Anesthetic implications and role of preoperative beta blockade in esophageal substitution with stomach in pediatric surgical patients

Background There is a paucity of literature on the anesthetic management of pediatric esophageal substitution using the stomach. We did a retrospective analysis of all such cases done at our institution. We analyzed the patient’s demography, indication, and type of surgery, co-morbid conditions, anesthesia techniques, duration of postoperative ventilation, hospital stay, complications, and mortality. The use of beta-blockers and their effect on the incidence of intraoperative and postoperative tachycardia in gastric pull-up patients was also analyzed. Results Thirty-four cases of gastric substitution of the esophagus in children were done over 19-year period; gastric pull-up was done in 28 patients and a gastric tube was made in 6 patients. General anesthesia was given to all; a thoracic epidural for pain was sited in 25 patients. Twenty-eight patients were ventilated postoperatively; the mean duration of ventilation is 54 h. Significant intraoperative tachycardia was observed in 85.7% of patients without beta-blocker as compared to 23.8% patients with beta-blocker (p = 0.004). Postoperatively, tachycardia was absent in patients receiving beta-blocker and present in 71.4% of patients not receiving beta-blockers (p < 0.001). Overall mortality was 8.8% but mortality due to cardiac arrhythmia was 42.9% in the patients not receiving beta-blockers (p = 0.001). Conclusions A thorough preoperative preparation, control of tachyarrhythmias, postoperative ventilation, and pain management is recommended for a favorable outcome. In addition, our paper supports the preoperative use of beta-blockers in reducing the incidence of fatal tachyarrhythmias associated with gastric pull-up surgery without any serious adverse effects. Level of evidence Level III

Successful muscle regeneration by a homologous microperforated scaffold seeded with autologous mesenchymal stromal cells in a porcine esophageal substitution model

Background: Since the esophagus has no redundancy, congenital and acquired esophageal diseases often require esophageal substitution, with complicated surgery and intestinal or gastric transposition. Peri-and-post-operative complications are frequent, with major problems related to the food transit and reflux. During the last years tissue engineering products became an interesting therapeutic alternative for esophageal replacement, since they could mimic the organ structure and potentially help to restore the native functions and physiology. The use of acellular matrices pre-seeded with cells showed promising results for esophageal replacement approaches, but cell homing and adhesion to the scaffold remain an important issue and were investigated. Methods: A porcine esophageal substitute constituted of a decellularized scaffold seeded with autologous bone marrow-derived mesenchymal stromal cells (BM-MSCs) was developed. In order to improve cell seeding and distribution throughout the scaffolds, they were micro-perforated by Quantum Molecular Resonance (QMR) technology (Telea Electronic Engineering). Results: The treatment created a microporous network and cells were able to colonize both outer and inner layers of the scaffolds. Non seeded (NSS) and BM-MSCs seeded scaffolds (SS) were implanted on the thoracic esophagus of 4 and 8 pigs respectively, substituting only the muscle layer in a mucosal sparing technique. After 3 months from surgery, we observed an esophageal substenosis in 2/4 NSS pigs and in 6/8 SS pigs and a non-practicable stricture in 1/4 NSS pigs and 2/8 SS pigs. All the animals exhibited a normal weight increase, except one case in the SS group. Actin and desmin staining of the post-implant scaffolds evidenced the regeneration of a muscular layer from one anastomosis to another in the SS group but not in the NSS one. Conclusions: A muscle esophageal substitute starting from a porcine scaffold was developed and it was fully repopulated by BM-MSCs after seeding. The substitute was able to recapitulate in shape and function the original esophageal muscle layer.

DOZ047.29: Pleural flap for partial esophageal substitution in case of difficult anastomosis

Esophageal reconstruction in long-gap atresia remains challenging for the surgeon. Complications of surgery, regardless of choices and methods proposed, are frequents, sometimes serious, and can significantly delay baby's feeding, with increased disruption of orality. The ideal is a reconstruction with only esophageal tissue available. There is renewed interest for technical of elongation described initially by Foker, especially modified by Van Der Zee.1 But, elongation is not always so simple that provided. We report an observation of esophageal atresia (type 1 Ladd), treated by rapid elongation. On the sixth day of procedure, right pleurisy reveals a rip at the apex of inferior esophagus. Anastomosis was possible on the posterior plane, but impossible on the anterior plane. The anterior plane has been reconstituted with a flap of parietal pleura. The operative course was simple without any fistula. Oral feeding started at fifteenth day postanastomosis was quickly complete. Gastrostomy left by security has not been used. Three endoscopic dilations have been necessary at six weeks, two and five months after anastomosis. At the age of eleven months, the orality was perfect, and diet was diversified with pieces. Use a pleural flap to bury or isolate sutures is well known technic.2 But use only pleura to replace the esophageal wall is not described. Partial reconstruction of a hemiesophageal wall with only pleura is possible, despite difficult conditions. It is a trick easily achievable in case of difficulty, with a good result that is maintained over time.

DOZ047.119: Five year experience of a tertiary-level referral center in children with anastomotic strictures after esophageal atresia repair

Background Esophageal atresia (EA) is the most common congenital anomaly of the esophagus. Anastomotic strictures (AS) frequently occur in patients surgically treated for esophageal atresia (EA). The primary aim of this study is to determine the role of esophageal dilations in the management of AS in childhood after reconstruction of EA. Methods A retrospective chart review of patients treated with esophageal dilation for EA was conducted at our tertiary referral center from 2013 to 2017. We included patients treated at our Institution since diagnosis and patients referred from other Institutions. All dilations were performed with Savary-Gilliard polyvinyl bougies. Dilation was performed on an ‘as needed’ basis. Results Eighty-nine patients (68.5% males, 31.5% female) underwent 433 dilations overall in the study period (median: 3, range: 1–36). Type I of EA was 26.1%, Type II was 9.1%, Type III was 64.8%. Associated malformations in 52.8% cases. Six patients received 33 local applications of mitomycin C (MMC) and two of triamcinolone acetate for recurrent stenosis. Four patients developed a preanastomotic diverticulum-treated endoscopically. Nine patients (10.1%) underwent dynamic esophageal stent placement after a median of six dilations. Antireflux surgery was performed in 28 patients (31.5%), Nissen fundoplication in 20 patients, Toupet in 6, and both in 2. Patients treated with antireflux surgery received a mean of 7.1 dilations before surgery, versus 3.9 in patients without antireflux surgery (P = 0.0285, unpaired t test). Seven patients (7.9%), 5 referral, needed major esophageal surgery (4 esophageal reanastomosis and 3 esophagocolonplasty). Patients underwent major surgery received a mean of 19.3 dilations versus 3.6 dilations in no-surgery patients (P = 0.0002, Mann-Whitney U test). Six of 9 stented patients did not require surgery. Perforation was present in 0.4% of 433 dilatations. Conclusions Esophageal dilatation remains the mainstay of treatment for AS after EA repair. Stricture resection with end-to-end anastomosis is the reconstructive option of choice; esophageal substitution is reserved only in cases of intractable stricture. The use of esophageal dynamic stent, MMC, or steroids could help in avoiding or delaying the need of operative stricture resection. Antireflux surgery is mandatory in case of severe pathological gastroesophageal reflux to prevent intractable strictures from developing.

DOZ047.101: Preclinical studies of tissue engineering for long-gap esophageal atresia in pigs. A systematic literature review

Introduction Current approaches for esophageal substitution in long-gap esophageal atresia (LGEA) are associated with complications that impact quality of life. Tissue-engineered (TE) esophagus appears as a promise to overcome these issues. The pig has been used as large-animal model to test TE esophagus before its clinical application. Different approaches have been reported. This study aims at conducting a systematic review of TE approaches for complete esophageal defects in pigs. Materials and Methods This work was registered in PROSPERO (ID 127838). A systematic literature review was performed following SYRCLE’s guidelines, using the CAMARADES-NC3Rs platform (SyRF). PubMed and OpenGrey databases were reviewed identifying articles on complete esophagus defects in pigs restored by TE. The analyses of bias and 3Rs were based on the ARRIVE guidelines. Results In the period 2009–2018, 14 articles were identified using pigs as a model for a TE approach in complete esophageal defects. Animal age/weight/sex, size/localization of the defect, TE strategy, follow-up, and outcomes greatly differ among different studies. Few studies report strategies to improve 3Rs and internal validation. Discussion Further studies in LGEA preclinical models should be performed in an attempt to create a defect in the intrathoracic esophagus. Methodological design may help to avoid bias and define strategies related to the 3Rs. TE approaches with best results include the use of different cell populations seeded in scaffolds that are maturated in bioreactors before their implantation. The next questions to be addressed are developing techniques to avoid stent migration and promoting regeneration of the enteric nervous system.