Department of Pediatric Surgery, University Hospital Center of Lausanne, Switzerland.
J Pediatr Surg. 2013 Apr;48(4):887-92. doi: 10.1016/j.jpedsurg.2012.10.070.
Esophageal replacement for caustic stenosis in children poses a challenging surgical problem. Blind removal of the injured esophagus without thoracotomy through a left cervical and transhiatal approach followed by an orthotopic esophageal replacement using either the colon or the stomach is a difficult procedure and can be dangerous in children. We performed our first total laparoscopic transhiatal esophagectomy in February 2007. We aim to compare this new technique to the previously applied method of blind closed-chest esophagectomy through a cervicotomy and laparotomy.
We analyzed the surgery and follow-up of 40 children operated upon for extensive irreversible caustic burns of the esophagus. The first 20 esophageal replacements were performed following a blind dissection of the mediastinum through a cervical incision and a laparotomy for esophagectomy (Group I). The last 20 esophageal replacements were performed after laparoscopic transhiatal dissection in the mediastinum and cervicotomy in the neck for esophagectomy (Group II). All operations were performed under the supervision of the same senior surgeon.
Average age at the time of surgery was the same in both groups. Total esophagectomy was achieved in 45.0% of cases in Group I versus in 90.0% of cases in Group II. Colon was used in 80.0% of cases in Group I and in 90.0% in Group II. The mean duration of surgery was one hour longer in the laparoscopy group. One vascular injury was reported in the blind laparotomy group. Pneumothorax was more frequent in Group II without significant consequences besides drainage. Average time of extubation was about the same in both groups (1.8days).
Laparoscopic transhiatal esophagectomy for caustic burns before esophageal replacement in children is safe and effective. It could avoid vascular and bronchial mediastinal injuries as the dissection is performed under direct visual control. The routine use of laparoscopic assistance by a senior surgeon improves the safety of esophageal dissection and reduces life-threatening complications.
对于儿童腐蚀性狭窄，食管替代是一个具有挑战性的外科问题。不进行开胸手术，通过左颈和经食管裂孔入路盲目切除受损食管，然后使用结肠或胃进行原位食管替代，这是一种困难的操作，在儿童中可能很危险。我们于 2007 年 2 月进行了首例全腹腔镜经食管裂孔食管切除术。我们旨在将这种新技术与先前应用的经颈切口和剖腹术盲目闭式胸腔食管切除术进行比较。
我们分析了 40 例广泛不可逆腐蚀性食管烧伤患儿的手术和随访情况。前 20 例食管置换是通过颈切口和剖腹术盲目纵隔解剖完成的（I 组）。最后 20 例食管置换是在腹腔镜经食管裂孔纵隔解剖和颈部颈切口完成的（II 组）。所有手术均由同一位资深外科医生监督完成。
两组患儿手术时的平均年龄相同。I 组中 45.0%的病例可完成全食管切除术，而 II 组中 90.0%的病例可完成。I 组中 80.0%的病例使用结肠，II 组中 90.0%的病例使用结肠。腹腔镜组手术时间平均延长 1 小时。在盲目剖腹术组中报告了 1 例血管损伤。气胸在 II 组更为常见，但除引流外无明显后果。两组的平均拔管时间大致相同（1.8 天）。
儿童腐蚀性烧伤食管替代前腹腔镜经食管裂孔食管切除术是安全有效的。由于在直接可视控制下进行解剖，因此可以避免血管和支气管纵隔损伤。资深外科医生常规使用腹腔镜辅助可以提高食管解剖的安全性，减少危及生命的并发症。
