Esophageal replacement in children: evaluation of the one-stage procedure with colic transplants

After having practiced two-stage esophagoplasties by retrosternal Iso-peristaltic colic transplant since 1966, we introduced the one-stage procedure in 1989, placing the transplant in the posterior mediastinum following a closed-chest esophagectomy. We have performed 121 such esophagoplasties in children until now. To evaluate the possible effects of the different techniques as accurately as possible, we recorded two uniform series of 32 and 41 esocoloplasties carried out under identical conditions by two operators respectively. All of the children, aged 1.2 to 13.9 years (mean age: 4.3 years and 4.8 years, limits 1.2-13.9 years), were operated upon for caustic burns of the esophagus. The general concept of both interventions is the same. Improvements such as optimizing the proximal and the colo-gastric anastomosis and the creation of an anterior anti-reflux hemi-valve were aimed for. The one-stage esophagoplasty has become a shorter procedure (mean 4.9 h) than the two-stage one (mean 5.7 h). The one-stage procedure has no higher rate of per-operative complications than those observed during the two-steps of the staged operation. One-stage esophagoplasty provides better morphological results. The redundancy of the transposed colon, the narrowing effect of the upper cervical passage and of the point of re-entry into the abdominal cavity are avoided. The mediastinal colon is straighter, which allows better emptying by gravity. The improvement of the lower anastomosis decreases the reflux rate in the transplant to 12%. Postoperative care demands a longer stay in the intensive care unit because of pharyngeal and left pulmonary respiratory complications. For these reasons we kept our patients intubated for a period of 2 to 5 days (mean period: 3.4 days). All patients survived the intervention