Intercostal Pedicled Flap in Esophageal Atresia

By A. Soriano, N. Hern,andez-Siverio, A. Carrillo, A. Alarc6, and F. Gonz~lez Hermoso Tenerife, Spain

�9 Since 1974 we have used an intercostal pedicled flap (IPF) between the esophageal anastomosis and the sutured trachea in a single case of recurrent tracheoesophageal fistula (TEF) and in four cases of primary repair of esopha- geal atresia (EA) and TEF in which the distance between both ends was greater than 2.5 cm and with a certain degree of tension in the anastomotic line. Futhermore, in the last t w o cases reported in this article, we have been able to use the IFP in an extrapleural approach in a way not previously reported. The short-term and long-term follow- ups have been excellent without any complications relating to the esophagus itself or to the pedicle flap of intercostal muscle. The method is considered particularly useful in recurrent fistulas. �9 1987 by Grune & Strat ton, Inc.

INDEX WORDS: Esophageal atresia; intercostal muscle pedicle flap; recurrent tracheoesophageal fistula.

T HE INTERCOSTAL pedicled flap (IPF) has long been used in the treatment of different

thoracic surgical problems, eg, to close tracheobron- chial defects, 1-3 esophageal defects, or to protect risky esophageal suture lines. 3-7

The use of the IPF in esophageal pediatric surgery was first reported in 1967 by Dooling and Zick 8 in closing a recurrent tracheoesophageal fistula (TEF), three days after its primary closure, and recently by Gustafson (1982) 3 in similar problems. In 1975 Zajt- chuk et al 9 had gone further with the use in the primary closure of EA with TEF claiming a lower mortality and morbidity and better long-term results.

In using an IPF it is presumed that the pleural cavity will be opened. It is proposed by some that the extra- pleural approach to EA with TEF has reduced its morbidity; in our last two cases we have combined the advantages of the IPF interposed between the trachea and the esophagus, with the extrapleural approach.

The technique involved in this approach is much the same as that previously described but care is taken to avoid entering the pleural cavity by dissecting the periosteum of the bordering ribs and by separating the pleural covering from the intercostal muscle in a quite accesible fashion (Fig 1).

CASE REPORTS

Case 1

A 6-month-old boy developed a cough, respiratory distress, and cyanosis on feeding. He had had an EA and TEF corrected at birth by the extrapleural route and one layer anastomosis with 5-0 silk. On admission a recurrent TEF was diagnosed by roentgenogram stud- ies. On February 1974 the fistula was again divided and the trachea and the esophagus closed. A posteriorly based IPF was taken from

the fourth intercostal space and interposed loosely between the trachea and the esophagus at the site of the closures. The child made an uneventful recovery and has done well during these past 11 years.

Case 2

A 2.4 kg newborn female child was diagnosed soon after birth as having an EA and TEF. Through a right thoracotomy an IPF was taken. After dividing the fistula through a transpleural approach, an end-to-end one-layer esophageal anastomosis was done with 5-0 silk. The completed anastomosis was left under some tension and the IPF was interposed between the trachea and the esophagus at the site of the fistula. The postoperative recovery was straightforward and the child has remained well for 5 years.

Case 3

A 2.3 kg male was born with and EA and TEF, anal atresia rectourethal fistula, and hypospadias. He was taken to the operating theater and a gastrostomy, and an end transverse colostomy was done prior to a right thoracotomy when the fistula was closed; and an end-to-end esophagostomy was done through a transpleural approach; and a IPF was interposed between the esophagus and the trachea. One year later, the anal atresia and the rectourethal fistula was repaired and the colostomy closed soon after. He has done very well during these past 31/2 years while awaiting the repair of the hypospadias.

Cases 4 and 5

A 3.2 kg female baby (case 4) and a 1.9 kg female baby (case 5) were operated on for an EA and TEF soon after birth, 2 and 1 years ago, respectively. On both occasions an IPF (fourth interspace) was taken without opening the pleural cavity. Through this extrapleural approach the TEF was closed and an end-to-end esophagostomy was done (Fig 1). The previously prepared IPF was interposed between the trachea and the esophagus. Both children have done very well since.

DISCUSSION

In sp i t e o f t h e t e c h n i c a l a d v a n c e s in t h e m a n a g e -

m e n t o f n e w b o r n i n f a n t s w i t h E A a n d T E F , t h e r e s u l t s

a r e st i l l b u r d e n e d by c e r t a i n c o m p l i c a t i o n s s u c h as

a n a s t o m o t i c leaks , s t r i c t u r e , a n d r e c u r r e n t T E F .

T h e a n a s t o m o t i c l e a k is t h e m o s t se r ious c o m p l i c a -

t ions ; i ts f r e q u e n c y is e s t i m a t e d b e t w e e n 5% a n d 10%

a n d is d u e to u n d u e t ens ion , i s c h e m i a , a n d foca l

i n f e c t i o n a t t h e a n a s t o m o t i c l ine (Boyle~~

S e v e r a l e t io log ic f a c t o r s a r e be l i eved to b e i m p o r t a n t

in t h e d e v e l o p m e n t of a n a n a s t o m o t i c s t r i c t u r e fol low-

From La Laguna University Medical School, Tenerife, Spain. Address reprint requests to A. Soriano, Servicio Cirugia, Hospi-

tal la Candelaria, Tenerife, Spain. �9 1987 by Grune & Stratton, Inc. 0022-3468/87/2202-0004503.00/0

Journal of Pediatric Surgeru Vo122, No 2 (February), 1987: pp 115-116 115

1 16 SORIANO ET AL

L

Fig 1. Technique of intercostal pedicle flap.

ing esophageal primary repair. These include excessive tension and exaggerated fibroplasia at the suture line, and anastomotic leak and tenuous blood supply in the esophageal ends. The incidence of these strictures is between 14% and 80%, and 30% and 50% of those that require dilatations. ~~

It is difficult to estimate the incidence of recurrent T E F but its range is between 5% and 11% 1~ and most are the results of a small anastomotic (suture line) leak with local infection, abscess formation, and erosion through the previous site of the TEF.

It is helpful to separate the t rachea and the esopha- gus at the fistula site by interposing adjacent tissue, like mediast inal tissue, pleural flap, pericardial flap, etc, but it is not always possible. 15'16'18

We believed that the advantages of using the IPF over other tissues were overwhelming, in spite of its apparent difficulty, due to the fact that being a thick tissue with its own blood supply it is able to give an extra vascular supply to assure healing of the anasto- mosis, dec rea s ing all the c ompl i c a t i ons l is ted before. 3,6,7

We have been able to use the I P F by an extrapleural approach without adding undue overtime or difficul- ties to the operation and we think that this achieve- ment is to be taken in considerat ion in the managemen t of these neonates, especially when there is undue tension on the anastomotic line, and particularly, in the instance of recurrent TEF.

R E F E R E N C E S

1. Penton RS, Brantigan OC: The use of a viable pedicle graft for repairing an extensive tracheo bronchial defect. Ann Surg 135:709- 712, 1951

2. Blair E: Study of the viable intercostal pedicle graft in tracheo-bronchial surgery. J Thorac Surg 36:869-878, 1958

3. Gustafson RA, Hrabousky EE: Intercostal muscle and myo- osseous flaps in difficult pediatric thoracic problems. J Pediatr Surg 17:541-545, 1982

4. Bryant LR: Experimental evaluation of intercostal pedicle grafts in esophageal repair. J Thorac Cardiovasc Surg 50:626-633, 1965

5. Lawson RAM, Butchart EG, Soriano A, et al: Spontaneous rupture of the oesophagus. J Royal Coil Surg Edinburg 19:363-367, 1974

6. Soriano A: Plastias pediculadas esof~igicas (estudio experimen- tal), Tesis Doctoral. Universidad de La Laguna, 1979

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8. Dooling JA, Zick HR: Closure of an esophagopleural fistula using onlay intercostal pedicle graft. Ann Thorac Surg 3:553-557, 1967

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