Seventy Cases of Partial Gastric Pull-Up According to the Schärli Technique for Esophageal Replacement in Pediatrics

Abstract

Esophageal replacement (ER) is indicated in patients with long gap esophageal atresia (LGEA) or failure of the primary anastomosis.
Also, severe caustic or peptic strictures, resistant to conservative treatment with medication and dilations, may require an ER. Numerous
techniques with different organs and routes have been described, all with satisfactory results.
Objective
Our objective is to describe the experience obtained with partial gastric pull-up according to the Schärli principles (SGPA).
Materials and Methods
Medical records of patients who required a SGPA between October 1995 to June 2018 were reviewed. The analysis was observational,
longitudinal, retro-prospective and descriptive. Epidemiological data, surgical aspects and postoperative complications of the patients
were considered.
Results
Seventy ER were performed with SGPA. The indication was esophageal atresia (EA) in 58 cases (44 long gap and 14 failure of the
anastomosis), 10 caustic strictures, one peptic stricture resistant to conservative treatment and the other due to a retained foreign
body. The age of the ER was on average 2-years and 9-months. The route was: posterior mediastinal (35), retrosternal (29) and
transpleural (6); without a thoracic approach in 59 patients. The duration of the procedure was 4.7-hours on average. There were
13 cases of intraoperative complications, 8 cases of pneumothorax, 5 bleeding injuries (3 in the spleen, 1 liver and 1 cervical), and
one injury to the cervical trachea. Anastomotic dehiscence was observed in 37 patients (52%), which closed spontaneously after an
average of 17.8-days in all except one patient. Thirty-one patients (44%) developed anastomotic stenosis, requiring redo anastomosis
in 6 cases; 37% developed dumping and 23% gastroesophageal reflux disease. There were 3 deaths (4.2%): all in EA patients with
associated malformations, following a morbid postoperative period with infectious complications in intensive care at 10-days, 7 and
8-months after ER. Follow-up was an average of 8-years. All 67 living patients are currently tolerating oral feeding.
Conclusion
In our experience with ER using SGPA, we observed a high incidence of complications, generating a longer post-operative evolution
and with greater morbidity than that described in other techniques. Given these results, we changed our strategy to complete gastric
transposition, in order to reduce morbidity and improve the evolution of this complex group of patients.