Chapter 25

### Key Points

1. When native esophagus is not available, there are a number of esophageal replacement techniques that are effective in restoring the continuity of the gastrointestinal tract.

2. Selection of the appropriate technique depends on the anatomy and function of the stomach, the availability of the colon, and the experience and preference of the surgeon.

3. The 2 dominant replacement procedures are colon interposition and gastric pull-up. The overall outcomes of these 2 procedures are comparable, although both have strong proponents.

### Historical Overview

The decision to replace the esophagus of a child is one of the most difficult decisions a pediatric surgeon must make. Although most surgeons attempt to preserve the native esophagus, there is sometimes no alternative but to consider esophageal replacement. Fortunately, the need for this procedure has decreased in recent years because of public health initiatives concerning the avoidance of caustic ingestion and because of the increased success pediatric surgeons have had in lengthening the upper pouch of patients with long-gap esophageal atresia by performing myotomies. Esophageal replacement is, however, used in the management of a number of conditions, including congenital absence of the stomach, long-gap esophageal atresia, severe injury to the esophagus from caustic ingestion, prolonged gastroesophageal reflux disease, trauma, and inflammatory and infectious conditions.

In 1894, Bircher first devised a neoesophagus by creating an antethoracic skin tube that was constructed to traverse the gap between the proximal esophagus and the stomach. While this procedure allowed patients to eat as normally as possible, the frequency of fistulae and strictures was high.

Subsequently, 4 operative replacement techniques, all of which were developed for adults following resection of esophageal carcinoma, were adapted for use in children. In the most widely used technique (colon interposition), the right or left colon is used as an esophageal substitute. First reported by Lundblad in 1921, this technique was adapted to children in 1955 by Dale and Sherman. They used a retrosternal isoperistaltic colon graft based on the middle colic artery for esophageal replacement. In 1957 Sherman and Waterston modified this technique, creating a transthoracic interposition graft. In 1982 Freeman and Case modified the technique by using a posterior route through the esophageal hiatus.

The stomach is also used as an esophageal substitute either by creating a gastric tube (gastric tube interposition) or by transposing the entire stomach to traverse the gap between the cervical esophagus and the abdomen (gastric interposition). Described by both Gavriliu and Heimlich in the mid-1950s, the reversed gastric tube approach was later adapted to children by Burrington, Anderson, and Randolph. The key proponents in the use of the entire stomach for esophageal replacement have been Spitz and Coran.

The fourth esophageal replacement technique, jejunal interposition, was performed by Roux in 1907 and Herzen in 1908, and adapted for use in children by Leven and Varco in 1950s. Although Ring, Varco, and a number of ...

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