University of Nigeria Virtual Library Serial No. AGUGUA, N.E.N - - PDF document

SLIDE 1

University of Nigeria

Virtual Library

Serial No. Author 1 AGUGUA, N.E.N Author 2 Author 3 Title

Colon Bypass for Corrosive Esophageal Strictures in Nigeria Children

Keywords Description

Colon Bypass for Corrosive Esophageal Strictures in Nigeria Children

Category Publisher Publication Date

February, 1988

Signature

Ojionuka Arinze B.

Digitally signed by Ojionuka Arinze B. DN: CN = Ojionuka Arinze B., C = US, O = University of Nigeria, Nsukka, OU = Innovation Centre Reason: I have reviewed this document Date: 2007.02.18 20:16:40 -08'00'

SLIDE 2

' ORIGINAL ARTICLES

w Colon bypass for corrosi~

in Nigerian children.

N.

• E. N.

Agugua

ABSTRACT

bypass

. .

u - r g - r , j v r araarurruvss s v r r w * r c vsauyrsugcus rrr*a,rurcu wlth~n

the I0;vearperiod of January 1978 to December 1987. Cervical complications accounted for 60% and the commonest was a leak at the colo-oesophageal anastomosis. There was one death due to undetected oesophago-tracheal

• fistula. The longest fol-

low up was 10 years.

v e

• esophageal strictures

RIASSUNTO

Tra il gennaio I978 ed il dicembre 1987 quindici bambini di etd compresa fra i tre ed i dodici annisono statisottoposti ad in- tervento di bypass eso fageo con colon-interposizione per steno- si da ingestione di caustici. 1 1 60% dele complicanze interessa- vano la regione cervicale e la pit) comune t? stata la deiscenza dell'anastomosi colon-esofagea. Un decesso si t? verificato per una fistola esofago-tracheale non diagnosticata. I 1 follow-up va da 3 mesi a 10 anni. KEY WORDS

Oesophageal strictures, Colon bypass Stricture of the oesophagus consequent on corrosive burns is a common disease in the Nigerian environment. Infants under 2 years appear immuned due to the utmost protection they get from being tied at the mothers back. Corrosive fluids ingested range from battery fluids to hairdressers lotions, washing up li- quids and local pests' poisons. In most cases, the initial treat-

, ment is given at the primary and secondary health care centers.

The tertiary or specialist center deals with the resultant strictu- res. Lundblad in 1921 was the first to describe the use of the tran- sverse colon for total oesophageal replacement (I). He interpo- sed the transverse colon between the cervical oesophagus and the stomach in a 3-year old child with a lye stricture. Other sur- geons before him have replaced the oesophagus with skin tubes (Bircher 1984)(2), Jejunum (Roux 1907)C). and combined skin and colon (Kelling 191 From: Department of Paediatric Surgery - College of Medici- ne - University of Nigeria Teaching Hospital - Enugu - Nigeria. Address reprint requests to: dott. N. E. N. Agugua, Depart-

ment of Paediatric Surgery, College of Medicine, University of

Nigeria Teaching Hospital. P.M.B. 01 129 - Enugu - Nigeria. Alessandrini has indicated that titrated extracts of Centella Asiatica could be used to dissolve corrosive oesophageal strictu- res (5). Until such time as this drug becomes widely available and useful, surgery remains as a method of treatment. This pa- per presents a 10-year experience of retrosternal transverse co- lon bypass for intractable corrosive oesophageal stricture in Ni- gerian children.

MATERIALS AND METHODS

Records of 15 children who had colon bypass surgery for cor- rosive oesophageal strictures at the University of Nigeria Tea- ching Hospital, Enugu, within the 10-ytar.periud of 1978 to 1987 were reviewed. This series has not included other oesopha- geal diseases like oesophageal atresia nor tracheo-oesophageal

• fistulae. Patients with corrosive strictures who have failed oeso-

phageal dilatation and in whom the length of stricture is more than 66% of the oesophagus were offered a colonic bypass sur-

• gery. The T
• stricture was calculated as

lenght of stricture on X-ray

100

lenght of oesophagus on X-ray 1 All patients were initially managed with a feeding gastrosto- my until the weight gain was considered adequate for the age. The barium swallow was used to measure the Ienght of the stric- ture (Fig. 1). The width of the strictured organ as seen on the X-ray was not taken as significant. Figure 1

: Stricture of 80% of the oesophagus. Initial barium

study.

• It. J. Ped. Surg. Sci. - Vol. 2, No. 1-2 - 1988

7

SLIDE 3

Operative technique. Two paediatric surgeons worked synchronously using cervi- cal and abdominal routes. In no case was the thorax opened. The abdominal surgeon isolated the transverse colon, did a co- loncolic anastomosis to restore continuity of the gut, and a ga- strocolic anastomosis to transport food to the intact stomach. He delivered the isoperistaltic oesophageal transplant to the neck surgeon via the retrosternal space. The cervical surgeon sectioned the oesophagus, closed the distal end and anastomo- sed the proximal end to the colon. Case I A 3-year old male child of a military personnel ingested bleech and obtained a stricture of 70% of the oesophagus. On referral 6 months after the episode he already had a feeding ga- strostomy and an unremitting cough. The cause of the cough could not be identified pre-operatively. Chest X-rays were nor-

• mal. Attempts at oesophageal bouginage failed. He had a tran-

sverse colon bypass surgery via the retrosternal space. Posto- pertively he developed an intractable chest infection and respi- ratory distress which led to his death 14 days after surgery. At postmortem an oesophago-tracheal fistula was found as a com- plication of his corrosive stricture. Case 2 A 6-year old male child of a hairdresser ingestkd caustic soda and obtained a corrosive stricture of 80% of the oesophagus.

• Fig. 1 shows his initial barium swallow on referral. He

commen- ced serial oesophageal dilatation and a subsequent barium swal- low (Fig. 2) showed upper oesophageal dilatation with Figure 2: Upper oesophageal dilatation during conservative ma- nagement. symptoms of regurgitation and aspiration pneumonitis. A ga- strostomy was performed for feeding and when he had gained adequate weight he was subjected to a colon bypass surgery. Postoperatively, he did well and a barium study (Figs. 3 and 4) showed the functioning colonic transplant.,A reflux was not de- monstrated. 8

• It. J. Ped. Surg. Sd. - Vol. 2, No. 1-2 - 1988

Figure 3:Colon bypass, chest picture, post-operative barium study. Figure 4:Colon bypass, abdominal picture, post-operative ba- rium study.

RESULTS

Altogether, there were 9 males and 6 females in this series, and their ages ranged between 3 and 12 years (Tab. 1). Weight gain was obvious by 3 months after surgery. The commonest complication (Tab. 2) was a leak at the cervical anastomosis

SLIDE 4

Serial n.

• f cases

Sex Age at

• ~ e r a t

ion Ingested Corrosive " 7 Stricture

.-

1.

M 3

Bleech 70%

2. M

6 Caustic Soda 80% 3. M

5

Local Rat Poison 68

%

4.

M

11 Battery Fluid 78%

5. M

3 Bleech 70% 6.

M

8 Battery Fluid 86% 7. M

4

Local Rat Poison 68%

8.

M

5

Battery Fluid 68 VO

9. M

12 Battery Fluid 80%

10. F

3

Bleech 84 Yo

11.

F

3 Bleech 70% 12.

F

4

Caustic Soda 68 7 13.

F

3 Hair Dresser Liquid 68

70

14.

F

5

Bleech 80% 15.

F

4

Hair Dresser Liquid 66% Outcome

& Wt.Gain

Died

E E E

G

E

G

E E

G F G

F E

G

~ ~ p p ~ ~ p p p ~ ~ ~ ~ ~ ~ ~

E = Excellent G = Good F = Fair (Sex: M = Male; F = Female) Table 1 : Patient's data.

• ccurring in 5 patients. All five were re-operated on and a re-do

cervical anastomosis was done. There were 4 cases with stenosis

• f the oesophago-colonic anastomosis. All were treated with se-

rial bouginage. Altogether, the post-operative cervical pro- blems accounted for 60%. Abdominal complications were few. Three patients were readmitted for adhesive intestinal ob-

• struction. One settled on conservative management but 2 were

reoperated on and the adhesive bands which were obstructing the small intestine were lysed. There was no case of a leak at the colo-colic or gastro-colic anastomosis and there were no cases

• f pyloric obstruction as the vagi were all intact. Fourteen pa-

tients are alive and able to eat a regular diet and have gained weight (Tab. 1). The length of follow-up ranged from 3 months to 10 years. COMPLICATIONS

• NO. OFCASES %

NECK Leak, Cervical Anastomosis 5 25% Stenosis, Cervical Anastomosis 4 20% Regurgitation After Swallowing 2 10% Wound Infection

1

5% ABDOMEN

• Leak. Gastro-colic Anastomosis

Stenosis, Gastro-colic Anastomosis Pyloric Obstruction Leak, Colo-colic Anastomosis Stenosis, Colo-colic Anastomosis Adhesive Intestinal Obstruction

3 15%

Wound Infection 2 10% OTHERS Transplant Ischaemia Chest Infection (including the dead case) 3 15% Reflux Colitis Failure to Thrive Table 2

: Complications of surgery.

There was one death in this series due to undetected

• esophago-tracheal fistula, a complication of the corrosive

stricture.

DISCUSSION

A retrosternal, isoperistaltic transverse colon bypass has be- come the choice in this unit for intractable corrosive strictures

• f more than 66% of the oesophagus.

The choice of bypassing the oesophagus is based on the ina- dequate length of the healthy oesophagus far a primary end to end anastomosis, and moreover bypassing the thorax has remo- ved almost completely the lethal pulmonary complications of intrathoracic implant. The only death In the series was not due to a complication of the rranspIant surgery. Ein reported excellent results from gastric tube interposition but colonic transplants have avoided the prabterns of reflux and postural regurgitation (3. There was no case of reflux colitis in this series. Sieber and Sieber demonstrated that the colon tran- splant empties by gravity ('). Our colon transplant patients have maintained normal weight and size despite reports that they may be underweight and small

(9.

This disparity may be associated with the primary condition which necessitates the transplant. Our conditions were all ac- quired strictures but congenital tracheo-oesophageal fistula may be responsible for the failure to thrive rather than the co- lon transplant itself. Feeding by both oral and gastrostomy rou- tes for a period of one month after successful surgery is recom- mended. The high incidence of cervical complication is probably due to the precarious blood supply to the upper colon transplant. The children in these series have not been followed long enough to know the outcome of the intact but bypassed oesophagus.

• It. J. Ped. Surg. Sci. - Vol. 2, No. 1-2
• 1988

9

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ACKNOWLEDGEMENT I am grateful to Professor F.A. Nwako who shared the pa- tients with me.

REFERENCES

• 1. LUNDBLAD

0.: Antethoracic esophagoplasty. Acta Chir.

• Scand. 53: 535, 1921.
• 2. BIRCHER

E., EIN

BEITAG ZUR.: Plastis chen bildung eines neuen oesophagus. Zentralbl Chir. 34: 1979, 191

1.

• 3. Roux C.: L'oesophago-jejuno-gastromose, nouvelle opera-

tion pour retrecissement infranchissable de l'oesopage. Se- maine Med. 27: 37, 1907. 1 1

• 4. KELLING.

G.: Esophagoplasty with help of the transverse

• colon. Zentralbl Chir. 38, 1209, 1911.
• 5. ALESSANDRINI

H., PINESCHI A., GIANNOTTA A.: Use of ti- . trated extract of Centella Asiatica in the treatment of ac-

• quired stenosis of the oesophagus. It. J. Ped. Surg. Sci.,
• Vol. 1 NO. 1: 13-17, 1987.
• 6. EIN

S.H., SHANDLING B., SIMPSON et al.: A further look at the gastric tube as an oesophageal replacement in infants and children. J. Ped. Surg. 6: 859, 1973.

• 7. SIEBER

A.M., SIEBER W.K.: Colon transplant of oesopha- geal replacement, cineradiographic and manometric eva- luation in children. Ann. Surg. 168: 116, 1968. 8 GERMAN J.C., WATERSTON D.J.: Colon interposition for replacement of the esophagus in children. 3. Ped. Surg. 2: 227-234, 1976. 10

• It. J. Ped. Surg. Sci. -Vol. 2, No. 1-2 - 1988