Pediatric surgeons Dr. Daniel Von Allmen and Dr. Todd Ponsky from Cincinnati children's Hospital discussing the technique for treating long gap esophageal atresia.
For additional info please visit:
https://www.youtube.com/c/CincinnatiChildrens/featured
https://www.jpedsurg.org/article/S0022-3468(15)00181-5/fulltext
100:00:00,360 --> 00:00:03,920Hi, Rod Gerardo, a research resident at Cincinnati Children's
200:00:03,920 --> 00:00:07,080Hospital Medical Center, and a few weeks ago, we talked about
300:00:07,080 --> 00:00:09,960esophageal atresia and tracheoesophageal fistula.
400:00:10,120 --> 00:00:12,440We talked about the diagnosis and surgical management,
500:00:12,560 --> 00:00:15,120but one piece of the puzzle that we didn't get to touch on.
600:00:15,240 --> 00:00:19,160What happens when that space between the proximal and distal
700:00:19,160 --> 00:00:23,320esophagus is just too long or what
800:00:23,320 --> 00:00:26,320we call a long gap?
900:00:30,760 --> 00:00:31,440So today
1000:00:31,440 --> 00:00:35,600we're going to talk about long gap esophageal atresia with Dr.
1100:00:35,600 --> 00:00:36,680Dan von Allmen.
1200:00:36,680 --> 00:00:39,920He's the surgeon in chief at Cincinnati Children's Hospital Medical Center.
1300:00:39,960 --> 00:00:42,800And the first thing we should probably touch on is
1400:00:43,040 --> 00:00:46,320how do you even know if that gap is too long in the first place?
1500:00:46,800 --> 00:00:50,560Our method here is that if we have a child with no gas
1600:00:50,560 --> 00:00:53,240in the abdomen, we take them to the OR and put a G-Tube in.
1700:00:53,840 --> 00:00:55,040Many times will do.
1800:00:55,040 --> 00:00:58,040We'll put something up the distal esophagus at that point
1900:00:58,040 --> 00:01:01,280and just get a Fluoro shot but then would wait a couple of weeks.
2000:01:01,280 --> 00:01:04,480And we have our patients go down to interventional radiology,
2100:01:05,000 --> 00:01:08,120where we have a protocol for measuring the gap.
2200:01:08,120 --> 00:01:12,040OK, so at Cincinnati Children's, they have a protocol for how exactly
2300:01:12,040 --> 00:01:13,280they measure that gap.
2400:01:13,280 --> 00:01:15,200So it's the same for every patient.
2500:01:15,200 --> 00:01:19,080So then once you find out that you have a gap, you got some options.
2600:01:19,480 --> 00:01:22,280They all have advantages and disadvantages.
2700:01:22,760 --> 00:01:26,120As we all know, we like to try to preserve the esophagus if we can.
2800:01:26,120 --> 00:01:30,080And certainly John Foker and David who's been on and Kimura
2900:01:30,360 --> 00:01:34,040have described great elongation techniques
3000:01:34,440 --> 00:01:37,800that can be used to try to get the,
3100:01:37,880 --> 00:01:40,960to preserve the native esophagus and get the two ends together.
3200:01:41,480 --> 00:01:43,680First, let's talk about the Foker technique.
3300:01:44,360 --> 00:01:45,320In this procedure,
3400:01:45,320 --> 00:01:48,920the surgeon, through an open incision, will tie a suture to either
3500:01:48,920 --> 00:01:51,680end of the esophagus. Then they'll bring those sutures
3600:01:51,680 --> 00:01:53,680out through the chest wall and close the incision.
3700:01:54,360 --> 00:01:56,920Then they take those two free ends of the suture and tie them
3800:01:56,920 --> 00:01:58,480together in a knot.
3900:01:58,480 --> 00:02:02,720Then they place spacers underneath the knot periodically about every day
4000:02:02,720 --> 00:02:06,800or so until the two ends come together, and they take the patient
4100:02:06,800 --> 00:02:09,640back to the operating room for a primary anastomosis.
4200:02:09,960 --> 00:02:14,000The physiology, which I believe in intensely,
4300:02:14,000 --> 00:02:17,440is that stretch is a, is a very strong promoter of growth.
4400:02:17,840 --> 00:02:20,000And that if you put things on tension.
4500:02:20,000 --> 00:02:21,720They will actually grow over time.
4600:02:21,720 --> 00:02:24,520That's how the cardiovascular system develops in utero.
4700:02:24,800 --> 00:02:28,800And I did some research early in my career looking at one growth and using pressure
4800:02:28,800 --> 00:02:29,840to grow one. So.
4900:02:29,840 --> 00:02:33,560So but the philosophy here is that with traction, you can get
5000:02:33,720 --> 00:02:35,720the two ends of the esophagus to grow,
5100:02:35,720 --> 00:02:39,120and if you can get them to grow far enough, you can put them together.
5200:02:39,920 --> 00:02:41,960OK, next we'll talk about the Van Der Zee technique.
5300:02:42,120 --> 00:02:43,360It's the same concept,
5400:02:43,360 --> 00:02:47,240except it's done thoracoscopically and there are no external sutures.
5500:02:47,240 --> 00:02:50,320So all of the tension is inside the thorax.
5600:02:50,920 --> 00:02:55,240And lastly, the Kimura technique, which really isn't used all that often anymore.
5700:02:55,640 --> 00:03:00,600The idea here is you first create spit fistula and then periodically you move
5800:03:00,600 --> 00:03:05,000that fistula down the chest wall over time to stretch the proximal pouch,
5900:03:05,280 --> 00:03:09,080bringing it closer to the distal pouch to be able to create an anastomosis.
6000:03:09,760 --> 00:03:11,600Now, if we look specifically at the Foker
6100:03:11,600 --> 00:03:15,000technique, there is some good literature to support this technique.
6200:03:15,440 --> 00:03:16,680Here's Dr. von Allmen.
6300:03:16,680 --> 00:03:22,080There was a great article published by the Boston Group 2015.
6400:03:22,360 --> 00:03:26,000Divides the cases into two groups primary group and secondary
6500:03:26,000 --> 00:03:30,000groups, secondary being patients who have had operations previously.
6600:03:30,000 --> 00:03:33,920And the primary group being cases that they saw de novo.
6700:03:34,160 --> 00:03:38,360Obviously, you look at the result of getting the esophagus together,
6800:03:38,400 --> 00:03:42,160an intact esophagus in 96% of patients in the primary group.
6900:03:42,600 --> 00:03:45,480About two thirds of patients in the secondary group.
7000:03:45,920 --> 00:03:48,920But these procedures are not without some morbidity.
7100:03:48,920 --> 00:03:53,120And you look at the ICU stay is a median of 70 days, with,
7200:03:53,960 --> 00:03:56,520a couple of weeks being paralyzed for the primary group
7300:03:56,920 --> 00:03:59,640and 110 days
7400:03:59,640 --> 00:04:03,200for the secondary group with with a month of being paralyzed.
7500:04:03,320 --> 00:04:05,320About two thirds of patients with the primary
7600:04:05,320 --> 00:04:07,960repair were able to get the full oral nutrition,
7700:04:08,320 --> 00:04:12,520and about 10 percent of the patients who had the secondary repair.
7800:04:12,920 --> 00:04:15,600If you want the article, I'm going to link it below, so scroll down
7900:04:15,680 --> 00:04:17,440under the media player, you could open it up.
8000:04:17,440 --> 00:04:19,640We were all taught the
8100:04:19,640 --> 00:04:22,080the dictum that every effort should be made to conserve
8200:04:22,080 --> 00:04:25,440the native esophagus, as no other conduit can replace its function
8300:04:25,440 --> 00:04:29,120in transporting food from the oral cavity to the stomach satisfactorily.
8400:04:29,760 --> 00:04:31,880So all of these techniques are great, but
8500:04:32,400 --> 00:04:35,120what if none of them really work?
8600:04:35,840 --> 00:04:38,080Then what do we do? Great question, Rod.
8700:04:38,400 --> 00:04:42,200You could use the stomach that would be called a gastric transposition.
8800:04:42,440 --> 00:04:45,240The surgical group from the INOEA
8900:04:45,840 --> 00:04:49,480Their recommendation, their recommendation for the first option
9000:04:49,480 --> 00:04:52,920as a gastric pull up, I divide the esophageal stub
9100:04:52,920 --> 00:04:56,960that the esophageal hiatus and mobilize the fundus and pull the fundus up.
9200:04:56,960 --> 00:05:01,360And you can pull it off, either in the anterior or posterior mediastinum.
9300:05:01,600 --> 00:05:04,440You can actually use the colon as an interposition as well.
9400:05:04,720 --> 00:05:07,800I personally was trained to do colon interpositions.
9500:05:08,640 --> 00:05:11,040And just how exactly does Dr.
9600:05:11,040 --> 00:05:13,760von Allmen do this colonic interposition?
9700:05:14,240 --> 00:05:18,160Well, to answer that, we had this awesome video created
9800:05:18,160 --> 00:05:22,760by the Cincinnati Children's Media Lab, and they were gracious
9900:05:22,760 --> 00:05:26,720enough to share this with you so that you can learn.
10000:05:27,400 --> 00:05:28,920So we're going to start off with two incisions.
10100:05:28,920 --> 00:05:29,760first.
10200:05:29,760 --> 00:05:33,880Is your midline abdominal incision and second is your cervical incision,
10300:05:33,880 --> 00:05:37,000because think about it, that's where we're going to be doing these anastomosis.
10400:05:37,520 --> 00:05:41,400Now once you gain access to the abdomen, like Dr.
10500:05:41,400 --> 00:05:45,120von Allmen said, the piece of colon that we choose is really based
10600:05:45,120 --> 00:05:49,640on the blood supply and the diameter that you're going to need.
10700:05:53,400 --> 00:05:54,320Now, once you
10800:05:54,320 --> 00:05:57,960have that piece of colon, you're going to use for the interposition.
10900:05:58,360 --> 00:06:02,560Dr. von Allmen pulls that behind the stomach, maintaining
11000:06:02,560 --> 00:06:05,920the blood supply and obviously making sure that you don't make it
11100:06:05,920 --> 00:06:07,840too torturous.
11200:06:08,920 --> 00:06:10,720The stapled ends of both
11300:06:10,720 --> 00:06:13,840the proximal esophagus and the
11400:06:14,440 --> 00:06:18,760I guess now proximal colon part of the interposition are removed
11500:06:19,000 --> 00:06:22,720and then we can do our proximal anastomosis, which is what you see here.
11600:06:26,440 --> 00:06:30,040And then the distal anastomosis same things removed.
11700:06:30,040 --> 00:06:34,760The stapled end of the colon, create the gastrostomy,
11800:06:35,200 --> 00:06:39,040and we're going to do our distal anastomosis.
11900:06:39,040 --> 00:06:42,400Similarly, as you can see here.
12000:06:45,360 --> 00:06:48,720Boom, there you have it, but we're not done.
12100:06:49,080 --> 00:06:53,040So next to help with gastric emptying,
12200:06:53,400 --> 00:06:57,720we're going to do a pyloroplasty which is again depicted here.
12300:07:06,560 --> 00:07:08,040And then finally,
12400:07:08,040 --> 00:07:11,080we have to re approximate
12500:07:11,080 --> 00:07:15,080the two blind ends of the colon that we took.
12600:07:15,360 --> 00:07:16,480So same thing.
12700:07:16,480 --> 00:07:19,720Remove the stapled portion and you're going to do your Colo,
12800:07:19,720 --> 00:07:23,520Colo anastomosis.
12900:07:27,520 --> 00:07:28,280And like
13000:07:28,280 --> 00:07:32,080with any other anastomosis, the key here
13100:07:32,080 --> 00:07:34,720is preserving the blood supply
13200:07:35,200 --> 00:07:38,080once that arterial supply is confirmed.
13300:07:38,480 --> 00:07:42,640Then we know that we're in a good place to finish this surgery out.
13400:07:46,200 --> 00:07:49,440And now we're going to show you the side by side comparison on the left,
13500:07:49,440 --> 00:07:53,640the long gap esophageal atresia on the right, the colon and interposition.
13600:07:53,640 --> 00:07:56,800So thank you again to the Cincinnati Children's Media Lab.
13700:07:57,120 --> 00:07:58,400Scroll down under the media player.
13800:07:58,400 --> 00:08:00,640We're going to link some more videos that they've made.
13900:08:00,640 --> 00:08:02,720Now the downside to using colon.
14000:08:02,920 --> 00:08:07,640Common problems with this are that they dilate and they can become torturous.
14100:08:07,880 --> 00:08:10,640It's not uncommon to get kind of the sigmoid
14200:08:11,520 --> 00:08:14,560sink drain deformity just above the diaphragm.
14300:08:14,800 --> 00:08:17,280All right. Dr. von Allmen, how do you avoid that?
14400:08:17,520 --> 00:08:20,320I was taught initially that that you can't fix that
14500:08:20,320 --> 00:08:21,480and that it's too dangerous
14600:08:21,480 --> 00:08:24,160and that your risk the blood supply to the colon interposition.
14700:08:24,720 --> 00:08:27,120But I found that actually, that's not really true.
14800:08:27,320 --> 00:08:31,320I passed the interposition posterior to the stomach, which leaves
14900:08:31,320 --> 00:08:36,320the vascular pedicle along the spine, and you can mobilize the colon.
15000:08:36,320 --> 00:08:40,280You can divide the gastric, do a laparotomy, divide the
15100:08:41,560 --> 00:08:43,200colon attachment to the stomach
15200:08:43,200 --> 00:08:47,680and then mobilize the, that sigmoid redundancy,
15300:08:48,000 --> 00:08:51,840transhiatally and then re-anastamos the colon to the stomach.
15400:08:51,840 --> 00:08:56,560So I wouldn't pretend to say that these don't need to be revised sometimes,
15500:08:56,560 --> 00:09:00,560but it is not impossible to revise them, and the kids tend to do pretty well.
15600:09:00,960 --> 00:09:05,280But the good thing about using the colon, you can get extraordinary length on this.
15700:09:05,360 --> 00:09:08,520Mike and I have done a few cases for kids who had
15800:09:09,200 --> 00:09:13,560disasters, multiple operations elsewhere, who had caustic injuries
15900:09:13,800 --> 00:09:16,000that were involved all the way up to the pharynx,
16000:09:16,000 --> 00:09:20,040where we had to do a lot of work just on the pharynx to get that open.
16100:09:20,040 --> 00:09:23,240And then literally sew the colon interposition to the pharynx
16200:09:23,240 --> 00:09:26,040and then down to the stomach, which is obviously tough to do
16300:09:26,080 --> 00:09:27,520with the gastric colon.
16400:09:27,520 --> 00:09:31,360And then here's some images of a colonic conduit in the O.R.,
16500:09:31,360 --> 00:09:33,560as well as a contrast image.
16600:09:33,560 --> 00:09:37,080Now, keep in mind that this video is from a live webinar.
16700:09:37,400 --> 00:09:40,160So here's a question from the interactive audience.
16800:09:40,160 --> 00:09:42,600Sheika brings up a great point he says.
16900:09:42,600 --> 00:09:44,960You know, is this growth or stretch?
17000:09:44,960 --> 00:09:47,240Looking at the short interval between the time of traction
17100:09:47,240 --> 00:09:49,440and anastomosis, which is less than five days.
17200:09:49,480 --> 00:09:51,120Is it stretching or growing?
17300:09:51,120 --> 00:09:54,280Because this will impact the results and likely reflects on the complication.
17400:09:54,280 --> 00:09:56,360I would love to hear the comments from the experts on that.
17500:09:56,840 --> 00:09:59,920I don't think we know we should do the studies to understand that.
17600:09:59,920 --> 00:10:03,800But I would say that this gets back to David van der Zee's comment about.
17700:10:03,800 --> 00:10:06,320Go have a cup of coffee and come back and it will be fine.
17800:10:06,400 --> 00:10:08,320Clearly, that's not growth that's stretch.
17900:10:09,760 --> 00:10:10,840And yet
18000:10:10,840 --> 00:10:14,000there's the there's very good physiologic data.
18100:10:14,000 --> 00:10:16,640That tension is a growth promoter,
18200:10:16,640 --> 00:10:19,280not necessarily in the esophagus, but in other organs.
18300:10:19,280 --> 00:10:24,320So I think that it's area ripe for for a little more basic science.
18400:10:24,640 --> 00:10:25,640So there you have it.
18500:10:25,640 --> 00:10:27,360A little advice from Dr.
18600:10:27,360 --> 00:10:31,960Dan von Allmen about what to do when you have esophageal atresia,
18700:10:31,960 --> 00:10:36,800and the gap is just too long to put together right then and there.
18800:10:36,960 --> 00:10:40,360So if you like this episode, go ahead and subscribe to our YouTube channel.
18900:10:40,360 --> 00:10:44,000Follow us on social media, download the Stay current pediatric surgery app
19000:10:44,840 --> 00:10:47,080and until next time, remember, knowledge
19100:10:47,840 --> 00:10:49,160should be free.
19200:11:07,960 --> 00:11:11,080Now, if you're listening to this podcast, like an audio
19300:11:11,080 --> 00:11:12,920only version of this podcast,
19400:11:12,920 --> 00:11:16,720that's totally fine, just know that we want to give you the steps of how Dr.
19500:11:16,720 --> 00:11:18,280von Allmen does this surgery.
19600:11:18,280 --> 00:11:20,520So you got a couple options?
19700:11:20,520 --> 00:11:22,640Scroll down under the media player, you can see a couple of links.
19800:11:22,640 --> 00:11:25,680one of them is to our YouTube page,
19900:11:25,680 --> 00:11:29,040and you can watch a video version of this podcast.
20000:11:29,440 --> 00:11:32,200And in that video version, we're going to have an animation
20100:11:32,480 --> 00:11:35,200created by the Cincinnati Children's Media Lab
20200:11:35,560 --> 00:11:38,960that walks you through the steps of this colonic interposition.
20300:11:39,720 --> 00:11:42,120Or if you just want to watch
20400:11:42,120 --> 00:11:45,360like just that part of the video,
20500:11:45,800 --> 00:11:49,360we're going to link you to the Cincinnati Children's
20600:11:49,360 --> 00:11:53,960Media Lab's video animation of just the surgery itself.
20700:11:53,960 --> 00:11:57,560So you can click on that and watch that pop back into this audio podcast,
20800:11:57,560 --> 00:12:01,040or you can watch a video version of this whole podcast.
20900:12:01,400 --> 00:12:04,360You know, there's just so many options that we want to give you
21000:12:04,360 --> 00:12:07,480all of this content, either on YouTube or on
21100:12:07,480 --> 00:12:10,560audio podcasts or on our stay.
21200:12:10,560 --> 00:12:13,920Current in Pediatric Surgery app, which is in the Google Play Store
21300:12:13,920 --> 00:12:19,520and the Apple App Store, you got a lot of different ways you can learn from Dr.
21400:12:19,520 --> 00:12:20,640von Altman.
21500:12:20,640 --> 00:12:21,920We're going to give them all to you.
21600:12:21,920 --> 00:12:23,840So follow the links, do whatever you want.
21700:12:23,840 --> 00:12:25,480But in the meantime, here's the rest of the episode.
