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A staged approach to long gap esophageal atresia employing a spiral myotomy and delayed reconstruction of the esophagus: An experimental study

Authors
Journal
Journal of Pediatric Surgery
0022-3468
Publisher
Elsevier
Publication Date
Volume
23
Issue
12
Identifiers
DOI: 10.1016/s0022-3468(88)80348-8
Keywords
  • Esophageal Atresia
  • Spiral Esophageal Myotomy

Abstract

In beagle dogs, the cervical esophagus was divided 5 cm cranial to the thoracic inlet employing a stapler. The distal esophageal stump was attached to the external surface of the trachea. A spiral myotomy (21/2 revolutions) was made in a 3-cm long segment constituting the distal end of the proximal esophageal segment. This was twisted on a bias with the muscle edges approximated by interrupted stitches to cover the denuded submucosal layer. With moderate traction, this segment could be elongated to a length of 5 cm. A subcutaneous tunnel was created in the anterior chest to accommodate the reconstructed proximal esophageal segment (under slight traction), with its distal end forming a cutaneous esophagostomy. A gastrostomy was created using a Gauderer button (Bard Interventional Products, Billerica, MA) for feeding. After 3 weeks, the proximal esophageal segment was mobilized and removed from the subcutaneous tunnel. The distal esophageal segment was freed from the trachea and 5 to 8 cm of its proximal end was excised. The proximal (myotomized) esophagus was brought down to the stump of the remaining distal esophagus and an anastomosis formed in an end-to-end fashion. Oral feeding was reestablished within 1 week. Prolonged ingestion, observed soon after operation, gradually improved. During a period of 1 to 6 months after the operation, motility of the myotomized segment was tested by barium swallow and manometry. There was neither diverticulum formation nor stenosis. Transit of contrast material in the myotomized segment was smooth and rapid. Manometry demonstrated preservation of motility in the myotomized segment of the esophagus. This technique would appear to have the following advantages in the management of long gap esophageal atresia: (1) preservation of motility in the myotomized esophageal segment by continuity of muscle layers; (2) substantial elongation of the myotomized esophagus; (3) further elongation by continuous traction after creation of the cutaneous esophagostomy; and (4) reduction in the incidence of major anastomotic complications, when compared with the primary combined procedures of concurrent circumferential myotomy and esophageal anastomosis.

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