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J Thorac Cardiovasc Surg 2007;134:1592-1593
© 2007 The American Association for Thoracic Surgery
Brief Communication |
a Department of General Paediatric Surgery and EA3102, Robert Debre Hospital and Paris VII University, Paris, France
b Department of General Paediatric Surgery, Robert Debre Hospital, Paris, France
c Department of Paediatric Intensive Care Unit, Robert Debre Hospital, Paris, France.
Received for publication July 25, 2007; accepted for publication August 30, 2007. * Address for reprints: Arnaud Bonnard, MD, Division of General Pediatric Surgery, Robert Debre Hospital and University Paris VII, EA3102, 48 Boulevard Serurier, 75019 Paris, France.
Congenital esophageal atresia (EA) and tracheoesophageal fistula (TEF) are common surgical congenital abnormalities. In approximately 75% of patients, the EA repair can be done during the first days of life to repair the atresia and fix the TEF. Respiratory issues are usual in the postoperative course and may be related to tracheomalacia and gastroesophageal reflux. Recurrent TEF can occur in 10% to 15% of EA repairs1
and remains challenging to treat. Several surgical solutions have been proposed, such as use of glue, diathermy,2 and surgery. When surgery is required, some authors have reported the use of natural flap tissue between the esophageal anastomosis and the sutured trachea.3-5 We report an original technique using an omental flap as a natural tissue harvested previously to the TEF repair with a laparoscopic approach.
We report the use of an omental flap tissue brought over the tracheal closure and sutured between the trachea and the esophagus for 2 patients with recurrent TEF. The flap was dissected and taken down before the TEF repair with a laparoscopic approach. The data are shown in Tables 1 and 2.
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The immediate postoperative course was uneventful, but she rapidly presented a second recurrence of TEF. The patient was then transferred to our institution.
A repeat endoscopic examination for a second cervical TEF was performed; the result was negative. In turn, a recurrent TEF was observed at the same location previously described. We then decided to reoperate by using an omental flap as a natural tissue sutured between the trachea and the esophagus.
A 5-mm trocar introduced through the umbilicus was used for a 5-mm and 30-degree camera. The pneumoperitoneum was established at 8 mm Hg. Three additional 5-mm trocars were inserted. The omentum was taken down from the right part of the great gastric curve using the cautery, going up along the curve and paying attention not to burn the gastroepiploic vessels. The omentum was dissected to the top of the great curve, creating a pediculated omental flap (Kiricuta technique).5 An additional Nissen procedure was performed. The hiatus was opened to place the omental flap into the chest at the end of the wrap confection. An open thoracic approach was used to fix the TEF, and the omental flap was sutured between the esophagus and the sutured trachea. The postoperative course was uneventful. The patient is doing well at 24 months of follow-up.
Patient 2
A female infant was born at 41 weeks of gestation with a prenatal diagnosis of EA. She underwent operation at 1 day of age with EA repair and TEF closure. Soon after the drain removal, a right pneumothorax presented that required a chest tube placement (removed 3 days later). After feeding was started, the patient presented with respiratory distress and desaturation. An endoscopic examination for a recurrent TEF showed a tracheomalacia and an anastomotic stenosis that required 2 pneumatic dilatations. Despite the dilatation, the baby presented continuous feeding difficulties with desaturation. Therefore, another endoscopic examination was performed that showed a recurrent TEF. Treatment with glue was performed without any success. She underwent operation. An omental flap was harvested using a laparoscopic approach and the same technique as previously described without Nissen fundoplication. The postoperative course was simple, and she is doing well at 17 months of follow-up.
To our knowledge, this is the first report of using an omental flap for a recurrent TEF repair in a baby. Furthermore, this is the first report to describe a laparoscopic approach for this indication.
Recurrence of the TEF occurs in approximately 10% of cases, most often within 2 months after initial repair.1 It remains challenging to treat. This should be differentiated from a second congenital fistula, which is best done by an endoscopic examination before the surgery. Anastomotic tension, leak, or stenosis, which are well-known factors of recurrent TEF,1 should be avoided.
When a surgeon decides to use a flap as an interposition tissue between the sutured trachea and the esophagus, it is traditionally done using a surrender tissue such as a pericardial flap, an intercostal pedicle flap, or a costal cartilage grafting.2,3
The use of the great omentum as a natural tissue to fill a space or cover a defect has been described in adult surgery, especially in cancer surgery or wall defect reconstruction.4 This flap offers several practical advantages: adaptable size of the mucosal patch, great plasticity (including the omentum), and large length and size of the pedicle. The disadvantage may be the need for abdominal operation. The laparoscopic approach limits the abdominal trauma and offers a good cosmetic result. Moreover, in case of EA and TEF, the need for an antireflux procedure or a gastrostomy justifies the abdominal surgery.
The surgical technique is more similar to harvesting an epiploic candlewick, as initially described by Kiricuta,5 than to using a real pedicled omental flap. The flap can be placed in the chest without any risk of devascularization.
We described the use of an omental flap harvested laparoscopically to use in case of recurrent TEF. The laparoscopic approach offers a better cosmetic result and less abdominal trauma. This technique should be an alternative for a recurrent TEF surgical treatment, especially if an antireflux procedure or a gastrostomy is required.
References
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