Embed Size (px)
Citation preview
Accepted Manuscript
Thoracoscopic and laparoscopic esophagoplasty for congenital esophageal stenosis
Naoto Urushihara, Hiroshi Nouso, Masaya Yamoto, Koji Fukumoto, Go Miyano,Hiromu Miyake, Keiichi Morita, Masakatsu Kaneshiro
PII: S2213-5766(13)00140-1
DOI: 10.1016/j.epsc.2013.11.004
Reference: EPSC 139
To appear in: Journal of Pediatric Surgery Case Reports
Received Date: 29 October 2013
Revised Date: 3 November 2013
Accepted Date: 5 November 2013
Please cite this article as: Urushihara N, Nouso H, Yamoto M, Fukumoto K, Miyano G, Miyake H, MoritaK, Kaneshiro M, Thoracoscopic and laparoscopic esophagoplasty for congenital esophageal stenosis,Journal of Pediatric Surgery Case Reports (2013), doi: 10.1016/j.epsc.2013.11.004.
This is a PDF file of an unedited manuscript that has been accepted for publication. As a service toour customers we are providing this early version of the manuscript. The manuscript will undergocopyediting, typesetting, and review of the resulting proof before it is published in its final form. Pleasenote that during the production process errors may be discovered which could affect the content, and alllegal disclaimers that apply to the journal pertain.
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
Revised manuscript:
Thoracoscopic and laparoscopic esophagoplasty for congenital esophageal stenosis
Naoto Urushihara, Hiroshi Nouso, Masaya Yamoto, Koji Fukumoto, Go Miyano, Hiromu Miyake,
Keiichi Morita, Masakatsu Kaneshiro
Department of Pediatric Surgery, Shizuoka Children’s Hospital, 860 Urushiyama, Aoi-ku, Shizuoka
420-8660, Japan
Address correspondence to:
Naoto Urushihara, MD, PhD
Department of Pediatric Surgery
Shizuoka Children’s Hospital
860 Urushiyama, Aoi-ku, Shizuoka 420-8660, Japan.
Phone: +81-54-247-6251 Fax: + 81-54-248-4763
E-mail: [email protected]
Short Running Head: Endoscopic esophagoplasty for congenital esophageal stenosis
Key words: Congenital esophageal stenosis; Laparoscopy; Thoracoscopy
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
Abstract
A congenital esophageal stenosis (CES) is a rare anomaly, and therapeutic strategies are still
controversial. Two children with CES located in the lower esophagus, who were treated by
endoscopic esophagoplasty that consisted of partial esophageal resection and transverse anastomosis,
are reported. A 23-month-old boy with CES at the level of T9 underwent esophagoplasty
thoracoscopically. A 13-month-old boy with CES at the level of T10 underwent esophagoplasty
followed by anterior partial fundoplication laparoscopically. Both patients are asymptomatic and eat
normally 5 years and 6 months after surgery, respectively. Thoracoscopic or laparoscopic partial
resection of the esophageal wall and transverse anastomosis are considered effective, less invasive,
and safe in the treatment of CES.
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
Congenital esophageal stenosis (CES) is a rare anomaly, with an incidence of about one per
25,000 to 50,000 live births [1]. CES is divided into 3 types: tracheobronchial remnants (TBR),
fibromuscular thickening (FM), and membranous webbing (MW). The therapeutic strategies,
including endoscopic balloon dilatation and resection of the stenotic site, are still controversial
[2][3][4][5][6][7][8]. Conventionally, esophageal resection has been performed via either
laparotomy or thoracotomy depending on the stenotic site. Recently, thoracoscopic or laparoscopic
surgeries have been reported for the treatment of CES [9][10][11][12]. The cases of two children
with CES located in the lower esophagus, who were treated by endoscopic esophagoplasty that
consisted of partial esophageal resection and transverse anastomosis, are described. A thoracoscopic
approach was used in one, and a laparoscopic approach in the other.
1. Case reports
A 23-month-old boy and a 13-month-old boy were admitted to our hospital for vomiting due to
foreign body impaction in the lower esophagus. The esophagogram and endoscopy showed a lower
esophageal stricture at the level of T9 and T10, respectively (Fig. 1). The proximal esophagus was
moderately dilated. Endoscopic ultrasonography (EUS) was performed to distinguish between TBR
and FM, and it did not show aberrant cartilage in both cases. The patients initially underwent balloon
dilatations 3 and 4 times, respectively, with no significant effect. Partial resections of the esophageal
wall were performed by less invasive surgery in these two children with CES. Histologic studies
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
revealed FM in one and TBR in the other.
1.1 Case 1: 23-month-old boy with CES at the level of T9 due to FM
Partial esophageal resection and transverse anastomosis by a thoracoscopic approach were
performed for stenosis at the level of T9 (Fig. 1A). One-lung ventilation by right mainstem
intubation was carried out for optimal surgical visualization. The patient was then placed in the right
lateral decubitus position. Four 5-mm ports were inserted into the left thoracic cavity in the fourth
intercostal space, midaxillary line for the 5-mm 30° scope; fifth intercostal space, anterior-axillary
line; seventh intercostal space, anterior-axillary line; and seventh intercostal space, posterior axillary
line (Fig. 2). Pneumothorax of 4-8 mmHg was established during surgery. After mobilization of the
inferior pulmonary ligament, the endoscope was introduced through the mouth, and the location of
the stenosis was identified. The stenotic site was about 2 cm proximal to the diaphragm. The area of
esophageal stricture was circumferentially dissected with sparing of both vagus nerves and encircled
with vessel tape. With traction of the vessel tape, the esophageal dissection was extended close to the
diaphragm distally and 4 cm proximally from the stenotic site. Several stay sutures were placed at
the cut line of the esophagus, and diamond-shaped partial resection of the esophageal wall was
carried out using scissors with electrocautery (Fig. 3A). The length of the resected stenotic segments
was about 2.0×1.5 cm. After placing a nasogastric tube, a transverse closure was carried out using 5
interrupted 4-0 absorbable sutures (Fig. 3B). Finally, a chest tube was placed through the port site.
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
Histologic examination of the resected specimen revealed fibromuscular thickening and fibrosis. A
minor leakage was observed postoperatively for 4 days, but this stopped with conservative treatment.
One month after surgery, balloon dilatation was performed due to slight stenosis at the anastomotic
site, revealing an easily dilatable stenosis. The postoperative esophagogram showed good results
with smooth passage of barium. The patient is asymptomatic and eats normally 5 years after surgery.
1.2 Case 2: 13-month-old boy with CES at the level of T10 due to TBR
Partial esophageal resection and transverse anastomosis followed by anterior partial
fundoplication by a laparoscopic approach were performed for stenosis at the level of T10 (Fig. 1B).
Under general anesthesia, the patient was placed in the supine position. Before surgery, an
esophageal balloon dilator was placed via a nostril into the esophagus to determine the stenotic
segment of the esophagus during surgery. Four 5-mm ports were used in the umbilicus for the 5-mm
30° scope, the right and left epigastric regions, and the left lateral region. Pneumoperitoneum of 10
mmHg was established. A Nathanson retractor was introduced directly at the subxiphoid region to
retract the liver (Fig. 4). First, the esophagus was circumferentially dissected, identifying the
posterior and anterior vagus nerves. The hepatic branch of the vagus nerve was not divided. The
esophagus was encircled with vessel tape above the hepatic branch of the vagus nerve. By traction of
the vessel tape, the hiatus was opened, and further dissection was carried out until enough of the
intra-abdominal part of the esophagus was obtained. The lower esophagus was then mobilized for
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
about 5 cm. Next, the balloon was inflated to identify the stenotic site under fluoroscopy. The
stenotic site was about 2.5 cm proximal to the gastroesophageal junction. The anterior vagus nerve
was mobilized from the esophagus and looped to obtain sufficient excision of the stenosis. Several
stay sutures were placed at the cut line of the esophagus. With traction of stay sutures, a
diamond-shaped partial resection of the esophageal wall from the 10- to the 3-o’clock position was
made across the stenotic site using scissors with electrocautery (Fig. 5A). The stenotic site was noted
to be stiff and revealed the presence of cartilage. The length of the resected stenotic segments was
about 2.0×1.5 cm. A nasogastric tube was placed, and the esophagus was then closed transversely
with 6 interrupted 3-0 absorbable sutures (Fig. 5B). The posterior crura were approximated, and the
esophagus was secured to the crura at the 10-, 2-, and 5-o’clock positions. Finally, Thal
fundoplication was performed to reinforce the suture line and prevent gastroesophageal reflux (GER).
Histologic examination of the resected specimen revealed cartilage, tracheobronchial glands, and
ciliated epithelium in the esophageal wall. The patient made an uneventful recovery. One month
after surgery, balloon dilatation was performed due to slight stenosis, revealing an easily dilatable
stenosis. The esophagogram 4 months after surgery showed smooth passage of barium without GER
(Fig. 6). The patient is asymptomatic and eats normally 6 months after surgery.
Discussion
CES is a rare anomaly and divided into 3 types: TBR, FM, and MW. Generally, the symptoms of
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
vomiting and regurgitation become significant when the patients start semi-solid and solid foods.
CES commonly affects the lower esophagus, and the diagnosis is made with esophagography and
endoscopy. EUS may be useful to distinguish between TBR and FM by detecting the cartilage [3],
but the precise diagnosis is difficult. In many cases, the diagnosis is made by intraoperative findings
and histologic study of the resected specimen. Appropriate therapeutic strategies, including
endoscopic dilatation and surgical repair, still remain controversial [2][3][4][5][6][7][8]. Generally,
endoscopic dilatation is attempted first. If ineffective, surgical repair is required. Many surgical
procedures, including segmental resection, partial resection, and myectomy of the esophageal wall,
have been reported [2][3][4][5][6][7][13]. The preferred treatment for TBR is resection of the
stenotic segment with end-to-end anastomosis. Conventionally, the surgical approach was performed
via either laparotomy or thoracotomy, depending on the stenotic site. Recently, minimally invasive
surgery using a thoracoscopic or laparoscopic approach has been reported for the treatment of CES
[9][10][11][12]. Deshpande et al [10]. reported laparoscopic esophagoplasty for TBR. In the present
two children with CES, endoscopic esophagoplasty that consisted of a diamond-shaped partial
resection of the esophageal wall and transverse closure was performed. A thoracoscopic or
laparoscopic approach was chosen depending on the stenotic site. In case 1 of CES at the level of T9,
thoracoscopic esophagoplasty was performed. In case 2 of CES at the level of T10, laparoscopic
esophagoplasty followed by anterior partial fundoplication was performed. The postoperative
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
esophagogram showed slight stenosis at the anastomotic site in both, but it was easily dilated by
balloon dilatation one month after surgery. Anastomotic leakage, anastomotic stricture, and GER are
postoperative complications. In the laparoscopic approach, a fundoplication should be performed to
prevent not only GER, but also anastomotic leakage. In conclusion, thoracoscopic or laparoscopic
partial resection of the esophageal wall and transverse anastomosis are considered effective, less
invasive, and safe in the treatment of CES, however, the longer follow-up period is necessary
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
References
[1] Bluestone CD, Kerry R, Sieber WK. Congenital esophageal stenosis. Laryngoscope
1969;79:1095-104.
[2] Nihoul-Fékété C, De Backer A, Lortat-Jacob S, Pellerin D. Congenital esophageal stenosis. a
review of 20 cases. Pediatr Surg Int 1987;37:86-92.
[3] Takamizawa S, Tsugawa C, Mouri N, Satoh S, Kanegawa K, Nishijima E, et al. Congenital
esophageal stenosis: therapeutic strategy based on etiology. J Pediatr Surg 2002;37:197-201.
[4] Vasudevan SA, Kerendi F, Lee H, Ricketts RR. Management of congenital esophageal stenosis. J
Pediatr Surg 2002;37:1024-6.
[5] Amae S, Nio M, Kamiyama T, Ishii T, Yoshida S, Hayashi Y, et al. Clinical characteristics and
management of congenital esophageal stenosis: a report on 14 cases. J Pediatr Surg 2003;38:565-70.
[6] Zhao LL, Hsieh WS, Hsu WM. Congenital esophageal stenosis owing to ectopic tracheobronchial
remnants. J Pediatr Surg 2004;39:1183-7.
[7] Jones DW, Kunisaki SM, Teitelbaum DH, Spigland NA, Coran AG. Congenital esophageal
stenosis: the differential diagnosis and management. Pediatr Surg Int 2010;26:547-51
[8] Romeo E, Foschia F, de Angelis P, Caldaro T, Federici di Abriola G, Gambitta R, et al.
Endoscopic management of congenital esophageal stenosis. J Pediatr Surg 2011;46:838-41
[9] Martinez-Ferro M, Rubio M, Piaggio L, Laje P. Thoracoscopic approach for congenital
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
esophageal stenosis. J Pediatr Surg 2006;41:E5-7.
[10] Deshpande AV, Shun A. Laparoscopic treatment of esophageal stenosis due to tracheobronchial
remnant in a child. J Laparoendosc Adv Surg Tech A 2009;19:107-9.
[11] van Poll D, van der Zee DC. Thoracoscopic treatment of congenital esophageal stenosis in
combination with H-type tracheoesophageal fistula. J Pediatr Surg 2012;47:1611-3.
[12] Takazawa S, Uchida H, Kawashima H, Tanaka Y, Sato K, Jimbo T, et al. Successful left
thoracoscopic esophagectomy for congenital esophageal stenosis with a useful adjunct of
preoperative endoscopic marking. J Laparoendosc Adv Surg Tech Part B Videoscopy 2013, DOI:
10.1089/vor.2013.0160.
[13] Maeda K, Hisamatsu C, Hasegawa T, Tanaka H, Okita Y. Circular myectomy for the treatment
of congenital esophageal stenosis owing to tracheobronchial remnant. J Pediatr Surg
2004;39:1765-8.
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
Consent
Written informed consent was obtained from the patient for publication of this case report and
accompanying images. A copy of the written consent is available for review by the Editor-in-Chief
of this journal on request.
Conflict of interest
The authors have no conflict of interest to disclose.
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
Figure Legend
Fig. 1 A. Esophagogram in case 1 showing a stenosis at the level of T9. B. Esophagogram
in case 2 showing a stenosis at the level of T10.
Fig. 2 Port placement in case 1.
Fig. 3 Case 1. A. Diamond-shaped partial resection of the esophageal wall across the
stenotic site (arrow). B. The esophagus was closed transversely with 5 interrupted 4-0
absorbable sutures (arrow head).
Fig. 4 Port placement in case 2.
Fig. 5 Case 2. A. Anterior vagus nerve was mobilized from the esophagus and looped
(arrow). Diamond-shaped partial resection of the esophageal wall from the 10- to 3-o’clock
position was made (arrow head). B. The esophagus was closed transversely with 6 interrupted
3-0 absorbable sutures.
Fig. 6 Esophagogram 4 months after surgery in case 2 showing smooth passage of barium without
gastroesophageal reflux.
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
MANUSCRIP
T
ACCEPTED
ACCEPTED MANUSCRIPT
