Unusual postoperative complication of minimally invasive transhiatal esophagectomy and esophageal substitution for absolute dysphagia in a child with corrosive esophageal stricture.

Esophageal substitution in children is a rare and challenging surgery. The minimally invasive approach for esophageal substitution is novel and reported from a few centers worldwide. While detailed report on the various complications of this approach has been discussed in adult literature, the pediatric experience is rather limited. We report the laparoscopic management of a rare complication which developed after laparoscopic esophagectomy and esophageal substitution. The timely recognition and management by the minimally invasive approach have been highlighted.

INTRODUCTION

Esophageal substitution is a major gastrointestinal reconstruction. The common indications for this surgery include esophageal atresia without tracheoesophageal fistula, delayed management of long-gap esophageal atresia, failed repair of different varieties of esophageal atresia, corrosive esophageal strictures not amenable to dilatations, and rarely peptic strictures. Esophageal substitution in children as opposed to the adults is almost exclusively indicated for nonmalignant conditions; therefore, this gastrointestinal reconstruction in a child as compared to adult has to stand the test of several decades ahead.

The safety, feasibility, and advantages of an endoscopic esophageal substitution for esophageal atresia in children have been demonstrated in several reports.[12] We have also reported our own limited experience of the novel technique of minimally invasive esophageal substitution for long-gap esophageal atresia in five cases with a minimum of 12-month follow-up with satisfactory results.[3] Esophageal substitution for corrosive esophageal strictures refractory to dilatations and medical management are far more challenging. The mediastinal adhesions and scarring make the endoscopic esophagectomy a daunting task.[45]

This case report highlights a hitherto unreported complication of this technique, its early recognition, laparoscopic management, and follow-up at the end of a year.

CASE REPORT

A 7-year-old boy from overseas was referred to us with corrosive stricture esophagus. The child had ingested corrosive 2 years back. This was followed by more than twenty attempts at esophageal dilatation in Pakistan and India at several centers. After each session of dilatation, he was able to take liquids for 4-6 weeks. In the last attempt at dilatation, he had developed a diverticulum with failure of even a guidewire to go through the stricture. Unfortunately, throughout these 2 years of endoscopic attempts, he had no significant nutritional support and was weighing (7 years, 14 kg) less than the third centile for his age.

The child was evaluated with a contrast swallow and esophagoscopy. The stricture was long with multiple pseudodiverticula. The thinnest guidewire (0.18 mm, Terumo) was not negotiable across the stricture. Since he had arrived in dehydrated emaciated state, he was kept on intravenous fluids for a week. This was followed by laparoscopic feeding gastrostomy, and he was nutritionally built up for the procedure for 1 week.

A week later, he was taken up for laparoscopic transhiatal esophagectomy and esophageal substitution with stomach. After endotracheal intubation and general anesthesia, the child was placed at the foot end of the table in low lithotomy position. The camera port was placed at the umbilicus and pneumoperitoneum created at a pressure of 10 mmHg. Two working ports were placed on the right and the left iliac fossa in the midclavicular line at the level of the umbilicus. The procedure was started with mobilization of the gastrostomy and closure of the gastrostomy site by intracorporeal suturing. The gastrostomy site at the left hypochondrium was used for retraction of the liver to aid in transhiatal dissection. There were dense adhesions around the esophageal hiatus of the diaphragm. The diaphragmatic crura were divided and scarred, and fibrosed esophagus was dissected from mediastinal adhesions.

The retromediastinal dissection was challenging due to dense postcorrosive ingestion adhesions and loss of tissue planes. During the difficult dissection at the lower end of the esophagus, a small tear was inadvertently created in the left hemidiaphragm. The small rent in the diaphragm was closed with interrupted sutures. The lower two-third of the esophagus was mobilized by the transhiatal route. The cervical esophagus was exposed through the neck incision and the upper esophagus mobilized, and entire esophagus was delivered through the neck wound.

The stomach and duodenum were mobilized by the division of short gastric vessels with kocherization and ligation of the left gastric artery. The posterior mediastinal gastric transposition was completed with the esophagogastric anastomosis in the neck.

The child was ventilated for 48 h and contrast swallow was done on the 7th day which showed wide patent neck anastomosis, no leak, and prompt gastric emptying [Figure 1]. He was started on semisolid diet, which he began to tolerate without any symptom. Later in the evening, he started developing progressive respiratory distress. The child was placed on oxygen by mask and close monitoring. A chest X-ray on the same evening revealed a diaphragmatic hernia with hugely dilated colon [Figure 2].

Figure 1

Postoperative contrast study showing wide esophagogastric anastomosis and no leak of contrast

Figure 2

The chest X-ray showing herniated, obstructed, and dilated loop of transverse colon into the left chest

In view of the high risk of strangulation and gangrene of the herniated loop of large bowel, he was taken up for surgery immediately. Laparoscopy was done through the same port sites used for transhiatal esophagectomy and esophageal substitution. The hiatal access was difficult with omentum, small bowel and large bowel adhesions blocking the approach to the hiatal area. Gentle traction and separation of adhesion led to definition of the hiatus, demonstrating snugly fitting lower end of the stomach. In the parahiatal region, the central tendon had a small rent where the repair of the iatrogenic injury had given way allowing colon to migrate up. The hugely dilated and obstructed, congested transverse colon was reduced back into the abdomen. The diaphragmatic defect was repaired by intracorporeal interrupted mattress suturing. Postoperative period was unremarkable with quick recovery and he was discharged 2 days later. He remains well on follow-up 1-year after surgery having gained significant weight.

DISCUSSION

The application of laparoscopy in pediatric population has been painstakingly slow and received much skepticism from the pediatric surgeons themselves in the initial years. Our own journey from the basic laparoscopic procedures to advanced laparoscopic reconstructions has followed a steady and structured path in the last decade. We had reported our collective experience of 5 years with minimally invasive surgery in children in 2012.[6] From there, the program has graduated to more complex reconstructions as reported by us in a ca se series of five babies who underwent total endoscopic esophageal substitution with a minimum follow-up of 12 months in each.[3]

Esophageal substitution in children is a major undertaking with attending risk of short- and long-term complications. Spitz et al. reported the largest series on esophageal substitution with 4.6% mortality.[7] The minimally invasive approach to esophageal substitution has been reported by several authors in the last decade and shown to be safe and acceptable. Ng et al. compared the results of minimally invasive and open gastric transposition. The minimally invasive group consisted of 66 children from multiple centers whose data were collected from literature search. The results of these patients were compared with 192 open gastric transpositions performed at Great Ormond Street Hospital, London. The authors concluded that there was no difference in complication and mortality rates of the two approaches.[2]

Postcorrosive esophageal stricture poses much more serious challenge for esophageal substitution than esophageal atresia. There are many large studies which have described minimally invasive esophagectomy and esophageal substitution in adults,[8] but there are only a few reports of this technique in children. Shalaby et al. in their experience of 27 children reported anastomotic leak in 11% and anastomotic stricture in 14.8% of children after laparoscopically assisted transhiatal esophagectomy and gastric transposition.[9]

In the adult population where the esophagectomy is done for malignancy, a variety of complications have been reported after minimally invasive esophagectomy. Postesophagectomy hiatal hernia is a known complication and has been reported in several adult studies. Benjamin et al., in a literature review of 4669 esophagectomies (including 756 minimally invasive), have observed the incidence of diaphragmatic hernia be 121 (2.6%) in all patients and 34 (4.5%) in the minimally invasive group.[10] Although the reported incidence of herniation across diaphragm is discussed in adult literature, there is no mention of this complication or its operative management in pediatric age group.

Laparoscopic repair of the hiatal hernia after esophagectomy has been reported in adults by a few authors. Better visualization of the hiatus and parahiatal region and a faster recovery time are the main advantages of this approach.[1112]

In our patient, the diaphragmatic hernia developed 7th day after the surgery. The chest X-ray revealed a dilated loop of the colon in the left side of the chest. The hernia was not through the hiatus but through a tear in the left hemidiaphragm which had developed during esophagectomy while releasing the dense adhesions around lower esophagus. The tear in the diaphragm had been repaired, but it gave way following a severe bout of coughing and acute rise in intra-abdominal pressure. This violent bout of cough may have been precipitated by the spontaneous migration of nasogastric feeding tube into the pharynx. The tube had been left past the anastomosis as a stent for future anastomotic dilatation.

It is important to recognize and treat this complication at the earliest because of the risk of significant complications such as incarceration and strangulation. In our accumulated experience of 26 cases of esophageal substitution done by either open of minimally invasive approach, this was the first complication of this nature.

CONCLUSION

Postoperative complication after minimally invasive reconstructive surgery can have initial laparoscopic assessment before final decision on open re-exploration or proceeding with laparoscopic surgery for treating the complication. The feasibility of laparoscopic approach to treat complication of a major laparoscopic undertaking has been demonstrated in this case.

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Conflicts of interest

There are no conflicts of interest.