the whole abdomen, right side of chest and neck were exposed for laparoscopic, thoracoscopic access and neck anastomosis.

The 5 mm camera port was inserted in the supraumblical crease and two 5 mm ports were inserted in midclavicular line on either side at the level of umbilicus. Pneumoperitoneum was created using carbon dioxide at the pressure of 10 mm Hg. The dissection was started with dismantling the gastrostomy site allowing the stomach to fall down from the back of the abdominal wall. The gastrostomy site was closed using Endo GIA linear cutting stapler. Harmonic shear (Ethicon) 5 mm was used for dissection. Dense adhesions between left lobe of liver, stomach and abdominal wall were released allowing access into lesser sac and hiatus. Subsequently the greater omentum was divided from the transverse colon, and the greater curve of the stomach was lifted up dissecting and exposing the left gastric pedicle. The left gastric pedicle was divided using low pulse harmonic shear and dissection in the esophageal hiatus begun by dividing the peritoneal reflection. The dissection in the hiatus was completed dissecting the esophageal stump all around and widening the hiatus with upward retraction of liver with an additional epigastric 5mm port.

Two thoracoscopic ports were inserted in anterior axillary line (5mm) after the camera port (5 mm) was inserted in post axillary line. Pneumothorax with carbon dioxide at 5 mm Hg was created to collapse the lung. The esophageal stump was pulled into the chest allowing the entire stomach to come up into the chest. Further blunt dissection was done in thoracic inlet after exposing the neck incision and widening the mediastinal inlet with blunt finger dissection and allowing the esophageal stump to be delivered into the neck wound. Further traction on the stump allowed the stomach, gastroesophageal junction and fundus to be delivered in the chest. The esophageal stump was excised, the junction closed and esophagogastric anastomosis was done at the gastric fundus in single layer.

The thoracoscopic wounds were closed and camera port was used to leave a chest drain. The laparoscope was used to site a feeding jejunostomy and anchoring stitch after extracorporeal tunnelled jejunostomy was done. No abdominal drain was left.

The baby was electively ventilated and required high pressures and frequent aspiration of the stomach for the initial five to six days. Subsequently once out of ventilatory support, gastric emptying remained a problem for nearly two weeks with need for frequent decompression of the stomach. Jejunostomy feeds were started from 3rd day after surgery. A gastrografin contrast study was done at the end of two weeks revealing wide open anastomosis and satisfactory drainage of stomach [Figure 1]. Satisfactory oral feeding could be established towards the end of third week.

Figure 1

Gastrografin contrast study showing stomach as esophageal substitute in posterior mediastinum

The baby has been seen at one, three and six months follow up. Feeding jejunostomy was removed at three months follow up and the baby continues to thrive with satisfactory weight gain. At six months postop follow up, the baby is on full oral semisolid feeds and has attained a weight of 9 kg.

DISCUSSION

Esophageal substitution is a relatively common surgery in adult gastrointestinal surgery units, commonest indication being carcinoma of the esophagus. The surgery for this condition has been developed over the years since its original description by Orringer et al, and subsequently very large series published from several countries including India.[1213] The pediatric practice however is limited by isolated indications for esophageal substitution including pure esophageal atresia, esophageal atresia and trachea esophageal fistula with long gap or its complications and corrosive stricture. Limited long term follow up studies have been published for different modalities of esophageal substitution as referred to earlier. Transhiatal gastric pull up has established as a popular technique with feasibility of the entire technique to be done by the minimally invasive technique.

The gastric pull up as an esophageal substitution has been used by us as an esophageal substitute for older children and those with corrosive stricture of esophagus. Although large series with gastric pull up has been reported in neonatal age group, it does carry serious morbidity and occasional mortality dependant on the expertise and availability of neonatal intensive care support. Invariably this technique leads to a longer stay in hospital, all babies needing variable length of ventilation with high pressures and delayed gastric emptying and better tolerated in older children. However, despite the early demanding post operative care compared to gastric tube the long term follow up study by Spitz et al, have lead several centres to adopt this technique.

The first laparoscopically assisted gastric pull-up for esophageal atresia was reported by Ure in 2003 and showed that this technique was safe and feasible.[14] Thereafter, only very few cases have been reported using the laparoscopic technique. The various reports have discussed details of surgical technique including extra corporeal pyloromyotomy, intracorporeal closure of gastrostomy site and additional fundoplication. We have not added these additional procedures as none of these have been proven to be required in all cases. A comparative table outlining the surgical details of the cases reported have been shown in Table 1. The index case underwent the entire procedure by an endoscopic technique with an operative time nearly double of our usual operating time and need for ventilation for nearly a week. However, we have been rewarded with a relatively trouble free late post operative period without the development of anastomotic leak or stricture. The entire hiatal and posterior mediastinal dissection was possible with magnification and under vision without opening the chest. The cosmetic results are very pleasing, satisfactory and functional outcome better with laparoscopic approach.

Table 1

Laparoscopic gastric pull up cases reported

CONCLUSION

The gastric transposition as an esophageal substitute for difficult cases of pure esophageal atresia done by the minimally invasive technique appears to be a promising approach to offer these babies an acceptable quality of life.