Background
Esophageal replace
ment for caustic stenosis in children poses a challenging surgical proble
m. Blind re
moval of the injured esophagus without thoracoto
my through a left cervical and transhiatal approach followed by an orthotopic esophageal replace
ment using either the colon or the sto
mach is a difficult procedure and can be dangerous in children. We perfor
med our first total laparoscopic transhiatal esophagecto
my in February 2007. We ai
m to co
mpare this new technique to the previously applied
method of blind closed-chest esophagecto
my through a cervicoto
my and laparoto
my.
Methods
We analyzed the surgery and follow-up of 40 children operated upon for extensive irreversible caustic burns of the esophagus. The first 20 esophageal replacements were performed following a blind dissection of the mediastinum through a cervical incision and a laparotomy for esophagectomy (Group I). The last 20 esophageal replacements were performed after laparoscopic transhiatal dissection in the mediastinum and cervicotomy in the neck for esophagectomy (Group II). All operations were performed under the supervision of the same senior surgeon.
Results
Average age at the time of surgery was the same in both groups. Total esophagectomy was achieved in 45.0 % of cases in Group I versus in 90.0 % of cases in Group II. Colon was used in 80.0 % of cases in Group I and in 90.0 % in Group II. The mean duration of surgery was one hour longer in the laparoscopy group. One vascular injury was reported in the blind laparotomy group. Pneumothorax was more frequent in Group II without significant consequences besides drainage. Average time of extubation was about the same in both groups (1.8 days).
Conclusion
Laparoscopic transhiatal esophagectomy for caustic burns before esophageal replacement in children is safe and effective. It could avoid vascular and bronchial mediastinal injuries as the dissection is performed under direct visual control. The routine use of laparoscopic assistance by a senior surgeon improves the safety of esophageal dissection and reduces life-threatening complications.