Esophageal replacement

Esophageal replacement is an infrequent procedure required after great effort has been put forth to save the native esophagus. The most frequent indications for esophageal replacement include long-gap esophageal atresia with or without tracheoesophageal fistula, and esophageal strictures most often due to caustic ingestion or secondary to gastroesophageal reflux disease. Although children with esophageal atresia, gastroesophageal reflux disease, and to a lesser degree, caustic ingestion, are commonly encountered in pediatric surgery, they rarely require esophageal replacement. Our ability to anastomose the two ends of the esophagus in infants with esophageal atresia has improved over the years with techniques such as circular myotomies, upper pouch flaps, and dilation or stretching of the upper pouch and distal esophagus prior to anastomosis. Caustic ingestions have become more infrequent with the changes in packaging of hazardous materials in the home. Peptic strictures due to acid reflux are on the decline due to our heightened awareness of the long-term damage caused by gastroesophageal reflux disease, and our improved medical armamentarium available to control acid reflux. In addition, novel procedures to save the strictured esophagus have been reported. These include stricturoplasty with placement of a vascularized colonic patch, and stenting of caustic esophageal strictures combined with steroid and acid reducing therapy. Despite these improvements, and our understanding that even a somewhat compromised native esophagus may be desirable when compared to the alternatives, there is a distinct subset of infants and children who will require an esophageal replacement.