Laparoscopic Gastric Pull-Up for Esophageal Replacement in Children: A Minimally Invasive Approach

Abstract

Introduction:

Esophageal atresia occurs in^1,3 in 2500–3500 live births, and caustic ingestion has an incidence of 15.8 in 100,000 persons. In both diseases, esophageal preservation is the recommended treatment; however, it is not always feasible in the setting of long-gap atresia, severe caustic injury, or stricture. When esophageal replacement is indicated, the stomach, jejunum, and colon are all possible candidates for a conduit. The gastric pull-up procedure has the benefit of being performed with relative ease and reproducibility. Here, we review our technique of laparoscopic gastric pull-up for esophageal replacement in children.

Materials and Methods:

After patient consent was obtained, records of children undergoing laparoscopic gastric pull-up for esophageal replacement were retrospectively reviewed from our database. Patients were placed supine in a split-leg position with a shoulder roll under the neck and the head turned to the right. Ports were placed in a configuration similar to a laparoscopic Nissen fundoplication. The procedure was initiated with bronchoscopy and esophagoscopy when indicated, followed by adhesiolysis with gastrostomy takedown and closure. The stomach was then mobilized with preservation of the right gastric and gastroepiploic arteries, and a mediastinal tunnel was created laparoscopically from the abdomen and digitally from the neck. A Heineke–Mikulicz pyloroplasty was then performed, and the stomach was placed within the mediastinal tunnel by gently pushing it from the abdomen and pulling it from the neck. Gastric fixation to the crura was then performed. A feeding jejunostomy was then created when indicated, and a two-layered intussuscepting esophagogastric anastomosis was performed at the neck, burying the esophageal portion of the anastomosis into the stomach.

Results:

Sixteen (16) patients with ages ranging from 6 months to 10 years underwent laparoscopic gastric pull-up using the described technique. ³ Esophageal replacement was indicated due to long-gap atresia in 13 patients and lye-related strictures in ²  3 patients. The postoperative course of ³  2 patients was complicated by anastomotic leak. Both leaks occurred before instituting the intussuscepting- type esophagogastric anastomosis, and both developed strictures that later required endoscopic dilation. Two additional patients had a breakdown of the jejunostomy site requiring operative revision. Patients were followed from a range of 6 months to 6.2 years.

Conclusion:

Given these outcomes, we believe that a laparoscopic gastric pull-up can be performed in children with good results and minimal morbidity.

The authors have nothing to disclose and no conflicts of interest. Authors have received and archived patient consent for video recording/publication in advance of video recording of the procedure.

Runtime of video: 7 min 41 sec.