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Mario Lima


Digestive Surgery

Pediatric Digestive Surgery
Mario Lima

Pediatric Digestive
Mario Lima
Pediatric Surgery
S. Orsola-Malpighi Hospital
Bologna University

ISBN 978-3-319-40523-0ISBN 978-3-319-40525-4(eBook)

DOI 10.1007/978-3-319-40525-4

Library of Congress Control Number: 2016960035

Springer International Publishing Switzerland 2017

This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or
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Printed on acid-free paper

This Springer imprint is published by Springer Nature

The registered company is Springer International Publishing AG
The registered company address is Gewerbestrasse 11, 6330 Cham, Switzerland
Dedicated to Pascal de Lagausie,
great friend,
talented surgeon,
and magnificent teacher

In recent decades, pediatric surgery has been enriched by new knowledge in

the field of surgical diseases, and the development of new technologies has
allowed the application of the most advanced surgical techniques also to the
pediatric patient. After publication of the previous volumes on thoracic sur-
gery and urology, this third volume comes from the need to create a focus on
digestive surgical pathology.
For its implementation, collaboration of leading experts in the interna-
tional scenario was sought in order to provide readers with an updated tool
for their knowledge.
The Symposium on Pediatric Digestive Surgery that was held in November
2015 in Bologna was the occasion to invite the best international pediatric
surgeons to offer their contribution.
This volume contains an assessment on prenatal, radiological, and anes-
thesiologic aspects of the main digestive disorders and chapters on the man-
agement of each topic.
This volume concludes with the treatment of pediatric cancer and with a
chapter on the use of augmented reality in digestive surgery.
I wish to thank all those who have actively collaborated on the creation of
this book, and all the authors, who for friendship and desire to pass on their
knowledge, agreed to provide their contribution.
I also thank all the staff of Springer for their long and patient work.

Bologna, Italy Mario Lima


1 Prenatal Diagnosis andObstetric Management 1

Gianluigi Pilu
2 Gastro-Intestinal Tract Radiology 11
Filomena Carfagnini, Michelangelo Baldazzi,
and Antonio Poerio
3 Diagnostic andTherapeutic Endoscopy 37
Giovanni Di Nardo, Giuseppe Pagliaro, and Andrea Pession
4 Anesthesia inPediatric Digestive Surgery 83
Andrea Gentili, Valeria Landuzzi,
and Maria Cristina Mondardini
5 Intensive Care inDigestive Surgery  99
Andrea Gentili, Rosina De Rose, and Elisa Iannella
6 Clinical Nutrition  113
Antonella Diamanti, Teresa Capriati, and Daniela Giorgio
7 Vascular Rings andPulmonary Sling 127
Gaetano Domenico Gargiulo, Francesco Petridis, Gabriele
EgidyAssenza, and Emanuela Angeli
8 Congenital Esophageal Stenosis 139
Michela Maffi and Mario Lima
9 Achalasia and Esophageal Motility Disorders 145
Olivier Reinberg
10 Laryngotracheal Clefts 157
Llus Nisa and Kishore Sandu
11 Esophageal Atresia and Tracheoesophageal Fistula  169
ArnoldG.Coran,StevenW.Bruch,and ShaunM.Kunisaki
12 Hiatal Hernia andGastroesophageal Reflux 183
Philippe Montupet and Reva Matta
13 Esophageal Replacements inChildren 193
Olivier Reinberg

x Contents

14 Pyloric Stenosis 211

Olivier Reinberg
15 Congenital Duodenal Stenosis 225
David C. van der Zee
16 Caustic Ingestion andForeign Bodies 229
Olivier Reinberg
17 Disorders ofIntestinal Rotation andFixation 245
Anastasia Mentessidou and Amulya K. Saxena
18 Alimentary Tract Duplications  255
Noemi Cantone and Mario Lima
19 Meckels Diverticulum 269
Franois Varlet, Sophie Vermersch, Nasser Bustangi,
Manuel Lopez, and Aurlien Scalabre
20 Acute Appendicitis  279
Michela Maffi and Mario Lima
21 Intussusception 291
Francesca Destro, Michela Maffi, and Mario Lima
22 Hirschsprungs Disease 297
Matthew W. Ralls, Arnold G. Coran, Daniel
H. Teitelbaum, Francesca Destro, and Mario Lima
23 Inflammatory Bowel Disease 311
Giovanni Di Nardo, Andrea Pession, Luca Bertelli,
Sara Isoldi, Rita Cozzali, Michela Maffi, and Mario Lima
24 Anorectal Malformations 327
Tommaso Gargano and Mario Lima
25 Congenital Hyperinsulinism  341
Giovanni Boroni, Filippo Parolini,
and Daniele Alberti
26 Hepatobiliary Pediatric Surgery 351
Arnaud Bonnard, Florent Guerin, and Pascal de Lagausie
27 Portal Hypertension inChildren 373
Neil Di Salvo, Michela Maffi, and Mario Lima
28 The Pediatric Short Bowel State: Practical
Concepts Toward Enteral Autonomy  389
Adrian Bianchi
29 Intestinal Polyposis 405
Luca Pio, Alessio Pini Prato, and Girolamo Mattioli
Contents xi

30 Gastrointestinal Tumors in Children

andAdolescents 411
Andrea Pession
31 Augmented Reality inMinimally Invasive
Digestive Surgery  421
Luc Soler, Stphane Nicolau, Patrick Pessaux,
Didier Mutter, and Jacques Marescaux

Index 433

Daniele Alberti, MD Department of Pediatric Surgery, Spedali Civili

Childrens Hospital, University of Brescia, Brescia, Italy
Emanuela Angeli Department of Pediatric Cardiac Surgery and GUCH
Unit, Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, Italy
Michelangelo Baldazzi Pediatric Radiology, S. Orsola-Malpighi Hospital,
Bologna, Italy
Luca Bertelli Pediatric Unit, S Orsola-Malpighi Hospital, Bologna, Italy
Adrian Bianchi, MD, FRCS, FRCSEd Neonatal and Paediatric
Reconstructive Surgeon, Manchester, UK
Arnaud Bonnard, MD, PhD Department of Pediatric Surgery, Robert
Debr Children University Hospital, APHP, Paris, France
Giovanni Boroni, MD Department of Pediatric Surgery, Spedali Civili
Childrens Hospital, Brescia, Italy
Steven W. Bruch, MD C.S. Mott Childrens Hospital, University of
Michigan, Ann Arbor, MI, USA
Nasser Bustangi Department of Pediatric Surgery, Centre Hospitalier
Universitaire, Saint-Etienne, France
Noemi Cantone Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna
University, Bologna, Italy
Teresa Capriati Artificial Nutrition Unit, Bambino Ges Childrens
Hospital, Rome, Italy
Filomena Carfagnini Pediatric Radiology, S. Orsola Malpighi Hospital,
Bologna, Italy
Arnold G. Coran C.S. Mott Childrens Hospital, University of Michigan
Hospital and Health Systems, Ann Arbor, MI, USA
Rita Cozzali Pediatric Gastroenterology Unit, Foligno Hospital, Foligno
(PG), Italy
Pascal de Lagausie, MD, PhD Department of Pediatric Surgery, Hpital
Timone-Enfant, Marseille, France

xiv Contributors

Rosina De Rose Department of Pediatric Anaesthesia and Intensive Care,

S. Orsola-Malpighi University Hospital, Bologna, Italy
Francesca Destro Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna
University, Bologna, Italy
Antonella Diamanti, MD Hepatology, Gastroenterology and Nutrition
Unit, Bambino Ges Children Hospital, Rome, Italy
Giovanni Di Nardo Pediatric Gastroenterology Unit, International
Hospital Salvator Mundi, Rome, Italy
Neil Di Salvo Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna
University, Bologna, Italy
Gabriele Egidy Assenza Department of Pediatric Cardiac Surgery and
GUCH Unit, Azienda Ospedaliero-Universitaria S. Orsola-Malpighi,
Bologna, Italy
Tommaso Gargano Pediatric Surgery, S. Orsola-Malpighi Hospital,
Bologna University, Bologna, Italy
Gaetano Domenico Gargiulo Department of Pediatric Cardiac Surgery
and GUCH Unit, Azienda Ospedaliero-Universitaria S. Orsola-Malpighi,
Bologna, Italy
Andrea Gentili Department of Pediatric Anaesthesia and Intensive Care,
S. Orsola-Malpighi University Hospital, Bologna, Italy
Daniela Giorgio Artificial Nutrition Unit, Bambino Ges Childrens
Hospital, Rome, Italy
Florent Guerin, MD, PhD Department of Pediatric Surgery, Kremlin
Bicetre Children University Hospital, APHP, Paris, France
Elisa Iannella Department of Pediatric Anaesthesia and Intensive Care,
S. Orsola-Malpighi University Hospital, Bologna, Italy
Sara Isoldi Pediatric Gastroenterology Unit, Sapienza University of
Rome, Rome, Italy
Shaun M. Kunisaki, MD C.S. Mott Childrens Hospital, University of
Michigan, Ann Arbor, MI, USA
Valeria Landuzzi Department of Pediatric Anaesthesia and Intensive Care,
S. Orsola-Malpighi University Hospital, Bologna, Italy
Mario Lima Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna
University, Bologna, Italy
Manuel Lopez Department of Pediatric Surgery, Centre Hospitalier
Universitaire, Saint-Etienne, France
Michela Maffi Pediatric Surgery, S. Orsola-Malpighi Hospital, Bologna
University, Bologna, Italy
Jacques Marescaux IHU Strasbourg, IRCAD, Strasbourg, France
Contributors xv

Reva Matta Clinical Surgery, University of Balamand, El-Koura, Lebanon

Division of Pediatric Surgery, Department of Surgery, Saint George Hospital
University Medical Center, Beirut, Lebanon
Girolamo Mattioli Pediatric Surgery Unit, Istituto Giannina Gaslini,
DINOGMI University of Genoa, Genoa, Italy
Anastasia Mentessidou, MD Department of Pediatric Surgery, Chelsea
Childrens Hospital, Chelsea and Westminster Hospital NHS Fdn Trust,
Imperial College London, London, UK
Maria Cristina Mondardini Department of Pediatric Anaesthesia and
Intensive Care, S. Orsola-Malpighi University Hospital, Bologna, Italy
Philippe Montupet Hpitaux Universitaires Paris-Sud, Bictre Hospital,
Universit Paris XI, Le Kremlin-Bictre Cedex, France
Didier Mutter IHU Strasbourg, IRCAD, Strasbourg, France
Stphane Nicolau IRCAD, Strasbourg, France
Llus Nisa Department of Clinical Research, University of Bern, Bern,
Giuseppe Pagliaro Pediatric Gastroenterology Unit, Sapienza, University
of Rome, Rome, Italy
Filippo Parolini, MD Department of Pediatric Surgery, Spedali Civili
Childrens Hospital, Brescia, Italy
Patrick Pessaux IHU Strasbourg, IRCAD, Strasbourg, France
Andrea Pession Pediatric Units, S Orsola-Malpighi Hospital, University of
Bologna, Bologna, Italy
Francesco Petridis Department of Pediatric Cardiac Surgery and GUCH
Unit, Azienda Ospedaliero-Universitaria S. Orsola-Malpighi, Bologna, Italy
Gianluigi Pilu Department of Obstetrics and Gynecology, Bologna
University, Bologna, Italy
Alessio Pini Prato Pediatric Surgery Unit, Istituto Giannina Gaslini,
DINOGMI University of Genoa, Genoa, Italy
Luca Pio Pediatric Surgery Unit, Istituto Giannina Gaslini, DINOGMI
University of Genoa, Genoa, Italy
Antonio Poerio Pediatric Radiology, S. Orsola Malpighi Hospital,
Bologna, Italy
Matthew W. Ralls C.S. Mott Childrens Hospital, University of Michigan
Hospital and Health Systems, Ann Arbor, MI, USA
Olivier Reinberg Pediatric Surgery, Pully, Switzerland
Kishore Sandu Department of Otorhinolaryngology Head and Neck
Surgery, Lausanne University Hospital, Lausanne, Switzerland
xvi Contributors

Amulya K. Saxena, MD, PhD, DSc(hon), FRCS(Glasg) Department of

Pediatric Surgery, Chelsea Childrens Hospital, Chelsea and Westminster
Hospital NHS Fdn Trust, Imperial College London, London, UK
Aurlien Scalabre Department of Pediatric Surgery, Centre Hospitalier
Universitaire, Saint-Etienne, France
Luc Soler IRCAD, Strasbourg, France
Daniel H. Teitelbaum C.S. Mott Childrens Hospital, University of
Michigan Hospital and Health Systems, Ann Arbor, MI, USA
David C. van der Zee Department of Pediatric Surgery, Wilhelmina
Childrens Hospital, University Medical Center, Utrecht, The Netherlands
Franois Varlet Department of Pediatric Surgery, Centre Hospitalier
Universitaire, Saint-Etienne, France
Sophie Vermersch Department of Pediatric Surgery, Centre Hospitalier
Universitaire, Saint-Etienne, France
Prenatal Diagnosis and Obstetric
Gianluigi Pilu

In Europe ultrasound examinations are commonly important to stress that caution is necessary when
performed in virtually all pregnancies, usually discussing the implications of antenatal diagno-
between 11 and 13 weeks gestation and around sis. The accuracy of sonography is limited, and
20 weeks gestation [1]. One of the main objec- anomalies identified in utero tend to have a dif-
tives of these investigations is the detection of ferent outcome than those that are identified after
fetal anomalies. The uptake of anomalies is vari- birth. Ancillary methods are now available for
able in different studies, and indeed, the value of prenatal diagnosis in selected cases, including
universal screening for anatomic malformations is genetic testing and magnetic resonance, and mul-
debated [13]. The detection rate much varies tidisciplinary discussion is certainly indicated.
depending upon different factors and the affected In the following pages, we will briefly review
organs in particular. Sonographic investigation of the state of the art of prenatal diagnosis of the
the fetal gastrointestinal tract suffers from many anomalies of the gastrointestinal tract, focusing
limitations mostly because the fetal bowel is upon the information that seem relevant for the
almost completely empty in early gestation. pediatric surgeons who work in close contact
Furthermore, the esophagus and anorectal tract with obstetric departments.
are incompletely seen. As a consequence of this,
most intestinal obstructions are not identified until
late in gestation or even after birth (Fig. 1.1). 1.1 Normal Sonographic
Nevertheless, the identification of abnormal Appearance of the Fetal
fetal sonographic findings of the gastrointestinal Gastrointestinal Tract
tract does occur, and in these cases, pediatric spe-
cialists are usually consulted to discuss the man- Fetuses start swallowing amniotic fluid early in
agement strategy in the perinatal period and the gestation, and the fluid-filled stomach is visible
prognosis. Such consultations have a particular as early as 9 weeks of gestation as a C-shaped
relevance when the diagnosis is made in early sonolucent structure in the upper left quadrant of
gestation and the couples are considering the the abdomen. The bowel has normally a uniform
option of a pregnancy termination. It seems echogenic appearance until the third trimester of
pregnancy when meconium-filled loops of large
bowel are commonly seen. The liver is large pre-
G. Pilu natally and comprises most of the upper abdo-
Department of Obstetrics and Gynecology,
men. The gallbladder is usually seen since
Bologna University, Via Massarenti 13,
40138 Bologna, Italy midgestation as an ovoid cystic structure to the
e-mail: right and below the intrahepatic portion of the

Springer International Publishing Switzerland 2017 1

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_1
2 G. Pilu

a b

Fig. 1.1 The normal appearance of the fetal gastroin- bladder are fluid filled and easily visible; the bowel is
testinal system at 20 weeks (a, b) and close to term empty and appears sonographically homogeneous; in
gestation (c); at 20 weeks the liver is large and occupies advanced gestation, the meconium-filled large bowel
the entire upper abdomen, and the stomach and gall- can be seen

umbilical vein. The spleen may also be visualized 1.2 Esophageal Atresia
posterior and to the left of the fetal stomach. The
proximal and distal esophagus can be at times As the esophagus is poorly and anyhow incom-
visualized, when the fetus is in a favorable posi- pletely visualized with fetal sonography, most
tion and particularly in the course of swallowing. cases of atresia escape antenatal detection [4].
However, it is impossible to visualize the entire The majority of cases are associated with a
length. The anal complex can also be seen tracheoesophageal fistula that allows distal
although usually only in late gestation (Fig. 1.2). transit of fluid and filling of the stomach. In
1 Prenatal Diagnosis and Obstetric Management 3

a b

Fig. 1.2 It is difficult to demonstrate sonographically the posterior to the trachea (a), and the echogenic anorectal
fetal esophagus and the anorectal complex. When the mucosa, surrounded by the sonolucent external sphincter
fetus is in a favorable position and the quality of the (b) may be seen
images is adequate, at least the distal esophagus coursing

late gestation, however, the size of the fistula more frequently suspected (polyhydramnios in
does not allow adequate transit and as a conse- 100 % of cases, small gastric bubble in over 80 %
quence of this fluid accumulated into the of cases) than cases with a tracheal fistula (poly-
amniotic cavity, and the stomach appears min- hydramnios 50 % of cases, small gastric bubble
imally distended. in 25 %) [4].
The diagnosis of esophageal atresia is sus- Esophageal atresia and tracheoesophageal fis-
pected when, in the presence of polyhydramnios tula are often associated with other major defects,
(usually only in the third trimester), repeated including chromosomal anomalies, malforma-
ultrasonographic examinations demonstrate a tions, and syndromic associations, that are not
small stomach bubble. In most cases the condi- always obvious on prenatal examinations
tion can only be suspected and the final diagno- (Fig. 1.3).
sis is only possible after birth. The only
exception is in cases in which during swallow-
ing the dilated proximal esophageal pouch is 1.3 Duodenal Atresia
seen, as an elongated upper mediastinal and ret-
rocardiac anechoic structure. This finding how- Prenatal diagnosis is based on the demonstration
ever is present only after 28 weeks and of the characteristic double bubble appearance
transiently [4]. of the dilated stomach and proximal duodenum,
The differential diagnosis for the combination commonly associated with polyhydramnios.
of a small stomach bubble and polyhydramnios Although the characteristic double bubble can
includes intrathoracic compression, by condi- be seen as early as 20 weeks, it is usually not
tions such as diaphragmatic hernia, and muscular- diagnosed until after 25 weeks suggesting that
skeletal anomalies causing inability of the fetus the fetus is unable to swallow sufficient volume
to swallow. Fetal magnetic resonance has also of amniotic fluid for bowel dilatation to occur
been reported to be of help in these cases [4]. before the end of the second trimester of
In one of the largest available series, polyhy- pregnancy.
dramnios was present in 50 % of cases, and the In a review of the literature, prenatal diagnosis
atresia was suspected or diagnosed antenatally in was made in 77 % of cases. Other malformations
about one-third of cases, at a median gestational were often present and trisomy 21 was found in
age of 31 weeks. As expected type 1 atresia was about one-third of cases [5] (Fig. 1.4).
4 G. Pilu

a b

Fig. 1.3 Esophageal atresia. The amniotic fluid is much increased (a), the stomach bubble is small (b), and the proxi-
mal esophagus forms a pouch when the fetus swallows (c)

1.4 Pyloric Atresia 1.5 Intestinal Obstruction

Few cases of pyloric atresia, often in association In early gestation the bowel is virtually empty
with other malformations, have been described. and it has a homogeneous echogenic texture.
The typical finding includes polyhydramnios and Only in the third trimester of gestation it becomes
a large stomach that usually appear only in the possible to visualize the large bowel, distended
third trimester of gestation. The index of suspi- by echogenic meconium. The appearance is very
cion is increased when dilatation of the esopha- variable and the size of the colon has been
gus is also seen [5]. reported to vary between 7 and 20 mm. Individual
1 Prenatal Diagnosis and Obstetric Management 5

a b

Fig. 1.4 Duodenal atresia; double bubble sign in the second (a) and third trimester (b)

a b

Fig. 1.5 Ileal atresia; gross dilatation of bowel loops. During real-time examination, increased perystalsis (a, b) was

small bowel loops may be seen at times, usually rare that the final diagnosis can only be made after
with a maximum diameter of few mm. birth. The whirlpool sign suggesting the presence
Small bowel obstruction is usually visible only of a volvulus has been described in fetuses.
late in pregnancy and almost invariably after In a review of the literature, about 50 % of
25 weeks of gestation. The diagnosis is easy when small bowel obstruction were detected antena-
distended, fluid-filled, and peristaltic bowel loops tally, and false-positive diagnosis was frequent
are seen. The presence of polyhydramnios (the specificity was as low as 30 %). The detection
increases the index of suspicion. However, at times rate was greater with jejunal than ileal obstruction
it may be difficult to differentiate bowel obstruc- (60 % and 25 %, respectively). Cystic fibrosis has
tion from normally prominent large bowel. It is not been reported in up to 13 % of cases [5] (Fig. 1.5).
6 G. Pilu

1.6 Meconium Peritonitis 1.7.2 Ovarian Cysts

Intrauterine perforation of the bowel may lead to Ovarian cysts are common, and they may be
a local sterile chemical peritonitis, with the devel- found in up to one-third of newborns at autopsy,
opment of a dense calcified mass of fibrous tissue although they are usually small and asymptom-
sealing off the perforation. Bowel perforation atic. Fetal ovarian cysts are hormone sensitive
usually occurs proximal to some form of obstruc- (hCG from the placenta) and tend to occur after
tion, although this cannot always be demon- 25 weeks of gestation; they are more common
strated. In many cases of meconium peritonitis, in diabetic or rhesus-isoimmunized mothers as
ultrasound will only reveal findings of intestinal a result of placental hyperplasia. The majority
obstruction. However, a specific diagnosis can be of cysts are benign and resolve spontaneously
made if dilated bowel loops are found in associa- in the neonatal period. Potential complications
tion with ascites and calcium deposit. It may also include the development of ascites, torsion,
be possible to document at times a typical infarction, or rupture. Prenatally, the cysts are
sequence of events: ascites associated with seg- usually unilateral and unilocular although if the
mental dilatation of bowel loops, followed by cyst undergoes torsion or hemorrhage, the
disappearance of the fluid and progression of appearance is complex or solid. Large ovarian
bowel enlargement, usually in the presence of cysts can be found in association with polyhy-
intra-abdominal calcifications. Cystic fibrosis has dramnios possibly as a consequence of com-
been reported in up to 20 % of these cases [5]. pression on the bowel. Obstetric management
should not be changed, unless an enormous or
rapidly enlarging cyst is detected or there is
1.7 Abdominal Cysts associated polyhydramnios; in these cases, pre-
natal aspiration may be considered. A difficult
Abdominal cysts are frequent findings at ultra- differential diagnosis is from hydrometrocol-
sound examination. Renal tract anomalies or pos, which also presents as a cystic or solid
dilated bowel are the most common explanations, mass arising from the pelvis of a female fetus.
although cystic structures may arise from the bili- Other genitourinary or gastrointestinal anoma-
ary tree, ovaries, mesentery, or uterus. The cor- lies are common and include renal agenesis,
rect diagnosis of these abnormalities may not be polycystic kidneys, esophageal atresia, duode-
possible by ultrasound examination, but the most nal atresia, and imperforate anus. Most cases
likely diagnosis is usually suggested by the posi- are sporadic, although few cases are genetic,
tion of the cyst, its relationship with other struc- such as the autosomal recessive McKusick-
tures, and the normality of other organs [6]. Kaufman syndrome with hydrometrocolpos,
polydactyly, and congenital heart disease
(Fig. 1.6).
1.7.1 Choledochal Cysts

Choledochal cysts represent cystic dilatation of 1.7.3 Mesenteric or Omental Cysts

the common biliary duct. They are uncommon
and their etiology is unknown. Prenatally, the Mesenteric or omental cysts may represent
diagnosis may be made ultrasonographically by obstructed lymphatic drainage or lymphatic ham-
the demonstration of a cyst in the upper right side artomas. The fluid contents may be serous, chy-
of the fetal abdomen. The differential diagnosis lous, or hemorrhagic. Antenatally, the diagnosis
includes enteric duplication cyst, liver cysts, situs is suggested by the finding of a multiseptate or
inversus, or duodenal atresia. The absence of unilocular, usually in the midline, cystic lesion of
polyhydramnios or peristalsis may help differen- variable size; a solid appearance may be second-
tiate the condition from bowel disorders. ary to hemorrhage.
1 Prenatal Diagnosis and Obstetric Management 7

a b

Fig. 1.6 Imperforate anus. In this fetus at 20 weeks of with the failure to demonstrate the echogenic anal mucosa
gestation with multiple anomalies, the diagnosis was sug- (b, c); the diagnosis was confirmed at the time of autopsy
gested by the enlargement of the rectum (a) in association (d)

1.7.4 Intestinal Duplication Cysts with other gastrointestinal malformations.

Differential diagnosis includes other intra-
They are quite rare and may be located along the abdominal cystic structures and also broncho-
entire gastrointestinal tract. They sonographi- genic cysts, adenomatoid cystic malformation of
cally appear as tubular or cystic structures of the lung, and pulmonary sequestration. The
variable size. They may be isolated or associated thickness of the muscular wall of the cysts and
8 G. Pilu

the presence of peristalsis may facilitate the diag- about fetal pain, and the ultimate psychological
nosis. Postnatally surgical removal is carried out. consequence of long-enduring distress, but stud-
ies on premature infants do suggest that this may
have a major impact [8]. Unfortunately, an effec-
1.8 Anorectal Malformation tive approach to pain therapy in utero is not avail-
able yet, but certainly this problem will have to
The fetal anus and rectum are poorly demon- be addressed in the future.
strated by ultrasound and are not a part of the
standard examination of fetal anatomy. As a gen- Conclusions
eral rule, anorectal malformations are not ame- In most cases, intestinal anomalies will escape
nable to antenatal diagnosis. In a handful of prenatal detection and will be recognized only
cases, however, anorectal atresia has been sus- postnatally. The pediatric surgeon may how-
pected antenatally, usually by the observation of ever be consulted prior to birth in the presence
a dilatation of the upper rectum and failure to of abnormal fetal sonographic findings. At
demonstrate the anorectal complex that is nor- times the diagnosis will be clear-cut (double
mally formed by the anechoic ring of the external bubble sign and polyhydramnios indicating
sphincter muscle surrounding the echogenic duodenal atresia, grossly dilated and peristal-
mucosa (Fig. 1.6) [7]. tic bowel loops suggesting small bowel
obstruction, a whirlpool sign suggesting a vol-
vulus). In other cases, there will be many
1.9 Obstetrical Management uncertainties. It is important to stress that the
of Fetal Intestinal Anomalies accuracy of antenatal imaging technique in the
identification and differentiation of gastroin-
Intestinal anomalies are invariably treated after testinal anomalies is limited. In many cases, a
birth, and standard obstetric management is usu- definitive diagnosis will only be possible after
ally not changed. As a general rule, delivery may birth.
occur at the term and vaginally. A possible excep-
tion is represented by the presence of polyhy-
dramnios that is frequently found with esophageal References
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demonstrate gross intestinal dilatation with Performance of prenatal diagnosis in esophageal atre-
intense peristalsis and overdistension of the sia. Prenat Diagn 35(9):888893
abdomen and vomit incessantly and not to think 5. Tonni G, Grisolia G, Granese R, Giacobbe A,
Napolitano M, Passos JP, Araujo E Jr (2015) Prenatal
the agony they are experiencing. Little is known
1 Prenatal Diagnosis and Obstetric Management 9

diagnosis of gastric and small bowel atresia: a case Oceania Perinatal Soc Inter Soc Perinatal Obstet
series and review of the literature. J Matern Fetal 29(10):16911699
Neonatal Med Off J Eur Assoc Perinatal Med 7. Perlman S, Bilik R, Leibovitch L, Katorza E, Achiron
Federation Asia Oceania Perinatal Soc Inter Soc R, Gilboa Y (2014) More than a gut feeling sono-
Perinatal Obstet 23:19 graphic prenatal diagnosis of imperforate anus in a
6. Catania VD, Briganti V, Di Giacomo V, Miele V, high-risk population. Prenat Diagn 34(13):13071311
Signore F, de Waure C, Calabro GE, Calisti A (2016) 8. Valeri BO, Holsti L, Linhares MB (2015) Neonatal
Fetal intra-abdominal cysts: accuracy and predictive pain and developmental outcomes in children born pre-
value of prenatal ultrasound. J Matern Fetal Neonatal term: a systematic review. Clin J Pain 31(4):355362
Med Off J Eur Assoc Perinatal Med Federation Asia
Gastro-Intestinal Tract Radiology
Filomena Carfagnini, Michelangelo Baldazzi, and
Antonio Poerio

The main diagnostic techniques for gastrointesti- The indications for each imaging modality,
nal pathology in childhood have always been and and the order in which examinations must be
still are plain abdominal radiographs and conven- conducted, should be considered carefully to
tional contrast studies. However, gastrointestinal avoid unnecessary examinations. In the radiolog-
imaging has continued to evolve over time, with ical examination of children, the problem of radi-
new techniques and methods gradually being ation protection should be addressed first and
added to the diagnostic procedures, particularly foremost, regardless of the part of the anatomy
ultrasound (US), magnetic resonance imaging being imaged.
(MRI), and computed tomography (CT).
For gastrointestinal studies in children, it is
important to know the indications for the differ- 2.1 Imaging Techniques
ent imaging techniques, to understand the rela-
tionship between the techniques, and to consider 2.1.1 Plain Abdominal Radiograph
the use of these newer techniques rather than con-
ventional radiological studies, also considering The plain abdominal radiograph uses the natural
the role of prenatal diagnosis and how this has, in contrast agent of air, and in the neonatal period is
some cases, changed the diagnostic process. the examination most frequently used; in some
The different diagnostic techniques for gastro- cases it is the only one required for the diagnosis.
intestinal tract studies in children are described In a healthy neonate, air can usually be identified
here, noting for each the main indications and in the stomach within minutes of birth, and within
specific characteristics, bearing in mind that a 3 h the entire small bowel usually contains gas.
diagnosis can be determined by a single investi- After 89 h, healthy neonates demonstrate
gation or can be the result of one or more sigmoid gas.
studies. Delayed passage of gas through the neonatal
gut may occur as a result of traumatic delivery,
hypoglycemia, septicemia, or brain damage.
Absence of gas in the bowel may be noted in
neonates with severe respiratory distress who are
F. Carfagnini (*) M. Baldazzi A. Poerio undergoing mechanical ventilation, and in neo-
Pediatric Radiology, S. Orsola-Malpighi Hospital, nates undergoing continuous nasogastric
Via Albertoni 15, Bologna, Italy
e-mail:;; antonio.poerio@ The diagnosis of obstruction is based on some interruption of this dispersion of air. Radiography

Springer International Publishing Switzerland 2017 11

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_2
12 F. Carfagnini et al.

is the most valuable means of determining duodenal atresia with a double-bubble sign; less
whether obstruction is present. This modality is frequently pyloric atresia, with a single-bubble
often diagnostic; even if it is not, however, it may sign; and jejunal atresia, with a few dilated loops
help to determine the next most useful diagnostic causing upstream obstruction and complete
procedure [15]. absence of air downstream (Fig. 2.2). None of
Congenital anomalies causing incomplete these conditions usually require further radiolog-
obstruction (e.g., stenoses, webs, duplications, ical evaluation after radiography: contrast studies
malrotations, peritoneal bands, aganglionosis) are usually contraindicated, and additional proce-
may not manifest until later in life, and other dures are not usually helpful and may even delay
types of examinations (e.g., US and barium surgery, resulting in death.
enema studies) are generally needed for The role of the plain abdominal radiograph
diagnosis. combined with a chest radiograph in the diagno-
Abdominal radiography is often performed sis of esophageal atresia should be mentioned;
only in the supine antero-posterior (AP) view, this disease is suspected at prenatal US by the
especially in the neonatal period; only if required combination of polyhydramnios, reduced intralu-
is the trans-lateral view with a horizontal beam minal liquid in the fetal gut, and inability to
added, and this allows the recognition of air-fluid detect the fetal stomach.
levels and facilitates the visualization of pneumo- Radiological confirmation of esophageal atre-
peritoneum (Fig. 2.1). In pneumoperitoneum, in sia is based on findings on AP and lateral chest
equivocal cases, the study can be completed by radiographs, which show a blind pouch of the
an additional view in the left lateral (LL) decubi- proximal esophagus, which is distended with air.
tus position, with a horizontal beam. Radiographic evaluation should always include
All cases of pneumoperitoneum, however the abdomen to assess the presence of gastroin-
determined, and upper-obstructive conditions testinal air due to the existence of the fistula,
have an exclusively radiographic diagnosis allowing the classification of tracheo-esophageal

a b

Fig. 2.1 Plain abdominal radiographs: supine antero-posterior view (a) and trans-lateral view (b) show the presence of
2 Gastro-Intestinal Tract Radiology 13

atresia. In types I and II there is a complete 2.1.2 Contrast Studies

absence of air in the stomach and bowel, whereas
in types III and IV, air is commonly present. Contrast studies remain as key to the demonstra-
When an H-shaped fistula without atresia is tion of many diseases, both congenital and
suspected, an esophagogram with low-osmolality acquired. Their use, however, is slowly declining,
water-soluble non-ionic contrast media can show thanks to the increased availability and dissemi-
the fistula [6]. nation of endoscopic techniques and video cap-
The plain abdominal radiograph also has a sule endoscopy (VCE).
role in the early diagnostic phase of anorectal The aim of the modern radiologist is to work
malformations; in such cases, you need to per- in close collaboration with the gastroenterologist
form, with classification intent, a plain abdomi- and surgeon, to perform contrast studies only in
nal radiograph in the trans-lateral prone view for selected patients, using the correct technique, at
the evaluation of the rectal cul-de-sac and its dis- the lowest radiation dose possible to meet spe-
tance from the perineum. cific diagnostic questions.
Furthermore, this study allows you to detect Many diseases are also studied exclusively by
the sacrococcygeal anomalies that are often a continuous fluoroscopy technique, by the last
found in caudal regression syndrome or other image-capture technique, or by pulsed fluoros-
skeletal abnormalities in a more syndromic copy with capture of the acquired series. High-
context (VACTERL association; vertebral dose standard full exposures are reserved for
defects, anal atresia, cardiac defects, tracheo- cases of difficult diagnosis or when more definite
esophageal fistula, renal anomalies, and limb anatomical detail is essential (e.g., in thin tracheo-
abnormalities). esophageal fistulas).

a b

Fig. 2.2 Plain abdominal radiographs: duodenal atresia (b), with a few dilated loops and absence of air in the
with the double-bubble sign, due to distension of the lower portion of the abdomen. Note the presence of tho-
stomach and proximal duodenum (a) and jejunal atresia racic right-side hemivertebra (a)
14 F. Carfagnini et al. Contrast Studies of the Upper

Gastrointestinal Tract
Contrast studies of the upper gastrointestinal
tract are upper gastrointestinal (UGI) series,
small bowel follow through (SBFT), and small
bowel enema.

Upper Gastrointestinal (UGI) Series

In well infants or children, barium is the preferred
contrast medium for UGI series.
For imaging of the esophagus, stomach, and
duodenum there is a choice of barium formula-
tions and the choice of preparation is at the
discretion of the radiologist.
As mucosal detail is rarely required, or indeed
obtainable in children, preparations with a lower
density are used; these can be successfully diluted,
do not settle out and set while in suspension, and do
not flocculate in the time taken to perform the test.
In neonates, especially premature infants, and
in circumstances where aspiration is a risk or a
perforation of the gastrointestinal tract is
suspected, a low-osmolality water-soluble non-
ionic contrast medium is ideally used (Fig. 2.3).
The child should be starved for approximately
34 h before the study, or for the maximum gap
between feeds if still breast-fed.
High-density high-osmolality water-soluble
non-ionic contrast media should never be used
because of the risk of aspiration and consequent
possible serious complications, such as acute pul-
monary edema [1, 35].
Although the 24-h pH probe is now the main- Fig. 2.3 Upper gastrointestinal series: gastroesophageal
stay for making or confirming the diagnosis of reflux with massive aspiration
reflux in children, UGI series are still used in
many centers to confirm that the underlying gas-
trointestinal anatomy is normal. Conversely, the cardinal sign that reflux is likely to occur immi-
presence or absence of reflux during a routine nently, and if the radiologist sees this he/she
UGI series should be noted, as this may be an should wait for a few more moments to see
important incidental finding. whether this is confirmed. If reflux does not occur
Reflux often occurs immediately after the pas- after two or three episodes of drinking water then
sage of the bolus (liquid or solid) through the child should be turned to the left lateral (LL)
fractionally delayed closure of the gastro-esoph- position and then slowly returned to supine. This
ageal junction (GEJ). Thus, if water is given (two encourages barium to wash over the GEJ, which
or three consecutive mouthfuls are sufficient) may cause reflex relaxation of the GEJ with sub-
even small amounts of reflux of barium at the sequent reflux. If after these two maneuvers
GEJ may be captured. Beaking of the GEJ is a reflux has not been demonstrated, then the study
2 Gastro-Intestinal Tract Radiology 15

should be ended. There is no indication for tilting bowel disease (IBD) if other modalities are not
the child head down or for performing any other suitable.
non-physiological reflux- or vomit-inducing The first part of the study is as for a UGI
maneuvers [35]. series, and the child can then sit outside the fluo-
Although tube esophagram has traditionally roscopy room for another 20 min. The child
been the gold standard examination for H-type should continue to slowly but steadily drink more
tracheo-esophageal fistula, a contrast swallow contrast media during this time to ensure that
(performed in the correct way) can be sufficient there is a continuous column of contrast passing
for making the diagnosis. However, a normal through the gut during the study. Serial images
contrast swallow does not absolutely rule out the are then acquired at appropriate intervals to
presence of a tracheo-esophageal fistula, and if answer the clinical question [15].
high clinical concern remains, then a tube esoph-
agram is still indicated. Contrast Studies of the Lower
The tube esophagram (as part of a UGI series) Gastrointestinal Tract
remains the test of choice in those children known Imaging of the lower gastrointestinal tract has not
to have a risk of aspiration or those being venti- changed substantially over recent years, and a
lated at the time of the study. UGI series may be water-soluble contrast enema (for neonatal con-
performed for no other reason than to reveal an ditions) and, less frequently, a barium enema for
alternative explanation for the childs symptoms, older infants and children remain the mainstay of
such as significant reflux. imaging [15, 711].
It is worth noting that even a contrast swallow Loopograms have an important role in chil-
followed by a high-quality tube esophagram does dren who have a stoma. Low-density water-
not always demonstrate an occult fistula, and in soluble contrast media is generally used, with the
occasional cases bronchoscopy may also have to benefit that as more is instilled it does not become
be performed. Similarly, bronchoscopy may miss excessively dense and cause technical problems
a fistula revealed by a contrast study. The tests are with exposure factors. However, there are a few
therefore complementary [6]. instances, such as when trying to demonstrate a
subtle fistula in an anorectal malformation, in
SBFT and Small Bowel Enema which the limited use of denser water-soluble
Both SBFT and small bowel enema examinations contrast media may be necessary to achieve suf-
are in precipitous, and probably terminal, decline ficient definition. This will largely be at the dis-
with the advent of VCE, MRI of the bowel, and cretion of the radiologist.
the use of US in examining the bowel. In neonates, enema studies are indicated in
The SBFT may still be performed in specific cases of bowel obstruction, especially lower
circumstances, including the following: in prepa- intestinal obstruction.
ration for elective gut resection for surgical plan- Upper intestinal obstruction in neonates is
ning, when information regarding small bowel characterized by bilious vomiting (which
transit is required (such as in pseudo-obstruction frequently occurs after the first feeding) and
and dysmotility states); in suspected subacute abdominal distension at clinical examination.
obstruction, or obstruction (noting that in adults Specific common causes of upper intestinal
CT is now routinely used for this indication, but obstruction include atresia of the jejunum or
this is not standard practice in pediatrics due to proximal ileum and peritoneal bands. Partial
radiation dose concerns); in confirming patency obstruction can be caused by jejunal stenosis,
in anticipation of VCE in patients at high risk of peritoneal bands, duplication cyst, malrotation,
stricture (including patients with Crohns and Meckels diverticulum.
disease); in children who cannot tolerate VCE; The generic diagnosis of upper intestinal
and to assess complications of inflammatory obstruction is usually straightforward at radiog-
16 F. Carfagnini et al.

raphy, which demonstrates a few dilated bowel

loops, more than would be seen in duodenal atre-
sia and fewer than in ileal atresia or other causes
of lower bowel obstruction. There is no gas in the
lower portion of the abdomen in jejunal atresia.
The patient usually requires no further radiologi-
cal investigation, although barium enema exami-
nations are still performed in attempts to exclude
second and third areas of atresia lower in the
bowel. In isolated proximal atresia of the jeju-
num, the colon is normal in size, because the
remaining small bowel distal to the atresia pro-
duces sufficient intestinal secretions to produce a
normal-caliber colon [15].
Lower intestinal obstruction is defined as an
obstruction that occurs in the distal ileum or
colon. Signs include large bowel obstruction with
vomiting, abdominal distension, and failure to
pass meconium. The differential diagnosis Fig. 2.4 Barium enema study shows severe functional
includes ileal and colonic atresia, meconium microcolon
ileus or peritonitis, Hirschsprung disease, and
functional immaturity of the colon. Anorectal
malformations are also an important cause of the colon has a normal location but a minute cali-
lower intestinal obstruction, but are almost ber (functional microcolon).
always evident at physical examination. Colonic atresia is less common than ileal atre-
The diagnosis of lower intestinal obstruction sia. It is often indistinguishable from obstruction
is usually apparent at abdominal radiography of the distal ileum, especially when the atresia is
because of the presence of many dilated intesti- located in the ascending colon. The colon proxi-
nal loops, but radiographic differentiation mal to the point of atresia is often massively
between ileal and colonic obstruction is diffi- dilated, and a mottled pattern of gas and feces
cult, if not impossible. This distinction can may be identified. Barium enema examination
readily be made with a barium enema study, usually reveals a distal microcolon with obstruc-
which helps to determine the presence of micro- tion to the retrograde flow of barium at the site of
colon (Fig. 2.4), indicates the position of the the atresia [25, 8].
cecum with regard to possible malrotation, and Meconium ileus is the result of intraluminal
shows the level of the obstruction in colonic obstruction of the colon and lower small bowel,
atresia [14]. due to the impaction of meconium, and repre-
Ileal atresia is an important cause of lower sents the earliest clinical manifestation of cystic
intestinal obstruction. Plain radiographs (AP and fibrosis. Mechanical obstruction occurs when
LL views) show numerous dilated loops of bowel desiccated meconium pellets occlude the distal
occupying the entire abdominal cavity and mul- small bowel and the more proximal small bowel
tiple air-fluid levels. When this degree of disten- loops are distended with tenacious meconium
sion is reached, the mucosal pattern of the small paste. The abdomen is filled with gas-distended
bowel is effaced and it may be impossible to dif- loops and occasionally there is a relative absence
ferentiate small bowel from colon. In such a case, of air-fluid levels due to abnormally thick intralu-
a barium enema study is mandatory to determine minal meconium. The admixture of gas with
the presence of a colonic lesion. In ileal atresia, meconium may give rise to a soap-bubble appear-
2 Gastro-Intestinal Tract Radiology 17

ance similar to the fecal pattern in the colon in intussusception, although some cases are idio-
older patients. pathic. The extruded bowel contents provoke an
Contrast enema examination will show a func- intense peritoneal inflammatory reaction, leading
tional microcolon, involving the entire large to the formation of dense fibrotic tissue. This tis-
bowel, and may show impacted meconium pellets, sue often calcifies, resulting in the characteristic
particularly in the right colon or in the distal ileum, intraperitoneal calcifications identified prior to
caused by retained meconium (Fig. 2.5). birth with US and after birth with abdominal
Meconium ileus is among the few pediatric condi- radiography and US. The calcifications of meco-
tions for which an enema is used, with high- nium peritonitis may extend into the scrotum
osmolality water-soluble iodinated contrast, through a patent vaginal process to produce a cal-
because of its therapeutic effects. Advantage is cified mass in the scrotum [25, 8, 9, 12].
taken of the high osmotic pressure of the contrast Hirschsprung disease is a form of lower intes-
medium: the surrounding tissue is forced to release tinal obstruction caused by the absence of normal
considerable amounts of fluid, which then flows myenteric ganglion cells in a segment of the
into the gut and dissolves the inspissated meco- colon. The aganglionosis varies in length but
nium. Therefore, the enema is both diagnostic and always extends proximally from the anal canal,
therapeutic, and can be followed by the expulsion and the rectosigmoid area is involved in most
of meconium during or after the procedure. cases. Ultrashort segment disease (in which
Meconium ileus may be complicated by vol- aganglionosis is essentially limited to the region
vulus of a distal intestinal loop, perforation, atre- of the internal sphincter) is very rare, as is agan-
sia, or peritonitis [24, 8, 9, 12]. glionosis involving the entire alimentary tract. In
Meconium peritonitis is a chemical peritonitis children with Hirschsprung disease, the absence
resulting from intrauterine bowel perforation. of ganglion cells results in the failure of the distal
Common underlying disorders include small intestine to relax normally. Peristaltic waves do
bowel atresia, meconium ileus, volvulus, and not pass through the aganglionic segment and
there is no normal defecation, leading to func-
tional obstruction. Abdominal distension, consti-
pation, and bilious vomiting are the predominant
signs and symptoms of obstruction and appear
within a few days after birth.
Radiography performed in children with
Hirschsprung disease yields findings similar to
those in other forms of lower small bowel
obstruction: variable gaseous distension of the
colon and small bowel, often with air-fluid levels.
The colon is usually difficult to identify accu-
rately, and gas is usually absent in the rectum.
Barium enema studies demonstrate patency of
the colon, which is short but usually normal in
caliber. A transition zone between the narrow and
dilated portions of the colon, in the shape of an
inverted cone, is the most characteristic radio-
logical finding. When this transition zone is
observed, the examination should be discontinued,
because filling of the more proximal dilated
Fig. 2.5 Contrast enema with high-osmolality water- bowel beyond the transition zone may lead to
soluble contrast in meconium ileus impaction (Fig. 2.6). However, the distension of
18 F. Carfagnini et al.

a b

Fig. 2.6 Hirschsprung disease. Plain abdominal radiograph (a) and barium enema (b, c). Note in c the ascent of the
contrast to the stomach in the late study, due to complete aganglionosis

the bowel proximal to the segment of deficient disease during the first week of life. Abnormal
innervation is gradual, and a transition zone is contractions and irregular peristaltic activity of
seen in only 50% of neonates with Hirschsprung the aganglionic portion of the colon may be use-
2 Gastro-Intestinal Tract Radiology 19

ful indicators of the disease, although they are the enema used exclusively for therapeutic pur-
nonspecific findings that are also seen in colitis. poses, since the diagnosis is made by
Twelve-hour-delayed postevacuation images sonography.
are useful in dubious cases. The role of the enema in reducing intestinal
The radiological diagnosis of total colonic intussusception is well known and recognized,
aganglionosis is difficult. Findings at barium but in the literature there are many differing
enema examination may be normal or may reports about the contrast medium to be used;
include a short colon of normal caliber, micro- namely, air or liquid. An air enema is considered
colon, or a transition zone in the ileum [24, to be better at reduction, cleaner (appearance of
10, 11]. peritoneal cavity at surgery when perforation
Functional immaturity of the colon is a com- occurs), safer, and faster, with less radiation
mon cause of neonatal obstruction, particularly in when compared with a liquid enema. Reported
premature neonates and in those whose mothers perforation rates are not significantly different.
were treated during labor with magnesium prepa- The recurrence rates for air versus liquid enema
rations or sedatives; the condition also occurs in reductions do not differ (approximately 10%).
neonates with diabetic mothers. The condition However, while the air enema may be preferred
has also been encountered in children with septi- in experienced hands, the liquid enema is also
cemia, hypothyroidism, or hypoglycemia. safe and effective. Barium is no longer the liquid
Functional immaturity of the colon comprises contrast medium of choice, due to the risk of bar-
several entities, most notably small left colon ium peritonitis, infection, and adhesions when
syndrome and meconium plug syndrome. perforation occurs during the enema procedure.
Affected patients have abdominal distension, dif- Neither sedation nor medications increase the
ficulty in initiating evacuation, and sometimes enema success rate. More recent reports of air
vomiting; typically, however, the bowel disten- enema intussusception reduction show better
sion is less severe than that seen with an organic results than liquid enema intussusception reduc-
obstruction. The condition is both diagnosed and tion. The air enema may use higher intraluminal
treated with a contrast enema. pressure, which results in a higher reduction rate.
In small left colon syndrome, barium enema To avoid ionizing radiation exposure to chil-
examination demonstrates a distended right and dren, the use of US with either water or air reduc-
transverse colon with a transition to a very small- tion techniques has been reported, showing
diameter descending and rectosigmoid colon intussusception reduction rates equivalent to
near the splenic flexure. The rectum is usually those using fluoroscopy.
quite distensible. The use of delayed attempts (reports vary
In meconium plug syndrome, barium enema between 30 min and 1 day) after the initial
examination with high-osmolality water-soluble attempt have shown further success in enema
contrast shows a small caliber of the left colon reductions of intussusceptions. Delayed enema
with a large meconium plug. The rectum is usu- should not be performed if the child is clinically
ally normal in size, unlike findings in unstable or if the initial enema does not partially
Hirschsprung disease. The enema can be both reduce the intussusception.
diagnostic and therapeutic and is usually accom- The most important potential complication of
panied by the passage of meconium during or enema use is bowel perforation (the mean perfo-
after the procedure [10, 11]. ration rate was 0.8%). There are no statistically
Typically, there is clinical improvement fol- significant differences between air and liquid
lowing the enema, and over the course of hours to enema perforation rates. This risk depends on
days the radiographic and clinical signs of each radiologists patient population and
obstruction subside. technique, as well as on the duration of symp-
In older children the main indication for a toms. Because of this small but real risk of bar-
barium enema is intestinal intussusception, with ium peritonitis, infection, and adhesions when
20 F. Carfagnini et al.

perforation occurs during the enema procedure, In the past few decades, advances in US
iodinated contrast is preferred over barium when technology have greatly improved the quality
using liquid enema reduction. of gastrointestinal US imaging, with a conse-
Children with evidence of peritonitis, shock, quent positive impact on its diagnostic yield.
sepsis, or free air on abdominal radiographs are Improvements in US probes, particularly high-
not candidates for enema use [4, 5]. resolution linear probes, permit better spatial
resolution and better penetration in the far field,
whereas improvements in contrast resolution
2.1.3 Ultrasound (US) can now be achieved with recent US modes
such as image compounding, speckle/noise
Ultrasound (US) is an excellent imaging modal- reduction filters, and (tissue) harmonic
ity for the evaluation of the gastrointestinal tract imaging.
in pediatric patients, so that it is now considered Likewise, progress in Doppler techniques
as an extension of the clinical evaluation, both in allows better depiction and quantification of even
emergency conditions and for elective studies the slow flow of small vessels within normal and
[13, 14]. pathological gastrointestinal structures.
In addition to the well established primary For any US examination the choice of ade-
role of US in specific diseases, such as in hyper- quate transducers, adjustment of basic parame-
trophic pyloric stenosis and intestinal intussus- ters, and the choice of US modality is fundamental
ception, the diagnostic reliability of US has been to obtain a proper image quality.
widely demonstrated in many other pathological In general, the optimal transducer must have
conditions, such as in acute appendicitis, chronic the highest possible frequency that is still able to
intestinal inflammatory diseases (IBD), necrotiz- penetrate the anatomical area of interest, provid-
ing enterocolitis (NEC), gastro-esophageal ing the best spatial resolution.
reflux, neonatal intestinal obstruction, intestinal The initial evaluation of the entire abdominal
malrotation, and acute volvulus in intestinal cavity is performed with a curved array trans-
malrotation. Furthermore, US is successfully ducer; then the individual structures of the gas-
used even in less conventional applications, such trointestinal tract are specifically examined with
as in esophageal atresia and anorectal a high-resolution linear probe, which allows
malformations. detailed visualization of the esophageal wall,
The well known advantages of US, particu- gastric wall, and bowel wall, as well as detailed
larly its lack of ionizing radiation and easy visualization of the relevant surrounding struc-
access, makes this imaging technique an ideal tures. Not infrequently, curved array probes may
one for the evaluation of the pediatric patient also be needed in order to obtain a better access
with gastrointestinal tract diseases. Major draw- window to image deeper structures in older chil-
backs include its operator-dependency and repro- dren (e.g., the esophago-gastric junction, the sig-
ducibility, apart from factors related to the moid colon, and the rectum) or to allow for a
patient, such as non-collaboration, obesity, and broader field of view.
the interposition of a large amount of gas. Most In addition to the conventional trans-
of these limitations can be overcome with a com- abdominal approach, other less common types
prehensive, careful, and dedicated examination of approaches might be necessary, and should
technique using modern US capabilities. be included in specific disease conditions, such
US is also an excellent bedside high-yield as the suprasternal and mediastinal US approach
imaging tool in intensive care units and it can to visualize the upper esophagus in
also be used to guide therapeutic maneuvers, tracheo-esophageal atresia or the perineal US
such as in the reduction of intussusception or in approach to evaluate the anal canal or the distal
enema for meconium ileus. rectal pouch location and its distance to the
2 Gastro-Intestinal Tract Radiology 21

skin surface in anorectal or in cloacal many factors, including the nonspecific nature of
malformations. symptoms in young children, the difficult distinc-
A well known limitation of US examinations tion between physiological and pathological
is bowel gas interposition, but with a careful and GER, and the impasse in establishing a cause-
proper bowel US technique this obstacle can effect relationship between GER and symptoms
often be partially overcome. Gentle graded com- or complications related to GERD.
pression is the essential technique in US of the Nevertheless, US is considered by many
gastrointestinal tract, as it displaces undesirable authors as the primary non-invasive imaging tool
gas, shortens the distance to the skin surface, and in a child with vomiting, particularly in patients
isolates the bowel loops, while displacing adja- younger than 2 years of age, as it can provide
cent ones. Furthermore, it helps to localize the alternative diagnoses other than GER and rule
origin of pain (sonopalpation) and to assess the out gastric outlet obstruction.
bowel compressibility. More important than the US detection of
In small patients and particularly in critically GER, per se, is the fact that one can correlate the
ill neonates, SBFT can be performed and fol- US findings with the occurrence of clinical symp-
lowed by US. toms. Furthermore, US can provide information
Filling techniques are the basis for therapeutic on functional aspects such as the esophageal
maneuvers under US guidance, such as in the clearance of the refluxed gastric content, the
nonsurgical reduction of an ileo-colic intussus- opening of the gastroesophageal junction (GEJ),
ception or in the attempt to resolve meconium and gastric emptying, and US can potentially
ileus. detect an associated hiatal hernia. Anatomical
details of the gastroesophageal structure, such as Upper Gastrointestinal Tract US the length of the abdominal esophagus and the
In neonates esophageal atresia is usually diag- gastroesophageal angle (angle of His), can be
nosed with frontal and lateral radiograms, but US assessed, and these features seem to have high
can provide additional precious information to sensitivity and high positive predictive value for
the surgeon. Besides the role of abdominal and GER.
cardiac US in searching for associated abnormal- US is generally considered the modality of
ities, mediastinal US allows the characterization choice to confirm or exclude the diagnosis of
of the length, morphology, and structure of the hypertrophic pyloric stenosis (HPS), as both the
wall in a blind upper esophageal pouch; this con- lumen and the surrounding musculature are
dition can be improved by the administration of a directly visualized [1517]. The diagnosis of
small amount of saline fluid through the esopha- HPS is based on US morphological and dynamic
geal tube. Rarely, even a tracheo-esophageal fis- findings: the most significant criteria are a thick-
tula may be recognized by US [13]. ened pyloric muscle (greater than 3 mm), a
With a superior abdominal US approach, the pyloric length greater than 18 mm, and the lack
cardia and the adjacent distal esophagus are often of luminal opening of the pyloric channel
easily depicted, although visualization of the (Fig. 2.7). The usually distended stomach, seen
entire distal esophageal length behind the heart is as an indirect sign of gastric outlet obstruction,
difficult and restricted. must be interpreted according to the time of the
In neonates and infants with suspected gastro- last meal. Changing the patient position may be
esophageal reflux disease (GERD), US is a necessary to improve visualization of the pyloric
widely available, non-invasive, and sensitive channel hidden by a distended stomach.
method that can provide useful anatomical and It is also important to evaluate the pyloric
functional information, although its role in canal over time, to differentiate HPS from pylo-
GERD is still controversial and debated. The rospasm, a transient phenomenon that can have
complex issue of GER and GERD is related to morphological features and measurements simi-
22 F. Carfagnini et al.

a b

Fig. 2.7 (a, b) Hypertrophic pyloric stenosis. Ultrasound than 18 mm), and distended stomach due to the lack of
(US) study (a, b) shows a thickened pyloric muscle luminal opening of the pyloric channel
(greater than 3 mm), increase of pyloric length (greater

lar to those of HPS. In doubtful cases a repeated evaluate the duodenum morphology, duodenal-
US after some time can clarify the diagnosis. jejunum junction position, and cecum position,
Gastric duplication cysts are usually easily and this study is still considered the standard cri-
recognized when they have the classic US appear- terion. Actually, in addition to these invasive
ance of localized fluid formations with a thick examinations that use X-rays, US examination
layered wall. Gastric emptying may be used to with color Doppler is used to identify intestinal
highlight the close relationship of the cyst with anomalies of rotation and fixation. The best
the gastric wall [18]. known US finding is an abnormal relationship
Other gastric pathologies can be suspected in between the superior mesenteric artery (SMA)
abdominal US examinations performed in a child and the superior mesenteric vein (SMV), although
with vomiting, epigastric pain, or other nonspecific a normal position does not exclude the presence
abdominal discomfort. Such pathologies may be a of abnormal midgut rotation. In addition, the nor-
cause of focal or diffuse thickening of the stomach mal position of the third duodenal portion is
wall (e.g., eosinophilic gastritis, chronic granulo- believed to be a more reliable marker than the
matous disease, tumoral diseases such as polyps position of the mesenteric vessels to exclude
and lymphoma), but also of intraluminal anomalies intestinal malrotation (Fig. 2.8).
(e.g., bezoar, ingested foreign bodies). The finding of an abnormal relationship
After the US evaluation of the esophageal- between the SMA and the SMV may be demon-
gastric junction, stomach, and pylorus, the next strated either incidentally or on specific examina-
step is to follow the duodenum to check the third tion. The SMA/SMV relationship should be
duodenal portion, which normally passes between considered part of abdominal US screening in
the abdominal aorta and the superior mesenteric infants and children with abdominal pain or in
artery; the normal position of the duodenojejunal asymptomatic pediatric patients to prevent future
junction can also be identified, on the left side of obstructive or ischemic complications.
the aorta. Midgut volvulus is the most frequent cause of
acute abdomen in newborns, and it is a common Small and Large Bowel US consequence of intestinal malrotation. However,
US can also be used to recognize intestinal mal- it can affect children also. It is a life-threatening
rotations [12, 1922]. The diagnosis of these emergency; early diagnosis is important in this
abnormalities has been modified in the past few disease, to avoid the risk of intestinal infarct and
years. Barium enema and radiographic study of necrosis. If not promptly diagnosed and treated,
the upper gastrointestinal tract has been used to midgut volvulus leads to death or a lifelong
2 Gastro-Intestinal Tract Radiology 23

punctuated with echodense particles of gas. The

distal bowel is small in size (34 mm) with ech-
odense or target-like meconial content [19].
Furthermore, US allows the assessment of
colon size and its content, a main marker to sug-
gest the probable location of the obstruction, thus
indicating the need to perform a contrast enema
in case of lower bowel obstruction. The colon is
of normal caliber (914 mm) in very proximal
small bowel atresia, while microcolon (35 mm)
is easily recognized in distal small bowel atresia
and in meconium ileus. In meconium ileus,
severe microcolon is present, but the small bowel
Fig. 2.8 Intestinal malrotation. US study shows abnor- is less dilated and less peristaltic than in other
mal relationship between the superior mesenteric artery
and superior mesenteric vein, the latter seen to the left of
small bowel atresias. The most important finding
the artery is the characteristic appearance of the dilated
bowel loops, which contain abnormal meconium:
the thick meconium sticks to the bowel walls,
dependence on total parenteral nutrition in survi- resulting in a pseudo-thickening. The distal
vors with short bowel syndrome. bowel loops, in the right lower quadrant, are
Therefore, learning to recognize the US find- small (34 mm), with a target-like appearance
ings of midgut volvulus is imperative: the volvu- due to impacted meconial pellets.
lus is responsible for a whirlpool-like appearance Hydrocolon is present in meconium plug syn-
on cross-sectional images, created when the drome and small left colon syndrome [2, 3, 19].
SMV and the mesentery wrap around the SMA in Besides being observed in small bowel obstruc-
a clockwise direction. Visualization is enhanced tion, hepatic, splenic, scrotal, and peritoneal calci-
by the vascular signal on color Doppler flow US fications are observed in meconium peritonitis
[2325] (Fig. 2.9). with single or multiple meconium pseudo-cysts
For the neonate with the classic appearance of and free intraperitoneal fluid [2, 3, 7, 8].
a whirlpool sign, additional imaging investiga- Occasionally US study highlights the cause of
tion is often unnecessary, and the surgeon should obstruction, either intrinsic (e.g., duodenal web)
be alerted to plan for emergency surgery. The or extrinsic (e.g., gastrointestinal duplication cyst
advantages of US for this age group are apparent, or annular pancreas).
since it can be performed at the bedside in inten- In anorectal malformations, the distance
sive care units and lacks the adverse effects of between the rectal cul-de-sac and the perineum
ionizing radiation. can be reliably measured with perineal US [13,
The diagnosis of neonatal bowel obstruction 26, 27]. Furthermore, US study can show associ-
or the confirmation of the prenatal diagnosis is ated genito-urinary tract and dysraphic abnor-
based on clinical and radiological signs on a plain malities; therefore, all patients with congenital
abdominal radiograph, occurring with a delay of anorectal malformations should have a genito-
1224 h; in very distal obstruction the signs may renal tract and spinal US examination as a screen-
appear even later. ing test in the early newborn period (Fig. 2.10).
US can contribute to the diagnosis of neonatal US is still not routinely used for the diagnosis
bowel obstruction with important additional infor- and follow up of NEC, but it can provide infor-
mation; first of all, it can document the obstruction, mation that is not provided by plain abdominal
showing severe distension of the proximal bowel radiography and that may affect the management
loops (diameter from 16 to 40 mm) with thin walls of NEC. Like radiography, US can depict intra-
and increased peristalsis, filled with fluid, and mural gas, portal venous gas, and free intraperito-
24 F. Carfagnini et al.

a b

Fig. 2.9 US study (a) with color Doppler (b) showing the whirlpool sign, with the superior mesenteric vein and mes-
entery wrapped around the superior mesenteric artery in a clockwise direction

a b

Fig. 2.10 Anorectal malformations. US of genital tract shows an associated didelphys uterus (a), while normal anat-
omy of the spinal cord on US spinal study (b) rules out occult myelodysplasia

neal gas; however, the main advantage of echogenicity of the full wall thickness; however,
abdominal US over plain abdominal radiography, this is a nonspecific sign, as it is also seen in other
including color Doppler US, is that abdominal causes of diffuse edema in the absence of inflam-
US can show intraabdominal fluid, bowel wall mation or ischemia.
thickness, and bowel wall perfusion [2831]. The third major advantage of abdominal US,
In NEC, the ability to depict abdominal fluid including color Doppler, in NEC is the ability to
is the first major advantage of US study over directly assess arterial perfusion of the bowel
plain abdominal radiography, showing whether wall, to infer the viability of individual loops.
the fluid is intraluminal or extraluminal and Three categories of flow are recognized on
whether it is free in the peritoneal cavity or is a color Doppler: normal, increased, and absent.
more localized fluid collection. The hyperemia is the result of the vasodilation of
The second major advantage of abdominal US mural and mesenteric vessels secondary to intes-
in NEC is its ability to visualize the bowel wall tinal inflammation, with specific flow patterns
directly and to assess bowel wall thickness, echo- (zebra pattern, Y pattern, and ring
genicity, and peristalsis. pattern).
With both bowel wall thickening and thinning Flow is absent when no color Doppler signals
the normal echogenicity of the wall (so-called gut are identified in the bowel wall.
signature) is lost and it may be difficult to differ- Thinning of the bowel wall and lack of perfu-
entiate the bowel wall from the echogenic intra- sion are highly suggestive of non-viable bowel
luminal content in severely affected loops. Bowel and may be seen before visualization of pneumo-
wall thickening is accompanied by increased peritoneum on plain abdominal radiography. As
2 Gastro-Intestinal Tract Radiology 25

mortality is higher after perforation, earlier other imaging techniques. Abdominal US is

detection of severely ischemic or necrotic loops, easily performed, readily available, and less
before perforation occurs, could reduce morbid- expensive than other imaging modalities, and
ity and mortality in NEC (Fig. 2.11). obviously it does not use ionizing radiation; the
US is the modality of choice to accurately fact that ionizing radiation is not used is essen-
diagnose or exclude intestinal intussusception, tial in pediatric patients with IBD, who are at
determining the location (ileo-ileal or ileo-colic) higher risk of increased diagnostic radiation
and the type (idiopathic or secondary to the pres- exposure than the general population, owing to
ence of a lead point), with a decisive impact on repetitive imaging. Unlike with MRI, sedation,
the therapeutic approach [13]. oral contrast, or bowel cleansing are not
Typical signs of intussusception are the tar- required with US.
get and the pseudo-kidney signs, respectively, Most published studies have found bowel US
on transverse and longitudinal planes. A small to be a valuable tool in children with suspected or
amount of intraperitoneal free fluid can often be known IBD [3235]. Bowel wall thickening is
seen and should not preclude a non-surgical the hallmark of intestinal disease: in the pediatric
reduction attempt. The lower success rates of age group, thicknesses greater than 2.5 mm and
non-surgical reductions are related to the pres- 2 mm, respectively, for the small and the large
ence of trapped fluid within the intussusception bowel are considered abnormal. A careful and
and the absence of flow on color Doppler in the attentive US examination also reveals the loca-
intussusception wall, indicative of vascular tion and extension of the involved segments, their
impairment of the bowel (Fig. 2.12). When these vascular features on color Doppler, and the extra-
signs are present enema reduction should be per- mural signs of disease, such as hyperechogenicity
formed with extreme caution, due to the high risk of the surrounding fat planes, regional lymphade-
of perforation. nopathy, abscesses, and fistulas; abnormal wall
Small bowel intussusceptions, in contrast to stratification and abnormal peristalsis can also be
intussusceptions of the large bowel, are transient, noted (Fig. 2.13).
asymptomatic, and relatively common. They are The correlation of these findings with the clin-
usually encountered around the periumbilical ical history and the laboratory data often permits
region, are small in diameter (less than 2 cm), and us to narrow the differential diagnosis, thus
tend to resolve spontaneously within a few directing further additional imaging.
minutes. Another important application of US in IBD is
The diagnostic role of US in IBD in children, in the follow-up of patients with known disease
and particularly in Crohns disease, continues to monitor treatment and to ensure early detec-
to increase, as it has several advantages over tion of intra-abdominal complications in relapse.

a b

Fig. 2.11 Necrotizing enterocolitis (NEC). Color Doppler sonography (a) shows two loops with a thickened bowel
wall and ring pattern with increased perfusion. Thinning bowel walls (b) are seen in a patient with a poor outcome
26 F. Carfagnini et al.

a b

Fig. 2.12 US study with color Doppler. Intestinal intussusception (a), with preserved vascular signal of the
intussusception with target appearance on tranverse loop on color Doppler US (b)
plane. Note the presence of lymph nodes within the

a b

Fig. 2.13 Crohns disease: bowel wall thickening with narrowed lumen (a) and hyperemia on color Doppler (b) of the
terminal ileum

Color Doppler US provides additional informa- peri-appendicular free fluid and/or fluid collec-
tion about disease activity and it may help to dis- tion. On color Doppler US, increased vascular-
tinguish between inflammatory and fibrotic ity of the appendicular wall is observed in early
bowel stenosis. inflammatory phases, whereas no flow can be
Appendicitis is the most common pediatric detected if the appendix is necrotic or
surgical emergency. US often provides a reliable perforated.
contribution to the diagnosis by supporting or Imaging is not necessary in every child sus-
excluding appendicitis; it is helpful in the differ- pected of having appendicitis, particularly in
ential diagnosis, thus avoiding unnecessary radi- boys with a clear clinical picture. Conversely, US
ation exposure when imaging is needed. is especially valuable in girls, in whom ovarian
Typical signs of appendicitis include an conditions must be considered in the differential
aperistaltic, noncompressible, dilated appendix diagnosis, which is difficult to achieve clinically.
(outer diameter greater than 6 mm) and white Mesenteric lymphadenitis is a self-limiting dis-
target appearance in axial section, sometimes order showing inflammation of mesenteric lymph
with appendicolith; other secondary changes nodes, caused by various types of bacteria, myco-
include echogenic prominent pericecal fat and bacteria, and viruses. It is a common cause of
2 Gastro-Intestinal Tract Radiology 27

abdominal pain in children, sometimes mimicking The primary characteristic of MRI must also
acute appendicitis. It should be noted that some be emphasized this is the obtaining of multipla-
mesenteric lymph nodes are commonly seen on nar images with high-resolution tissue contrast,
abdominal US in pediatric patients, even in those without the use of ionizing radiation.
who are asymptomatic, and the nodes are not nec- MRI for the study of the gastrointestinal tract
essarily related to any pathological process. sees continuous innovations, but the clinical indi-
Except for lymphoma, tumors of the small and cations are not always well defined. From this
large colon are rare in children. The most fre- point of view, the study of certain diseases of the
quent subtype of non-Hodgkin lymphoma occur- bowel, in particular chronic inflammatory dis-
ring in children is Burkitts lymphoma, and it eases, can be carried out with MRI, with its diag-
frequently affects the gastrointestinal tract, most nostic performance already established in the
commonly the ileocecal region and mesentery. literature, while MRI studies of the esophagus,
Burkitts lymphoma has a rapid growth and stomach, and colon are currently considered to be
can present with intestinal obstruction owing to experimental [36] (Fig. 2.14).
secondary intussusception. On US it is seen as a MRI imaging is now used for the study of
mass with low or heterogeneous echogenicity, extraluminal pathologies and for the study of
with low vascularity on color Doppler. oncological diseases.
Several other diseases may first come to atten- The use of MRI in the study of anorectal
tion during an abdominal US examination, abnormalities deserves special mention, par-
including intraluminal conditions, such as polyps ticularly in the preoperative evaluation of the
or abnormal content (such as in cystic fibrosis); newborn or infant prior to definitive pull-
bowel wall involvement in various inflammatory through repair surgery, and in the postoperative
(e.g., benign lymphoid hyperplasia), infectious review of the older pediatric patient with con-
(e.g., viral or bacterial enterocolitis), infiltrative, tinuing problems [27, 37]. Furthermore, when
and hematological (e.g. Henoch-Schonlein pur- the radiographic or US examination is abnor-
pura, graft versus host disease, neutropenic coli- mal, MRI can be used also to accurately depict
tis) conditions; or traumatic disorders. US may the likely associated intraspinal pathology,
also disclose other conditions, such as hernias, such as tethered cord, caudal regression syn-
Meckels diverticulum, duplication cysts, and drome, hydromyelia, or a lipoma of the termi-
other tumor and tumor-like conditions. nal filum.
Examination during sedation or spontaneous
sleep may provide more accurate estimation of
2.1.4 Magnetic Resonance the true level of an elevator sling.
Imaging (MRI) MRI allows direct visualization of the distal
rectum and related musculature (levator ani mus-
Gastrointestinal study is a relatively recent MRI cle, puborectal muscle, external sphincter) with-
application. For several years, in fact, the long out additional ionizing radiation, but with
acquisition times have limited the use of MRI in multiplanar capabilities (Fig. 2.15). Associated
the abdominal area, in which the study of struc- lesions such as sacrococcygeal hypoplasia and
tures with peristalsis led to low-quality diagnos- lumbar spine or renal anomalies can be evaluated
tic images because of the presence of motion [27, 39].
artifacts. The continuous technological develop-
ment of MRI, with a coil system gradient that Entero-MRI
currently allows us to capture images more MRI has good sensitivity and specificity for IBD
quickly, is best suited to gastrointestinal study in children. It is used to study the entire intestine,
[35]; however, the duration of the investigation is especially the small intestine, which still remains
still likely to require sedation in young children largely out of the range of the endoscope
and/or in those who are non-cooperative. (Fig. 2.16).
28 F. Carfagnini et al.

a b

Fig. 2.14 Magnetic resonance imaging (MRI): axial T2-weighted image (a) and coronal T2-weighted image (b) show
an ileal intraluminal filling defect (polypoid mass)

The survey preparation includes fasting from media are used for a better definition of the wall
the night before the study in larger children, and signal.
exclusive intake of clear liquids on the day of the The first acquisitions are possible after
examination. approximately 45 min from initiation of the con-
Entero-MRI also requires adequate bowel trast agent [40, 38].
distension, obtained through the oral adminis- Pharmacologically-induced hypotonia (with
tration of contrast medium. The contrast intravenous injection of hyoscine butylbromide)
medium used may be negative, positive, or is performed to reduce possible artifacts from the
biphasic. Biphasic media are preferred for better intestinal peristalsis and prolong the relaxation
visualization of the bowel wall; they consist of time of the small bowel.
aqueous solutions containing isoosmolar sub- The use of MRI in the study of anorectal
stances (polyethylene glycol) that possess the abnormalities deserves special mention, particu-
same intensity as the water signal, providing a larly in the preoperative evaluation of the newborn
high signal on T2-weighted sequences and a low or infant prior to definitive pull-through repair sur-
signal on T1-weighted sequences. These char- gery, and in the postoperative review of the older
acteristics make such media ideal in a digestive pediatric patient with continuing problems [27,
study, creating ideal conditions for contrast res- 37]. When the radiographic or US examination is
olution between the lumen and wall. Positive abnormal, then MRI can be used to accurately
contrast media, which were those used in the depict the likely associated intraspinal pathology,
past, have poor contrast resolution, and negative such as tethered cord, caudal regression syndrome,
2 Gastro-Intestinal Tract Radiology 29

a b

Fig. 2.15 Axial (a) and sagittal (b) T2-weighted MRI: apex directed posteriorly. Sagittal T2-weighted image (b)
postsurgical evaluation. Axial image shows left-sided shows the presence of an associated sacral anterior
puborectalis muscle that appears as a triangle with the meningocele

hydromyelia, or a lipoma of the terminal filum. paramagnetic contrast material with MRI can
Examination during sedation or spontaneous sleep provide information about the wall thickness and
may provide more accurate estimation of the true the presence of fixed bowel loops, and can detect
level of an elevator sling. MRI allows direct visu- superficial mucosal abnormalities, creases and
alization of the distal rectum and related muscula- ulcerations, abnormal wall morphology, and
ture (levator ani muscle, puborectal muscle, extraluminal abnormalities (lymphadenopathy,
external sphincter) without additional ionizing increased mesenteric vasculature, abscesses, and
radiation, but with multiplanar capabilities fistulas) [37, 40].
(Fig. 2.16). Associated lesions such as sacrococ-
cygeal hypoplasia and lumbar spine or renal
anomalies can be evaluated [27, 38]. 2.1.5 Computed Tomography (CT)
The administration of paramagnetic contrast
material by injection allows for proper evaluation CT investigation involves high doses of ionizing
of the intestinal walls; the enhancement follow- radiation, and in young patients it is therefore
ing injection of the contrast agent provides infor- reserved for cases in which it can be valuable for
mation on the activity of the disease and indicates diagnostic and therapeutic purposes and for man-
whether there is any hypervascularization of the agement, taking into account the ALARA (As Low
intestinal wall, as well as helping to distinguish As Reasonably Achievable) principle, according to
inflammatory processes by showing fibrotic which the administration of the lowest possible
aspects of thickened walls. The administration of radiation dose for the diagnostic purpose is planned.
30 F. Carfagnini et al.

a b

Fig. 2.16 Coronal MRI: T2-weighted dynamic FIESTA (a) and T1-weighted post-contrast image (b) show thickening
of the terminal ileum, with important contrast enhancement

Because of the relative poverty of intra- graphic findings and US doubts, or where more
abdominal adipose tissue, which greatly affects accurate morphological and anatomical assess-
contrast between different structures, we do not ment is required, especially in settings of
routinely acquire CT scans without contrast urgency, such as for the study of acute abdomi-
medium, as these would lack diagnostic sensitiv- nal conditions (complications of appendicitis or
ity. Thus, the CT scan is usually acquired only in cecal Meckels diverticula) or acute complica-
the portal-venous phase, with considerable sav- tions of chronic inflammatory conditions (bowel
ing of the radiation dose administered to the perforation, fistulas, or bleeding in Crohns dis-
patient. ease) [41].
Image acquisition during the arterial phase is In common clinical practice, CT angiography
reserved for cases where it is important to evalu- is frequently used for the evaluation of vascular
ate the arterial vascular anatomy or where it is thoracic and abdominal anatomy. A typical
necessary to typify extensive pathologies and example is that of research of abnormal vessels,
their relationships with vascular structures. one of the most frequently represented being an
The images are acquired with a 5-mm layer aberrant right subclavian artery (lusoria) origi-
thickness, and are subsequently reconstructed in nating directly from the medial aortic arch
the thinnest layer (12 mm), with the possibility profile; in these cases CT-depth investigation is
of multiplanar and three-dimensional (3D) performed after a pathological esophagogram
reconstructions. shows the classic compression sign, caused by
CT is therefore a level II methodology, and is the abnormal blood vessel, on the rear profile of
used exclusively to further elucidate radio- the proximal esophagus (Fig. 2.17).
2 Gastro-Intestinal Tract Radiology 31

a b c

Fig. 2.17 Upper gastrointestinal (UGI) lateral view (a) of (b) and three-dimensional (3D) (c) images on computed
the esophagus shows a pathological compression of the tomography (CT) study
rear profile of the proximal esophagus, confirmed by axial

Another characteristic indication for CT angi- sity barium contrast medium) is important to avoid
ography is in the study of suspected stenosis of the misinterpretation of normal collapsed seg-
mesenteric vessels or other pathological condi- ments for masses or wall abnormalities [4143].
tions that produce decisive changes in the normal The intravenous administration of iodinated
vascular anatomy. Examples are portal caver- contrast medium for entero-CT helps in the sub-
noma, a condition of pre-hepatic portal hyperten- sequent evaluation of the extension of tumor and
sion in the pediatric age group, where portal vein inflammatory disease of the intestinal walls, and
thrombosis occurs with subsequent arterializa- also helps in the evaluation of blood vessels and
tion of the hepatic blood flow and the progressive abdominal organs (Fig. 2.20).
development of portal systemic shunt in typical Pharmacologically-induced hypotonia of the
locations (Fig. 2.18). bowel to prevent movement artifacts is not indi-
CT scans are also used in the evaluation of cated beacuse of the high speed of scanning of
masses, especially in the thoracic region, and for modern CT equipment.
the staging of tumors (Fig. 2.19); the most com- In adult patients, entero-CT is used in both
mon form of tumor in children is undoubtedly the acute setting of acute small bowel obstruc-
Burkitt's lymphoma. tion and in the elective situation with respect to
Finally, entero-CT deserves particular mention. IBD and the investigation of small bowel tumors.
This is the investigation used in the evaluation of However, its use in children has remained lim-
the extension and complications of IBD, particu- ited due to the radiation burden, and MRI of the
larly Crohns disease, and which allows us to small bowel is now the preferred technique in
obtain a simultaneous display of both luminal and children.
extraluminal pathology, such as the presence of The benefits of CT when compared with MRI
fistulae or abscesses. Adequate opacification and include better spatial resolution, fewer motion-
distension of the bowel loops with an oral contrast related artifacts, increased availability, reduced
medium (most commonly water or oral low-den- cost, and shorter examination time. The benefits
32 F. Carfagnini et al.

a b

Fig. 2.18 Axial and coronal CT images show the presence of portal cavernoma (a) and collateral venous vessels due to
a portal systemic shunt (b, c)
2 Gastro-Intestinal Tract Radiology 33

Fig. 2.19 Coronal CT image shows an esophageal


a b

Fig. 2.20 Axial (a) and coronal (b) CT images show a pathological thickening of the terminal ileum
34 F. Carfagnini et al.

of MRI include better contrast resolution and the 14. Fonio P, Coppolino F, Russo A et al (2013)
Ultrasonography (US) in the assessment of pediatric
lack of ionizing radiation. It should be remem-
non traumatic gastrointestinal emergencies. Crit
bered that Crohns disease is a chronic disease Ultrasound J 5(suppl 1):S12
and any such patient is likely to be imaged more 15. Hernanz-Schulman M (2009) Pyloric stenosis: role of
than once, so the cumulative radiation dose must imaging. Pediatr Radiol 39:S134S139
16. Leaphart CL, Borland K, Kane TD et al (2008)
be considered by the pediatric radiologist in this
Hypertrophic pyloric stenosis in newborns younger
context. Recent studies have demonstrated simi- than 21 days: remodeling the path of surgical inter-
lar sensitivities for CT and MRI in the detection vention. J Pediatr Surg 43:9981001
of small bowel Crohns disease [4145]. 17. Huang YL, Lee HC, Yeung CY et al (2009) Sonogram
before and after pyloromyotomy: the pyloric ratio in
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gastrografin enema factors that contribute to success- 27. McHugh K (1998) The role of radiology in children
ful reduction. Pediatr Radiol 35:S97S98 with anorectal anomalies; with particular emphasis on
10. Jamieson DH, Dundas SE, Belushi SA et al (2004) MRI. Eur J Radiol 26:194199
Does the transition zone reliably delineate agangli- 28. Kim WY, Kim WS, Kim IO et al (2005) Sonographic
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34:811815 enterocolitis. Pediatr Radiol 35:10561061
11. Jester I, Holland-Cunz S, Loff S et al (2009) Transanal 29. Epelman M, Daneman A, Navarro OM et al (2007)
pull-through procedure for Hirschsprungs disease: a Necrotizing enterocolitis: review of state-of-the-art
5-year experience. Eur J Pediatr Surg 19:6871 imaging findings with pathologic correlation.
12. Sizemore AW, Rabbani KZ, Ladd A et al (2008) Radiographics 27:285305
Diagnostic performance of the upper gastrointestinal 30. Silva CT, Daneman A, Navarro OM et al (2007)
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13. Lobo ML, Roque M (2014) Gastrointestinal ultra- 31. Faingold R, Daneman A, Tomlinson G et al (2005)
sound in neonates, infants and children. Eur J Radiol Necrotizing enterocolitis: assessment of bowel viabil-
83:15921600 ity with color doppler US. Radiology 235:587594
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32. Horsthuis K, Stokkers PC, Stoker J (2007) Detection 39. Borthne AS, Abdelnoor M, Rugtveit J et al (2006)
of inflammatory bowel disease: diagnostic perfor- Bowel magnetic resonance imaging of pediatric
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33. Spalinger J, Patriquin H, Miron MC et al (2000) 16:207214
Doppler US in patients with Crohn disease: vessel 40. Lohan D, Cronin C, Meehan C et al (2007) MR small
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Diagnostic and Therapeutic
Giovanni Di Nardo, Giuseppe Pagliaro,
and Andrea Pession

3.1 Introduction performed. Laboratory tests are not required in

the pre-procedure assessment and need only be
3.1.1 Pre-procedure Preparation performed for clinical indications.
Endocarditis prophylaxis should be consid-
Physiologic issues (the emotional and psychoso- ered in patients with congenital heart disease; in
cial well-being of both patients and their caregiv- particular, those with significant valve lesions
ers) have an important role in preparation for and those with surgically placed shunts or artifi-
endoscopy in pediatric patients. Informed consent cial material in their circulation. Routine endos-
should be obtained from a parent or guardian or copy with or without biopsy does not warrant
from older children when appropriate. According antibiotic prophylaxis.
to the American Academy of Pediatrics (AAP), a The AAP guideline on sedation in pediatric
pre-procedure health evaluation specific to patients, with presumed normal gastric emptying,
elective procedures should be obtained, and it advises fasting for a minimum of 2 h after ingest-
includes a health history, American Society of ing clear liquids, from breast milk for 4 h and
Anesthesiology score of physical status, medica- from formula, nonhuman milk, and solids for 6 h
tion history, allergy assessment, age, weight, and before elective sedation. The risks of sedation
baseline vital signs. A physical examination without appropriate fasting in emergent cases
including a focused assessment of the heart, cir- must be weighed against the necessity for the
culation, lungs, head, neck, and airway should be procedure and the expected benefit.

3.1.2 Intra-procedural Sedation

G. Di Nardo (*) and Monitoring
Pediatric Gastroenterology Unit, International
Hospital Salvator Mundi, Rome, Italy Almost all gastrointestinal (GI) procedures in chil-
dren are performed using endoscopist-administered
A. Pession moderate sedation or anesthesiologist-administered
Pediatric Units, S. Orsola-Malpighi Hospital,
University of Bologna, Bologna, Italy deep sedation and general anesthesia to ensure
patient safety and comfort. Premedication with
G. Pagliaro
Pediatric Gastroenterology Unit, either oral (0.5 mg/kg) or intranasal (0.2 mg/kg)
Sapienza, University of Rome, Rome, Italy midazolam allows easier intravenous line

Springer International Publishing Switzerland 2017 37

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_3
38 G. Di Nardo et al.

placement and division from parents particularly in the endoscopy or sedation. Vital signs and oxy-
selected group of children with a high level of anxi- gen saturation should be monitored at specific
ety before sedation. intervals. The child should be easily awake, pro-
Routine oxygen supply is a low-cost, high- tective reflexes should be intact, and speech and
benefit practice because data suggest that a sig- ambulation appropriate for age should have
nificant number of children could have transient returned to pre-sedation levels. Patients who
apnea and oxygen desaturation during sedation have received reversal agents (e.g., flumazenil,
for endoscopy. naloxone) may require longer periods of obser-
Although the short duration of most endoscopic vation as the half-life of the sedative may exceed
procedures does not contribute to dehydration or that of the reversal medication leading to
hypothermia, children should be well draped, and resedation.
room temperatures should be appropriately Before discharge, specific written and verbal
adjusted to avoid these possibilities. instructions and information should be given to a
Neurologically impaired patients can be par- parent, legal guardian, or other responsible adults.
ticularly susceptible to benzodiazepines and opi- This should include signs and symptoms of poten-
ate/benzodiazepine associations. Administration tial adverse events, steps to follow in the event of an
of sedation in children should always be weight adverse event, and a phone number at which 24-h
based and usually titrated by response, allowing coverage is available. Special instructions to observe
adequate time between doses to assess effects the childs head position to prevent airway occlu-
and the need for additional medication. Higher sion should be given in cases in which the child will
relative doses may be finally required in the pre- travel in a car seat. In such cases, it may be prefer-
school, elementary, and pre-teenage groups com- able to have more than one adult who accompanies
pared with teenage patients. the child on the day of the procedure.
The AAP guidelines recommend continuous In this chapter, we will describe technique,
pulse oximetry and heart rate monitoring at all indication, and potential complications of the
levels of sedation by a dedicated trained atten- main diagnostic and therapeutic endoscopic
dant who is specifically assigned to monitor the procedures available for pediatric population
patients vital signs. Most pediatric gastroenter- [13].
ologists are well trained and certified to provide
moderate sedation, and most procedures can be
safely performed outside the operating room. 3.2 Esophagogastroduodenoscopy
However, because the high frequency of progres-
sion to deep sedation, personnel trained specifi- 3.2.1 Indications and Contraindications
cally in pediatric rescue maneuvers including
airway management and pediatric advanced life Common indications for esophagogastroduode-
support should be readily available. noscopy (EGDS) in children are summarized in
All supplies necessary to rescue any child Table 3.1. Diagnostic EGDS may be specifically
experiencing cardiovascular complications dur- indicated to evaluate common pediatric conditions
ing a procedure should be readily available in any such as allergic, infectious, or peptic esophagitis,
unit performing pediatric procedures. infectious or inflammatory gastritis, and celiac dis-
ease. Infants and children are unlikely to localize
their symptoms to the upper GI tract; a number of
3.1.3 Post-procedure Monitoring nonspecific signs and symptoms (failure to thrive,
and Discharge unexplained irritability, and anorexia) may moti-
vate upper endoscopy in young children.
After conclusion of endoscopic procedures, chil- Two other common pediatric diseases that
dren should be monitored for adverse effects of may require endoscopy are the ingestion of
3 Diagnostic and Therapeutic Endoscopy 39

Table 3.1 Common indications for upper endoscopy in magnets, was recently published and endorsed
by the North American Society of Pediatric
Diagnostic Gastroenterology, Hepatology, and Nutrition.
Dysphagia In cases of witnessed ingestion of caustic sub-
Odynophagia stances in which patients are manifesting symp-
Intractable or chronic symptoms of GERD toms, upper endoscopy should be performed to
assess for esophageal, gastric, and duodenal injury.
Persistent epigastric pain
Universal performance of EGD in the setting of
Unexplained irritability
unwitnessed caustic ingestion without evidence of
Weight loss/failure to thrive
oropharyngeal injury is controversial, especially in
Anemia (unexplained) asymptomatic patients. However, there is a well-
Diarrhea/malabsorption (chronic) recognized lack of correlation between symptoms
Gastrointestinal bleeding of caustic ingestion and degree of esophageal
Caustic ingestion injury. Endoscopy within 24 h of caustic ingestion
Therapeutic is usually considered safe and provides important
Foreign-body removal prognostic information.
Stricture dilation EGDS is usually not recommended in infants
Esophageal variceal ligation for the evaluation of uncomplicated gastroesoph-
Upper GI bleeding control ageal reflux disease (GERD) or congenital hyper-
Adapted by Ref. [1] trophic pyloric stenosis. It is also generally not
indicated in older children for evaluation of func-
tional GI disorders, including self-limited
foreign bodies and caustic substances. The proto- abdominal pain.
col for endoscopic evaluation of foreign body Upper endoscopy is a safe procedure in other-
ingestion is similar to that in adults and has been wise healthy children 1 year of age and older,
well described elsewhere. Compared with stan- although discharge instructions should address
dard practice in adults, it is generally recom- sore throat and hoarseness, which may occur after
mended that foreign body removal in children the procedure in as many as one third of patients.
should be done while they are under general There are few contraindications to perform
anesthesia with endotracheal intubation to pro- endoscopic procedures in children. The size of
tect the airway from aspiration. Emergent foreign the patient is rarely a contraindication, and upper
body removal in children is indicated for any endoscopic examinations can be performed
symptomatic esophageal foreign body and for safely in neonates as small as 1.52 kg. Relative
asymptomatic esophageal button batteries contraindications include coagulopathy, neutro-
because of the high risk of esophageal tissue penia, and unstable cardiopulmonary disease. In
necrosis and risk of fistula formation. Another patients with these conditions, it is important to
increasingly common indication for emergent ascertain whether the benefits of performing the
foreign body removal in children is ingestion of procedure outweigh its risks.
powerful magnets, often manufactured as toys.
Ingestion of two or more magnets has been
associated with significant risks of obstruction, 3.2.2 Equipment Requirements
perforation, and fistula development of the
upper and lower GI tracts, necessitating surgi- The technical aspects of performing upper
cal intervention and even bowel resection. An endoscopy are essentially the same in children
algorithm to assist emergency department phy- and adults. The main difference is the smaller
sicians and gastroenterologists in providing endoscopy equipment necessary to evaluate the
timely care, including endoscopic removal of smaller and more angulated anatomy of infants
40 G. Di Nardo et al.

Table 3.2 Neonatal and pediatric gastroscopes

Insertion tube (length/ Definition/magnification/color (diameter,
Manufacturer Model diameter, mm) enhancement mm)
Olympus GIF-N180 1100/4.9 Standard/none/NBI 1/2.0
GIF-XP 180N 1100/5.5 Standard/none/NBI 1/2.0
Fujinon EG530N 1100/5.9 High-definition/zoom/ 1/2.0
EG530NP 1100/4.9 High-definition/zoom/ 1/2.0
Pentax EG1690K 1100/5.4 Standard/zoom/iSCAN 1/2.0
EG1870K 1050/6.0 Standard/zoom/iSCAN 1/2.0
Adapted by Ref. [2]
NBI narrow-band imaging

Table 3.3 Equipment compatible with pediatric 3.2.3 Technique

Small biopsy forceps The patient lies on the left side with the chin
Small polyp snare tucked against the chest and the bite guard placed
Pediatric roth net between the teeth. Several methods can be used
Small alligator forceps to insert the endoscope. The safe way is under
Small rat-tooth forceps direct vision.
Small injection needle
Under direct vision (Fig. 3.1a, b), the instru-
Small argon plasma coagulator probe
ment tip is advanced to the larynx, and the open
Two-prong graspers
glottic aperture is visualized (Fig. 3.1c). A slit can
Adapted by Ref. [2]
be recognized between the posterior wall of the
hypopharynx and the cuneiform and corniculate
and young children. The newborn esophagus tubercles (Fig. 3.1d). This slit leads to the upper
measures 810 cm in length and approximately esophageal sphincter, which curves gently around
5 mm in diameter. In addition, the antrum and the posterior side of the cricoid cartilage. The
proximal duodenum may be more angulated in instrument tip should pass a little to the left or right
young children. Although standard adult endo- of the midline (Fig. 3.1e), taking care not to devi-
scopes are generally safe in children weighing ate into either piriform recess. The esophageal
more than 25 kg, there are a number of com- lumen becomes visible for a brief moment, and the
mercially available endoscopes less than 6 mm tip is advanced into the esophagus (Fig. 3.1f).
in diameter with the necessary tip deflection In the blind insertion method, the endoscope is
that should be used in infants and children first passed over the base of the tongue toward the
weighting less than 10 kg (Table 3.2). hypopharynx under external visual control. Care is
Gastroscopes 6 mm are recommended in chil- taken that the endoscope tip is not retroflexed
dren below 2.5 kg and preferred in children toward the nasopharynx and does not deviate to
below 10 kg. Standard adult gastroscopes may the left or right into the piriform recess. The instru-
be considered in children of 2.510 kg only if ment tip can be gently advanced just to the introi-
endotherapy is required. In children above tus of the upper esophageal sphincter. Following
10 kg, standard adult gastroscopes can be toler- initial resistance, a distinct give is felt as the
ated. The main limiting factor with all pediatric endoscope slips into the upper esophagus. Once
endoscopes is the small working channel the instrument tip is within the esophagus, the
(2.0 mm) that makes suctioning more difficult insertion is continued under endoscopic vision.
and limits their use for therapeutic maneuvers. In both methods (blind and direct vision inser-
Table 3.3 lists equipment compatible with most tion), there is always a short segment of the
of pediatric endoscopes. esophagus that must be traversed without vision.
3 Diagnostic and Therapeutic Endoscopy 41

a b c

d e f

Fig. 3.1 Endoscopic view showing the different phases of the under vision insertion method

The upper esophageal sphincter appears as a Endoscopy is the best procedure to evaluate
lip-shaped eminence surrounding a transversely the gastroesophageal junction. The endoscopist
oriented, slit-like lumen. The cervical esophagus identifies and evaluates the sphincter itself, the
is a straight, collapsed tube that appears largely diaphragmatic hiatus in relation to the incisor
featureless at endoscopy. Air insufflation distends teeth, and the transitional region between the
it to a round, symmetrical lumen that is affected squamous epithelium of the esophagus and the
very little by respiratory movements. columnar epithelium of the stomach, which are
The aorta indents the middle esophagus from separated by a visible junction called the Z-line.
the lateral side and runs almost horizontally as it It has an important role to assess whether the
crosses the esophagus. The left main bronchus lower esophageal sphincter is competent or
indents the esophagus from the anterior side just incompetent, although this assessment varies
below the aortic arch. In the endoscopic image, it considerably among different examiners.
runs obliquely downward in a counterclockwise The first region that is seen after entry is the
direction. The aorta and bronchus could not be junction of the fundus and body of the stomach.
always recognized. Unusual shapes are occasion- To improve vision, air is insufflated, the lesser
ally noted in thin patients. curvature being on the right and the angulus in
The retrocardiac esophagus appeared just distance. When liquids are present, suction is
below the middle esophageal constriction. This used to reduce aspiration risk. At this point, it is
portion of the esophagus is compressed anteri- better to rapidly progress in the duodenum to
orly by the left atrium and posteriorly by the avoid traumatic lesions and the overinflation
aorta, resulting in an elliptical lumen. Distinct required for retrovision. Progression is made
pulsations could be documented. with a clockwise rotation of 90, bending the tip
The lumen of the distal esophagus again upward (Fig. 3.2a). This double maneuver brings
appears round and symmetrical. The lower the pylorus into view. To put the pylorus in the
esophageal constriction is visible in the distance. antrum axis, the tip is angled down. The shaft is
The muscular contraction and accompanying then advanced toward the pylorus, which will
venous plexus create a typical endoscopic picture open with the help of air insufflation. The intuba-
of longitudinal folds with concentric luminal tion of the pylorus is achieved with the tip slightly
narrowing. bent down and right. A view of pale mucosa of
42 G. Di Nardo et al.

a b c

Fig. 3.2 Schematic view of the endoscopic maneuvers the tip in front of the duodenal angle; it is then bent to the
required for advancing the endoscope in the stomach and right and up; (c) withdrawal is necessary to obtain an opti-
duodenum. (a) Progression is made with a clockwise rota- mal view, because of the paradoxically progression of the
tion of 90, bending the tip upward; (b) pushing will bring endoscope owing to the straightening of the gastric loop

the bulb is achieved by withdrawal and air insuf- shafts axis will permit visualization of the greater
flation, the anterior wall placed to the left and the curve and the fundus (Fig. 3.3be). A key difference
posterior wall to the right. The superior duodenal between pediatric and adult diagnostic procedures is
angle is visualized before passage to the second that routine tissue sampling (usually performed dur-
portion of the duodenum. This progression is ing the withdrawal phase) is performed in children
usually carried out blindly because of the sharp from at least the duodenum, stomach, and esopha-
angle and needs to be made with care. Pushing gus during EGDS. It is standard pediatric endoscopy
will bring the tip in front of the duodenal angle; it practice to obtain biopsy specimens, even in the
is then bent to the right and up (Fig. 3.2b). At last, absence of gross abnormalities, because the risks of
withdrawal is normally necessary to obtain an sedation and performing repeat endoscopy in pediat-
optimal view, because of the paradoxically pro- ric populations are considered to outweigh the risks
gression of the endoscope owing to the straight- of obtaining biopsy specimens. Several studies have
ening of the gastric loop (Fig. 3.2c). Sometimes, also shown that it may be particularly difficult to rule
rectification of the last maneuver is needed with out clinically significant disease based only on endo-
deflection of the tip upward and to the left. scopic appearance of the upper GI tract in children,
During the withdrawal, a careful mucosal exami- and biopsies during pediatric EGDS are generally
nation is performed using circumferential move- considered necessary even in the absence of any
ments with air insufflation to provide a well-distended macroscopic endoscopic findings.
mucosa and to improve visualization of possible
small lesions. A retrovision maneuver in the stom-
ach is the best way to fully visualize the fundus, the 3.2.4 Complications
lesser curvature, and the cardia (Fig. 3.3). While it is
in the back portion of the proximal antrum, a 180 Although about one third of pediatric patients
210 angulation is necessary to bring into the view presented sore throat or hoarseness after EGDS
the angulus and the lesser curvature (Fig. 3.3a). under general anesthesia, all other reported com-
Keeping the angulation, a 180 rotation around the plications are uncommon particularly (less than
3 Diagnostic and Therapeutic Endoscopy 43

a b c

d e

Fig. 3.3 Schematic (a, b, c) and endoscopic view (d, e) of the retrovision maneuver

1 %) when performed by well-trained pediatric suspected perforation, surgical referral is urgent

equip. They are mostly related to the anesthesia to choose a conservative or a surgical approach.
and infrequently to the procedure itself. Hypoxic Intramural duodenal hematoma has been
episodes and aspiration are always possible under described after endoscopic biopsies and occurs
deep sedation. Allergic patients could react to the more frequently in children than in adults. The
medications or to the latex. Finally, rare compli- clinical presentation mimics abdominal occlu-
cations are hypotension, arrhythmia, and malig- sion, it is frequently associated with pancreatitis
nant hyperthermia. and always resolves spontaneously between 4
Complications related to the endoscopic pro- days and 2 weeks with fasting nasogastric suction
cedure include perforation, parietal hematoma, and fluid replacement. Surgical drainage is
embolism, and infection. Perforation principally unnecessary and therefore contraindicated. Fatal
involves the esophagus; it is due to therapeutic massive embolism has been reported in two chil-
endoscopy and its signs could appear with some dren with Kasai procedure because of potential
delay. To minimize this risk, it is mandatory to vessel leakage. Infectious complications can
never push forward without vision. In case of result from the patients own flora, from patient
44 G. Di Nardo et al.

to patient by the endoscope and between the cific abdominal pain, constipation with or without
patient and the staff. This seems rare and can be impaction, and inflammatory bowel disease that
seen in cardiac-risk patients; therefore, prophy- is responding to treatment.
lactic antibiotics are suggested only to selected There are few contraindications to perform
patients [4, 5]. colonoscopy in children. The size of the patient is
rarely a contraindication, and lower endoscopic
examinations can be performed safely in neonates
3.3 Colonoscopy as small as 1.5 to 2 kg. Diagnostic colonoscopy is
absolutely contraindicated in anyone with fulmi-
3.3.1 Indications and Contraindications nant colitis, toxic megacolon, or suspected perfo-
rated bowel. Recent intestinal resection represents
In the last years, colonoscopy has become a a possible contraindication to the examination.
routine procedure also for pediatric patients. It Relative contraindications include coagulopathy,
is safely used in all groups of children, includ- neutropenia, and unstable cardiopulmonary dis-
ing newborns. Common indications for colo- ease. In patients with these conditions, it is impor-
noscopy are shown in Table 3.4. There is no tant to ascertain whether the benefits of performing
pediatric colon cancer screening guideline, and the procedure outweigh its risks.
therefore patient volume of pediatric colonos-
copies at the population level is far lower than
that of adults. Uncommon, but nevertheless 3.3.2 Equipment Requirements
critically important, indications for colonos-
copy in children include surveillance for neo- Although the instruments are similar, pediatric
plasia in children with long-standing colonoscopy is different from adults in many
inflammatory bowel disease and hereditary pol- aspects such as preparation, sedation, technique,
yposis syndromes as well as for graft-versus- and spectrum of therapeutic manipulations. First
host disease. at all, in contrast to adults, endoscopic examina-
Colonoscopy is not recommended in children tions in children are usually performed under deep
with acute self-limited diarrhea, stable recog- sedation or general anesthesia to reduce emotional
nized irritable bowel syndrome, chronic nonspe- stress caused by separation from parents and the
preparation for the procedure itself. Moreover, in
children, colonoscopy is usually performed by
specialized pediatric gastroenterologists. However,
Table 3.4 Common indications for colonoscopy in
children surgeons or adult gastroenterologists may be con-
sulted for advanced or therapeutic endoscopy in
Chronic or profuse diarrhea
pediatric patients. Knowledge of the equipment
Lower GI bleeding available for use in smaller patients, primarily
Polyposis syndrome (diagnose and surveillance) those weighing less than 1015 kg, is required.
Failure to thrive/weight loss Pediatric colonoscopes have variable insertion
Lower GI tract lesions seen on imaging studies tube lengths (133170 cm), shaft diameters (9.8
Rejection of intestinal transplant 11.8 mm), and channel size (2.83.8 mm). Pediatric
Abdominal pain (clinically significant) colonoscopes with a shaft that can be stiffened as
Therapeutic needed are also available. These variable-stiffness
Polipectomy colonoscopes were designed to improve the ease of
Stricture dilation insertion by reducing looping in more mobile sec-
Hemostasis tions of bowel with the ability to maintain flexibil-
Foreign-body removal ity in more fixed sections. There are no published
Adapted by Ref. [1] data to support colonoscope choice in children, but
3 Diagnostic and Therapeutic Endoscopy 45

recommendations based on experience state that bowel preparations by using PEG-3350 without
the lower weight limit for the use of a standard electrolytes in children.
adult or pediatric colonoscope is 1215 kg. In chil- We have recently confirmed that low-volume
dren weighing between 5 and 12 kg, colonoscopy PEG preparations and sodium picosulphate plus
can be performed by using infant or standard adult magnesium oxide plus citric acid preparations
gastroscopes. Children weighting less than 5 kg (NaPico + MgCit) are a good alternative to the
may undergo successful ileocolonoscopy with standard PEG solutions for bowel preparation in
ultrathin gastroscopes, although this can be techni- children due to their comparable safety and effi-
cally challenging because of the flexibility of the cacy profile. Moreover, NaPico + MgCit-based
insertion tube. Pediatric colonoscopes with a work- preparations appeared to be more tolerated, rep-
ing channel of 2.8 mm will not accommodate resenting a promising regimen for bowel prepara-
larger accessories (e.g., jumbo biopsy forceps). tion in children [6, 7].

3.3.3 Bowel Preparation 3.3.4 Technique

Bowel cleansing for colonoscopy in pediatric Patient is placed in the left lateral decubitus posi-
patients must prioritize safety and compliance tion. Complete colonoscopy can be performed
and should take into account patients age, clini- successfully in the majority of children. Many
cal status, and anticipated willingness or ability factors can influence and complicate the proce-
to comply. To date, bowel preparation regimens dure, e.g., redundant large intestine, improper
for children have not been standardized and vary preparation, or previous surgeries. General prin-
greatly among medical centers and individual ciples of a safe and effective colonoscopy include:
practitioners. Ingestion of clear liquids for 24 h
and a normal saline solution enema (5 mL/kg) The intubated colon adopts configuration and
may be sufficient for infants younger than 2 years shape according to manipulations and move-
of age. For children older than 2 years of age, ments with the colonoscope, and the pattern of
cleansing can be accomplished with intestinal these changes are predictable, as well as the
lavage by using osmotic agents, such as polyeth- direction in which the colonoscope tip should
ylene glycol solutions with and without electro- be moved.
lytes, dietary restrictions, and stimulant laxatives, Rotation, twisting, withdrawal, deflation, and
such as senna and bisacodyl, and/or enemas. simultaneous to and from movements of the
Polyethylene glycol with electrolytes is used shaft will prevent formation of big loops
as the primary agent for bowel cleansing; most (Fig. 3.4), mesenteric stretching, and related
children will require approximately 80 mL/kg of abdominal pain and discomfort.
the solution. Most will also be unlikely to ingest Excessive insufflation leads to overdistension
sufficient volume because of its noxious taste. and diminishes ability to telescope the bowel.
Administration of polyethylene glycol with elec- Excessive pushing forward creates more prob-
trolytes via a nasogastric tube in a hospital setting lems than benefits.
for 24 h before the procedure is a safe and appro-
priate treatment, especially in children younger The principles of pediatric colonoscopy are
than 6 years of age. PEG-3350 without electro- similar to those in adults, but should be more
lytes in doses as much as 10 times higher than acute because of the childs small stature and
those recommended for standard treatment of angulations. In the child, it is frequently possible
constipation is emerging as the preparation of to palpate a loop of the scope in the abdomen, a
choice in many pediatric units. Several studies clue that instrument withdrawal and straighten-
have reported on the safety and efficacy of 4-day ing are needed. Meticulous attention to technique
46 G. Di Nardo et al.

a b c

Fig. 3.4 Schematic view of the loops that may form during colonoscopy. N-loop (a), alpha-loop (b) and gammaloop (c)

is required in children because the colon wall is difficulties with sedation (such as paradoxical
thin, and, in the presence of anesthesia using pro- reaction to the agent used).
pofol, there should not be any noticeable feedback Bowel perforation and hemorrhage related
from the patient that would provide a clue as to to pediatric colonoscopy are serious but rare
pain or discomfort from an overstretched mesen- complications. During diagnostic colonos-
tery or overdistended bowel. copy, the estimated frequency of colonic per-
The key to effective colonoscopy is to minimize foration, most commonly in the sigmoid, is in
pain and discomfort. It is critical to try and keep the the range of 0.20.8 %. The frequency is
lumen of the bowel in sight knowing where the tip higher with therapeutic colonoscopy proce-
of the colonoscope is and trying to keep the colo- dures such as polypectomy but is still compar-
noscope straight with avoidance of loops. atively rare ranging from 0.5 to 3 %. Mortality
The mucosal pattern of the colon is best studied is extremely low and should be substantially
as the instrument is slowly withdrawn. However, less than 0.2 %.
we believe that it is important to carefully pay
attention at the mucosa while advancing forward,
since trauma could sometimes occur to the mucosa 3.4 Capsule Endoscopy
with the passage of the instrument, and, if abnor-
malities are not identified beforehand, one is 3.4.1 Introduction
always left wondering whether what one sees is
due to colonoscopy vs. the underlying pathology. Since 2001, when it was introduced, capsule
An additional difference between pediatric endoscopy (CE) has become widely adopted as a
and adult diagnostic procedures is that routine clinical tool in the evaluation of small bowel dis-
tissue sampling is performed in children from at ease. Though the first pediatric studies were initi-
least from the colon and terminal ileum. ated in that year, marketing clearance for CE in
pediatric patients 10 years of age and older by the
US Food and Drug Administration, the Health
3.3.5 Complications Canada, and the European Medical Agency did
not occur until 2003. Supported by additional
The potential risks and complications of colonos- experience in children as young as the age of
copy include bleeding, perforation, infection, and 10 months, the Food and Drug Administration
3 Diagnostic and Therapeutic Endoscopy 47

(FDA) expanded the role for CE for the use in now for capsule endoscopy. Suspicious nonspe-
children ages 2 years and older in 2009, approved cific lesions and bulges seen with CE are being
the use of a patency capsule for this same age further explained when pathologic samples are
group, and has now approved mucosal healing as obtained with biopsy or surgical removal.
an additional indication.
Because CE avoids ionizing radiation, deep
sedation, or general anesthesia required by other 3.4.2 Small Bowel Capsule
imaging methods, CE has the potential to be par-
ticularly valuable in pediatrics. Most of the small Indications and Contraindications
bowel has been inaccessible for mucosal evalua- Guidelines have been promulgated regarding the
tion, and much of our knowledge of small bowel indications for CE use by societies such as the
disorders has been dependent on laboratory American Society for Gastrointestinal Endoscopy.
manifestations which are often surrogate mark- In pediatrics, the suspicion of CD and evalua-
ers, radiographic studies which provide indica- tion of existing inflammatory bowel disease
tions of more advanced disease and surgical/ (IBD) are the most common indications, fol-
pathological teachings that provide much infor- lowed by obscure/occult gastrointestinal bleed-
mation about severe conditions but a limited ing (OGIB), abdominal pain/diarrhea, and
understanding of their prelude and potential for polyposis (Fig. 3.5). Even within the pediatric
medical treatment. The recent developments population, clinical indications are age-stratified
with deep enteroscopy are difficult and invasive (Table 3.5). The approved indications for the
in children and as yet insufficiently evaluated pediatric and adult populations may expand as
with the indication for their use often abnormali- the broader utility of the capsule is recognized.
ties that are initially seen on the less invasive CE. Already, the capsule is useful to diagnose allergic
In many ways, this first decade of small intes- disorders, a newly recognized enteropathy in cys-
tinal CE has presented the equivalent of the tic fibrosis, and to evaluate unrecognized causes
expansion of knowledge that occurred when tradi- of abdominal pain. The capsule could be used in
tional endoscopy was introduced. Then, clinicians monitoring medical therapy in Crohns disease
began to realize the different visual manifesta- and graft-versus-host disease. The finding of
tions of gastroduodenal and colonic diseases that jejunal lesions in ulcerative colitis and the use of
could not be appreciated radiologically or patho- the capsule to differentiate patients thought to
logically. Additionally, visual findings were grad- have indeterminate colitis (IBD-U) and nonspe-
ually able to be explained and then associated cific colitis prove to be valid uses of CE espe-
with known conditions. The same appears true cially before a colectomy is performed. Though

a b c

Fig. 3.5 Capsule endoscopic findings of small bowel polyp (a), ulcers (b) and active bleeding from Angiodysplasia (c)
48 G. Di Nardo et al.

Table 3.5 Clinical indications for CE by age

Adult Pediatric Age <8 years
Procedures (n) 22,840 1013 83
OGIB + IDA (%) 66 15 36
CD/UC/IC (%) 10 63 24
Abdominal pain (%) 11 10 14
Polyps/neoplasms (%) 3 8 -
Others (%) 10 4 25
CD Crohns disease, IDA iron deficiency anemia, OGIB obscure gastrointestinal bleeding, IC indeterminant colitis, UC
ulcerative colitis

CE may not change the decision regarding sur- Technical Aspects
gery (though it has done that), CE may alter the CE is a painless noninvasive diagnostic proce-
type of surgery that is performed. Additionally, dure that is performed by swallowing a capsule.
diagnostic algorithms based on CE results have The original mouth to anus (M2A) capsule
been employed in selected intestinal motility dis- endoscope (PillCam SB, Given Imaging) has
orders and suggest that wider application of CE three components: a capsule endoscope an
are likely, expanding the thoughtful use of this external receiving antenna with attached portable
modality. hard drive, and a customized PC workstation
CE is contraindicated in pregnancy, patients with a dedicated software for review and inter-
with known or suspected gastrointestinal pretation of images M2A capsule which weights
obstructions, strictures or fistulas, Zenkers diver- 3.7 g and measures 11 mm in diameter 26 mm
ticula, small bowel motility abnormality, docu- in length. The slippery coating of the capsule
mented surgical ending blinding loop, cardiac allows easy ingestion and prevents adhesion of
pacemakers, or other implantable electromedical lumen contents, whereas the capsule moves via
devices. Despite this last indication, recent stud- peristalsis from the mouth to the anus. The cap-
ies have shown that the clinical use of capsule sule includes a complimentary metal oxide sili-
endoscopy is safe in patients with implantable con (CMOS) chip camera of 256 256 pixels, a
cardioverter defibrillators (ICDs), and even when short focal length lens, 46 white light-emitting
the capsules were in closest proximity to the diode (LED) illumination sources, two silver
ICDs, no interference was observed. oxide batteries, and a UHF band radio telemetry
The main limitations of CE include its lack of transmitter.
therapeutic capabilities (including biopsy), the Image features include a 140 field of view, a
inability to control its movement, its high rate of 1:8 magnification, a 130 mm depth of view, and
incidental findings, difficulty in localizing iden- a minimum size of detection of about 0.1 mm.
tified lesions (because of the impossibility to The activated M2A capsule provides images at a
wash out the lesion or reexamined it), and the frequency of two frames per second until the bat-
potential to miss single-mass lesions. Certain tery expires after 7 1 h, which enables the device
segments of the SB, such as the second portion to take up to 55,000 .jpg images during 8-h pro-
of the duodenum or the terminal ileum, may not cedure. The pictures are transmitted via an eight-
be seen well by the capsule and therefore have lead sensor array, arranged in a specific fashion
limited diagnostic accuracy. Accuracy can be on the patients belly, to a recorder, which is worn
also decreased by the obscuration of the lens by on a belt. The recorder is downloaded into a
food, bile, or stools. Moreover, despite the Reporting and Processing of Images and Data
expected life span of ~8 h, the capsule battery computer workstation and seen as a continuous
may run out before the entire small bowel is video film.
visualized, particularly in cases of delayed small Now in its second generation, PillCam SB 2
bowel transit time. has the same dimension as the previous PillCam,
3 Diagnostic and Therapeutic Endoscopy 49

but it has an angle of view of 156. The wider attached to the belt around the patients waist.
angle of view permits to cover more than double Actually there is a RAPID real-time device that
the visualized mucosal surface area; therefore, enables real-time viewing during a PillCam
the entire circumferences of the intestinal folds procedure.
can be visualized. In patients who are unable to swallow the cap-
Moreover, the second-generation capsule sule as younger children, or patients with diffi-
includes a three-lens system, an automatic light culty in swallowing, the examination is carried
exposure sensor to improve the optics. An out placing the capsule with the endoscope
improved method to process the digital informa- directly in the duodenum. Many different tech-
tion produces images with uniform exposure to niques to deliver the capsule have been described
light with a higher image resolution and a better even for the pediatric population with different
sharpness of the mucosal detail, as well as an device as a foreign body retrieval net alone, a
increase in the depth of view. The software also retrieval net and translucent cap or translucent
has additional support systems as a localization ligation adaptor, a polypectomy snare, and the
system, a blood detector, a double and quadri pic- others with or without an overtube.
ture viewer, a quick viewer, a single picture Before the procedures, all parents or legal
adjustment mode, an inflammation (Lewis) scor- guardians have to give informed consent for their
ing system, and an atlas to assist the interpreter. children, and this consent was given in full oral
By now, there are five CE systems: the PillCam explanation and in writing, above all for the risk
SB2 (Given Imaging, Yokneam, Israel), the Endo of retention.
Capsule (Olympus America, Center Valley, PA), Upper and lower endoscopies are necessary
the OMOM capsule (Jinshan Science and before performing capsule endoscopy, to exclude
Technology, Chongqing, China), the MiroCam lesions from the upper and lower gastrointestinal
(IntroMedic, Seoul, Korea) and CapsoCam Plus tract.
(CapsoVision, Saratoga, CA, USA).
The patient fasts overnight, and, on the morn- Patient Preparation
ing of the procedure, a comfortable belt contain- The presence of intestinal contents or a delayed
ing sensors is fitted at the patients waist, with gastric or intestinal transit may cause the failure
easy-fasten straps for quick adjustments and of the complete visualization of the intestinal
removal. The camera is activated by the removal mucosa. Despite several studies have examined
of the capsule from its magnetic holder, and it is the possibilities of improving bowel cleanliness
given to the patient with a glass of water. After and shortening transit time with different medi-
the patient has successfully swallowed the cap- cation, small bowel preparation is still a contro-
sule, then the capsule is passively moved along versial issue. Capsule manufacturer recommend
by peristalsis. Two hours after ingestion, the a bowel preparation with a 12-h fast. From
patient is allowed to drink, while eating is allowed European guidelines, there is evidence for a ben-
after 4 h. During the procedure the patient may efit from bowel preparation for capsule endos-
carry on with his daily activities. After 8 h, the copy, but there is so far no consensus on the
patient will return to the physicians office to preparation regimen.
return the sensor belt and data recorder. The
PillCam video capsule passes naturally with a Adverse Events
bowel movement, usually within 24 h. The physi- Capsule retention is defined as having a capsule
cian will then download images from the data that remains in the digestive tract for more than 2
recorder for review. weeks. Causes of retention cited in the literature
The data recorder is a small portable recording include: NSAID strictures, Crohns disease, small
device that communicates with the capsules as bowel tumors, intestinal adhesions, ulcerations,
the capsule passes through the GI tract. The data and radiation enteritis. The frequency of this prob-
recorder is placed in the recorder pouch which is lem varies: in some studies in adults, it has been
50 G. Di Nardo et al.

reported in less than two percent of all capsule has dual timer plugs that gradually implodes if
endoscopy in adults. In a recent pediatric review, passage does not occur within 30 h. The PC can
the percentage of capsule retention was reported to serve as a useful guide and may lessen the likeli-
be variable from 0 % up to 20 %. Prior to the devel- hood of CE retention, particularly in known CD
opment of the patency capsule, gastroenterologists where the risk of retention is greatest.
were dependent on clinical history and radio-
graphic studies to determine the safety and utility
of CE. Radiographic studies to evaluate the poten- 3.4.4 Colon Capsule
tial safety for CE have been misleading because
capsule retention has been documented in patients Colon capsule endoscopy represents an innova-
with normal small bowel radiography, and con- tive noninvasive, painless, swallowed colono-
versely safe capsule passage has been described in scope that is able to explore the colon without
patients with strictures identified radiographically requiring sedation and air insufflation. The US
(see section Patency Capsule). It is important to FDA did not approve it yet, but it is available in
underline that in some circumstances, capsule Israel and in part of Europe.
retention is permitted to identify the exact local- Theoretically, all patients with suspected or
ization of lesions that needed surgery anyway. In known colonic disease, referred for conventional
our experience, this happened in a patient in whom colonoscopy are potentially candidates for a colon
the capsule was retained in a blinding surgical capsule examination including suspected lesions
ending loop with multiple mucosal ulcerations and detected at a previous exam, gastrointestinal
a gut wall dilatation. The surgeon found immedi- bleeding, unexplained iron deficiency anemia,
ately the lesions because of the capsule retention. positive fecal occult blood test, clinically signifi-
It appears that the risk of retention is dependent cant diarrhea of unknown origin, surveillance for
upon the clinical indication and not on the age dif- colonic neoplasia, colorectal cancer screening,
ference. The highest risk factors for capsule reten- chronic inflammatory bowel disease, etc.
tion include known IBD, previous SBFT But we know from adults study that colon cap-
demonstrating small bowel CD, and a BMI <5th sule should not be considered alternative to con-
percentile combined with known IBD, though ventional colonoscopy but complementary to
retention occurred despite the absence of stricture traditional colonoscopy in case of incomplete
on SBFT. Rare cases of perforation, aspiration, or colonoscopy, when conventional colonoscopy is
small bowel obstruction have been reported in contraindicated or in patients who are unwilling
adults with none reported in children. However, to undergo colonoscopy. There are also several
children have suffered mucosal trauma when cap- studies for the utilization of the colon capsule for
sules have been placed with the Roth net. As a screening of colorectal cancer, but to date there
result, specific capsule placement devices are now are not reasonable results because of the low sen-
being used. sitivity in identifying patients with colonic pol-
yps as compared with standard colonoscopy.
Although colon capsule endoscopy represents a
3.4.3 Patency Capsule reliable system that is not invasive and well toler-
ated, there are no studies in children.
The majority of capsule retentions have occurred
in patients with normal small bowel radiological Technical Aspects
studies, yet functional patency may be present in There are some differences between the small
patients with radiologically documented stric- bowel and colon that make the evaluation of the
tures. To avoid this concern, an identically sized colon more difficult. First of all, the colon has a
patency capsule (PC) containing a mixture of much wider diameter. This allows the capsule to
barium, lactose and a radiofrequency identity tag flip around its own axis and change directions pre-
was developed. The currently available version venting, full visualization of the mucosal surface.
3 Diagnostic and Therapeutic Endoscopy 51

This problem has been partially solved by adding The possibility to identify the site of the cap-
another camera, allowing both ends of the capsule sule permits to notify at the patient by a sounding
transmit images. The first generation of the colonic signal and by a vibration that the capsule is still
capsule had two cameras on both heads, taking into the stomach, and the preparation protocol
four frames per second. It is 5 mm longer than the needs to be continued with prokinetic agents. In
small bowel capsule (dimension 11 32 mm). the small bowel, a beeping sound, a vibration,
Moreover, the angle of view from each imager and a message on the display inform the patients
is 156, and it permits greater imaging coverage to finish the preparation with a laxative to accel-
of the larger cross-sectional diameter of the erate the small bowel transit. Transfer of the
colon. The second problem is that the capsule has recorded images to the workstation and review of
to travel through the stomach and the small bowel the videos with rapid software are similar to
to reach the colon and this journey is time con- small bowel capsule. The new rapid software
suming. Two changes were made to solve this does however now include a simple graphic inter-
problem. First of all, a third battery and a sleep face tool for polyp size estimation.
mode were added to economize on energy. The Another difference between the small bowel
transmission of images ceases for an hour and a and colon is that the colonic surface is covered
half after ingestion to allow travel to the target by fecal material and the mucosa of the colon
area. With increased energy stores (third battery) will not be visualized by the capsule. The bowel
and decreased energy consumption (sleep mode), cleansing has to be superior to the cleansing
the capsule transmits images from the entire process applied for conventional colonoscopy
colon. It acquires images at a rate of four frames since no suction of liquid is possible during
per second (two for each imager) and has a total capsule endoscopy so if colon is unclear the
operating time of 10 h, approximately. Images bowel mucosa may not be seen by CCE.
transmitted by CCE are recorded in a portable, Therefore, novel colon preparation regimens
external recorder (DR2C) specifically developed were developed to provide a clean colon and to
for colon capsule, and then the images are down- promote CCE propulsion through the entire
loaded in a workstation and visualized. colon to the rectum.
Recently a second-generation colon capsule By now, there is not any study to determinate
has been developed to improve the sensibility of the optimal bowel preparation for children, and
the examination. The new colon capsule is slightly also for adults, the optimal bowel preparation has
longer than the previous (31.5 mm versus 31 mm), yet to be determined. For adults, the most widely
and the angle of view has been increased from used preparation regimen includes an oral prepa-
156 up to 172 for each camera, thus offering a ration of polyethylene glycol (PEG) osmotic
panoramic view of the colon (360). In order to solution, boost doses of sodium phosphate solu-
conserve battery energy, the capsule is equipped tions, and prokinetic agents.
with an adaptive frame rate, and it captures 35 With this regimen, colonic preparation was
images per second when in motion and four judged adequate in a median of 77 % (range
images per second when it is virtually stationary. 3589 %) of cases, and the rate of complete exam-
This specific image rate is controlled in real ination appears to be very close to the 95 % rate
time by the new data recorder which both stores recommended for screening colonoscopy.
the images and analyzes the capsule images. The In children, the preparation protocol is similar
data recorder is able to recognize the localization to adults, including for three days before the
of the capsule, and to save more battery, colon examination patients take a diet without fibers,
capsule 2 works at a low rate of images per min- the day before a clear liquid diet with or without
ute during its journey into the stomach and the a small breakfast (only milk), and 24 L (50 ml/
small bowel, and then when images from small kg) of split dose polyethylene glycol (PEG), half
bowel are not anymore detected, then it switches on the previous evening and half in the morning
into the adaptive frame rate. until 2 h prior to capsule ingestion.
52 G. Di Nardo et al.

A written informed permission is signed by dures, respectively, indicated a need for new
parents patients to carry out the procedure. methods.
Twenty minutes before capsule ingestion, patients Device assisted enteroscopy (DAE) has
take prokinetic agents as domperidone at the dose recently been reported as an effective method to
of 1020 mg, and the capsule is then swallowed achieve deep small bowel intubation allowing
with water. By real-time modalities, it is possible histologic evaluation and therapeutic interven-
to check when the capsule reaches the duode- tion and has replaced push and surgically assisted
num. If, after an hour from ingestion, the capsule enteroscopy. This advancement has assisted in
is still in the stomach intramuscular prokinetic is the care of not only adults but also children and
administered. Once the capsule arrives to adolescents, although indications and number of
duodenum, the physician activates the capsule application of these techniques may differ
and the patient can go home. because of disease frequencies.
Patients or their parents were asked to inform
the physician when the capsule was passed in the
stools [811]. 3.5.2 Indications and Contraindications

Indications for enteroscopy are well known in

adults. International societies have published
3.5 Enteroscopy algorithms for the different clinical indications
clarifying the role of this invasive and potentially
3.5.1 Introduction dangerous technique in each clinical setting.
Main indications and contraindications in chil-
Evaluation of small intestinal mucosa has an dren are listed in Table 3.6.
important role in the treatment of children with
different gastrointestinal disorders. Although, for
many years small bowel contrast studies were the Table 3.6 Common indications and contraindications
for enteroscopy in children
only practical and effective diagnostic tools on
the basis of the length and tortuosity of the small Indications
intestine. Obscure gastrointestinal bleeding
Complete visualization of the small bowel Suspected or known Crohns disease
mucosa has been obtainable since the introduc-
Altered intestinal anatomy (e.g., Roux-en-Y)
tion of capsule endoscopy (CE) in 2001. Whereas
Eosinophilic gastroenteropathies
CE has revolutionized diagnostic approach to
small bowel disorders, inherent limitations of
CE exist. The main limitations of capsule endos- Intestinal perforation
copy include an inability to control the capsule Peritonitis
and direct the viewing in real time, as well as Patient toxicity
Cardiovascular instability
inability to perform biopsies or therapeutic inter-
vention and the possible risk of retention. In Patient size/age
addition, for some children, voluntary ingestion Severe neutropenia
of the CE can be daunting or impossible, and the Severe thrombocytopenia or coagulopathy
capsule should be endoscopically inserted with Recent digestive surgery
Partial or complete bowel obstruction
dedicated device. Extensive intra-abdominal adhesions
Historically, push enteroscopy or surgically Toxic megacolon
assisted enteroscopy was used to further evaluate Connective tissue disorders
or treat detected lesions. However, the lack of Intra-abdominal vascular aneurysm
efficacy and the invasive nature of these proce-
3 Diagnostic and Therapeutic Endoscopy 53

a b c

Fig. 3.6 Vascular malformation (a), deep ulcer (b) and giant jejunal polyp (c) detected during Single Balloon Enteroscopy

OGIB is the most common indication for diagnosis (lymphoma, tuberculosis, or carcinoma)
enteroscopy in children. To date, considering the or undertake a therapeutic procedure including dila-
published pediatric case series, a total of 84 tion of small bowel stricture, removal of retained
patients were studied for OGIB, and it was diag- capsule, and treatment of bleeding lesions (Fig. 3.8).
nostic in 62 patients (73.8 %). Diagnoses were Small bowel polyps may cause intermittent
Meckels diverticulum (16.6 %), vascular lesions bleeding, obstruction, intussusception, or progres-
(15.4 %) (Fig. 3.6a), Crohns disease (13 %) sion to malignancy. Polypectomy might reduce the
(Fig. 3.6b), ulcer (5.9 %), and polyps (5.9 %) risk of multiple or urgent laparotomies with intes-
(Fig. 3.6c). Endoscopic therapeutic procedures tinal resection, which can result in morbidity and
were described in 11 patients (13 %), although the mortality. In published pediatric case series, 50
published data did not evaluate the outcome. pediatric patients underwent enteroscopy for sur-
Only in our recent study, CE has been system- veillance and treatment of small bowel polyps; 98
atically performed (including second look with procedures and at least 318 polypectomies were
CCE-2) before enteroscopy in children with performed. Not all the procedures allowed a com-
OGIB, and this combined approach significantly plete evaluation of the small bowel. Although fur-
increased the overall diagnostic yield (86 %) as ther studies are needed to assess the role of
compared to previous pediatric data. enteroscopy in the management algorithm of chil-
In conclusion, enteroscopy has a high diag- dren with suspected or established small bowel
nostic yield in diagnosing the cause of OGIB in polyps, it is an effective and safe alternative to sur-
children with the advantage of therapeutic inter- gery for the treatment of isolated and easy acces-
vention and histologic diagnosis. Nevertheless, sible small bowel polyps in children.
future prospective studies are needed to establish Contraindications for DAE are listed in
the correct place of enteroscopy in the diagnostic Table 3.6.
algorithm of children with OGIB.
In children with suspected Crohns disease
(CD), DAE is recommended when conventional 3.5.3 Equipment
studies including EGDS, ileocolonoscopy, imaging
of small bowel, and CE have been undetermined DAE was introduced for the first time in 2001 with
and histological diagnosis and/or therapeutic proce- double-balloon enteroscopy (DBE). Subsequently,
dure would alter disease management (Fig. 3.7). In single-balloon enteroscopy (SBE) and spiral enter-
the setting of established CD, DAE is indicated oscopy have become available during the follow
when endoscopic visualization and biopsies of the years. Unfortunately, no data reporting the use of
small intestine beyond the reach of EGDS or ileos- spiral enteroscopy in children have been published
copy is necessary in order to exclude an alternative to date, and the 16 mm outer diameter of the
54 G. Di Nardo et al.

Suspected CD

Negative upper & lower GI Endoscopy

MRI or other SB imaging technique

No stricture Stricture
Easily accessible SB lesions

Capsule Endoscopy

Diagnostic Unspecific
findings findings


Fig. 3.7 Proposed algorithm in patients with suspected small bowel Crohns disease. (Adapted by ref 16)

Unexplained clinical symptoms

despite presumably adequate therapy

Upper & lower GI Endoscopy

MRI or other SB imaging technique

No stricture and absence of Stricture

lesions explaining symptoms Suspected alternative diagnosis

Capsule Endoscopy (CE) Enteroscopy

CE findings Unclear CE findings

explaining symptoms Retained capsule

Adaptation of medical therapy

and/or surgery

Fig. 3.8 Proposed algorithm in patients with established small bowel Crohns disease. (Adapted by ref 16)
3 Diagnostic and Therapeutic Endoscopy 55

overtube currently makes this technique impracti- pulling, ultimately leads to successful advance-
cal for the majority of pediatric patients. ment throughout the small bowel. Complete
Commercially available since 2003, DBE small bowel viewing, from duodenum to cecum,
(Fujinon Inc., Saitama, Japan) utilizes two pri- is feasible although difficult. A combined ante-
mary models of endoscopes both with a working grade and retrograde approach is often used to
length of 200 cm (but with different outer diam- increase the amount of small bowel examined.
eters and channel diameters, 8.5 mm / 2.2 mm Regarding SBE, the primary difference with
and 9.8 mm / 2.8 mm, respectively) plus a soft DBE is that there is no balloon on the tip of the
overtube, measuring either 12.2 or 13.2 mm in enteroscope, which some feel makes it less com-
the outer diameter with a balloon located at the plex to perform. In the past, DBE seemed to be
distal tip, and a length from 105 cm to 145 cm. able to achieve a greater depth of insertion com-
The second balloon of the double-balloon system pared to SBE. However, a recent randomized
is located on the tip of the enteroscope and is multicenter trial showed a similar depth of inser-
inflated during overtube advancement to anchor tion and diagnostic yield in both techniques.
the scope and prevent slippage. For both DBE and SBE, the patients need only
Single-balloon enteroscopy (Olympus to fast before the oral examination (approxi-
America Inc.) includes an enteroscope (outer mately 12 h for solid food and 4 h for clear liq-
diameter of 9.2 mm, channel diameter of 2.8 mm, uids). For retrograde examinations, a standard
working length of 200 cm) and a soft 13.2 mm colonoscopy preparation is necessary. BAE in
outer diameter overtube (length of 140 cm) with adults is usually performed either with conven-
a distal balloon designed to deeply intubate the tional conscious sedation or with propofol based
small bowel. The overtube and the distal tip bal- on local attitudes. General anesthesia with intu-
loon are made of silicone rubber. bation is strongly recommended in children.
Depending on experience, radiologic fluoros-
copy can be used as an aid in BAE, especially
3.5.4 Technique early on in the learning curve (Fig. 3.9); it can
also be of usefulness when adhesions are expected
Balloon-assisted enteroscopy (BAE) including because of prior abdominal surgery or massive
SBE and DBE is performed in children with the SB involvement in children with Crohns disease.
same technique described in adults. Obviously,
there are some special considerations to take into
account in performing BAE in children. The
patient size could be the greatest limitation to the
use of BAE in pediatric age. On data, DBE has
successfully been performed from 2 years of age
and SBE from 3 years of age, with a weight at
least of 14 kg for both procedures. A smaller
abdominal cavity, thinner intestinal walls, and a
narrower intestinal lumen make BAE technically
more difficult in younger children; thus, it
requires a higher level of skill by the endosco-
pists. DBE is performed inflating the balloon that
facilitates anchoring and shortening of the intes-
tine, thus leading to straightening of the bowel
yet to be examined and allowing deep advance-
ment of the enteroscope. The bowel that has
already been examined is telescoped onto the
overtube during retraction. In this way, repeated Fig. 3.9 Fluoroscopic view during oral enteroscopic
advancement and retraction, or pushing and approach
56 G. Di Nardo et al.

When stenosis is expected, radiology is certainly major complications have been reported in the
useful to assess stricture complexity. pediatric literature when endoscopic therapy has
Choice of oral versus anal approach is guided been performed. A laparoscopic-assisted DBE
by the location of suspected disease. Several with the resection of several polyps was compli-
tools, including CE, MRI, and US, may be used cated by a pelvic abscess in the absence of perfo-
to assist in localizing the lesion and direct the ration. One bleeding that was effectively treated
choice of the enteroscopic approach. In cases in endoscopically in a patient who had multiple
which lesions are difficult or unable to be previ- resected polyps over a span of several endoscopic
ous identified and located, both approaches can procedures. Finally, a jejunal perforation occurred
be considered. Complete small bowel assess- in a child with Peutz-Jeghers syndrome who
ment may at times be desired but in many cases underwent two consecutive therapeutic DBE pro-
is not necessary (e.g., primary lesion is encoun- cedures within 18 days. The limited number of
tered, obviating the need for complete examina- major complications in children would suggest a
tion) or unachievable. In many cases, the oral highly favorable safety profile. However, given
approach is chosen first due to the lower techni- the small number of patients studied, it may be
cal difficulty and consequently the greater depth premature to make definitive conclusions
of insertion when compared with the anal [1216].
approach. Indeed, published series for DBE and
SBE in adults and children have noted technical
challenges to consistent passage through and
beyond (proximally) the ileocecal valve. This 3.6 Cholangiopancreatography
can be explained by several factors inherent to and Endoscopic Ultrasound
normal anatomy, patient disease characteristics,
and procedural difficulties. Total enteroscopy 3.6.1 Introduction
with BAE is defined as a complete evaluation of
the small bowel, with either a single approach or Diseases requiring endoscopic retrograde chol-
a combined oral (anterograde)-anal (retrograde) angiopancreatography (ERCP) and/or endo-
approach. However, it may not be feasible in all scopic ultrasound (EUS) in children have a low
patients; the reported success rate is 1686 %. If incidence, thus limiting the experience and giv-
the lesion is not reached with a single approach, ing the impression that these procedures are
an Indian ink tattoo performed at the deepest more difficult in children. There is also lack of
point of insertion is used to document a com- consensus about the indications to these proce-
plete SB examination. dures in the pediatric population. Generally,
All therapeutic procedures available for tra- patients are referred to a tertiary care facility,
ditional endoscopy can be performed during and often the procedure is performed by an adult
BAE using dedicated devices. On data, there are endoscopist.
not specific and well-established learning pro-
grams for enteroscopy, especially for pediatric
endoscopists. 3.6.2 Indications

ERCP is important in the evaluation of neonatal

3.5.5 Complications cholestasis to support a diagnosis of biliary atre-
sia and other causes of biliary obstruction includ-
In adult population, the rate of complications ing choledocholithiasis. In recent years,
ranged from 1.2 to 1.6 %. Self-limited and mild indication to ERCP is mainly limited to therapeu-
post-procedure throat pain, abdominal pain, and tic purposes, on the basis of the evolution of diag-
discomfort were frequently described in both nostic imaging technique. During ERCP, a variety
adult and pediatric patients. To date, only three of therapeutic maneuvers could be achieved
3 Diagnostic and Therapeutic Endoscopy 57

including sphincterotomy, sphincteroplasty, nography or magnetic resonance cholangiography,

stones extraction, stricture dilation, and stent failed to establish the diagnosis.
placement. Most common indications to ERCP Cystic dilatations of biliary ducts originally
in the pediatric age are discussed below. were termed choledochal cysts, considering only
ERCP can be a less invasive approach to cysts of the extrahepatic bile duct. Since 1977, a
obtain a cholangiogram in children with sus- new clinical classification includes intrahepatic
pected biliary atresia. According to several stud- cysts. Biliary cysts are found by abdominal ultra-
ies, ERCP could avoid unnecessary surgery by sound, computed tomography (CT), or magnetic
distinguishing biliary atresia from other causes of resonance cholangiopancreatography (MRCP).
neonatal cholestasis. In one report of 140 infants ERCP can be used as a supplementary test to
with suspected biliary atresia, ERCP was suc- confirm the diagnosis and categorize the type of
cessfully performed in 87 %. ERCP findings were cyst to facilitate surgical planning.
confirmed by intraoperative cholangiogram in The Todani classification is based on site of
80 % of the cases. In another series, ERCP was the cyst or dilatation and includes five types of
86 % sensitive and 94 % specific for detecting cysts:
biliary atresia and 100 % sensitive and 90 % spe-
cific for detecting choledochal cysts. Type I: The most common (8090 %), saccu-
Biliary atresia was classified by Kasai into lar, or fusiform dilatation of common bile duct
three main types depending on the level of biliary (CBD)
obstruction. In Kasai type I, the common bile Type II: Diverticulum protruding from the
duct is obliterated. In Kasai type IIa, the common CBD
hepatic duct is obliterated; in type IIb, there is Type III (choledochocele): Dilatation of the
atresia of the common bile duct, common hepatic duodenal portion of CBD
duct, and cystic duct. In Kasai type III, the entire Type IVa: Multiple dilatations of the intrahe-
extrahepatic biliary tree is obstructed. Kasai patic and extrahepatic ducts
types I, IIb, and III are indistinguishable based on Type IVb: Multiple dilatations of the extrahe-
ERCP findings because the obstructed common patic bile ducts
bile duct prevents visualization of the remainder Type V: Cystic dilatation of intrahepatic bili-
of the biliary tree. ary ducts, excluding Caroli disease
There is also a classification of ERCP
findings: The Todani classification does not include
type VI: An isolated cyst of the cystic duct (very
Type 1: Nonvisualization of the biliary tree rare). Only single case reports are documented in
Type 2: Visualization of the distal common the literature.
duct and gallbladder Types I, II, and IV biliary cysts are associated
Type 3: Visualization of the gallbladder and with an increased risk of malignancy, and surgi-
the complete common duct, with both hepatic cal excision is recommended.
ducts and visualization of biliary lakes at the Endoscopic sphincterotomy is indicated in the
porta hepatis following types of cysts:

Caroli disease is a congenital disorder charac- 1. Fusiform bile duct dilation with a widely dilated
terized by multifocal, segmental dilatation of large common channel. In contrast to cystic dilation,
intrahepatic bile ducts. The condition is frequently fusiform dilation is more commonly associated
associated with renal cystic disease of varying with low-grade, short strictures located at or
severity. Caroli initially described two variants, distal to the pancreaticobiliary junction.
with (Caroli syndrome) or without (Caroli disease) 2. Distal bile duct stricture, which typically
hepatic fibrosis. ERCP is usually required only if occurs at the point of connection with the
other less invasive imaging studies, like ultraso- pancreatic duct. Up to 8 % of such patients
58 G. Di Nardo et al.

develop cystolithiasis (which may be multi- magnetic resonance cholangiopancreatography

ple) involving intrahepatic and extrahepatic (MRCP) or endoscopic ultrasound (EUS) are
ducts. often required to evaluate patients with a clinical
3. Choledochocele (type III cyst). suspicion.
The role of ERCP and the benefit of endo-
Noteworthy, an anomalous pancreaticobiliary scopic sphincterotomy in children with choledo-
junction (APBJ) can present in up to 70 % of cholithiasis have not been confirmed. Infants and
patients with biliary cysts. It is characterized by a children who presented no symptoms but have
junction of the bile duct and pancreatic duct out- small common bile duct stones on an imaging
side the duodenal wall with a long common duct study should usually be managed conservatively,
channel. According to the Kimura classification, since the stones (or sludge) are likely to pass
there are three types of APBJ: spontaneously. Sphincterotomy generally should
be reserved for symptomatic patients or those
1. Type B-P Common bile duct joining the with underlying lithogenic disorders.
main pancreatic duct. Malignant strictures of extrahepatic ducts are
2. Type P-B Pancreatic duct joining the com- rare in children. There are few cases described in
mon bile duct; this type is more likely to be literature in which stenting successfully relieved
associated with recurrent pancreatitis than the the obstruction.
B-P type. Bile duct complications after liver transplanta-
3. Long Y type A long common channel, with- tion include bile duct strictures, leaks, and bile
out common bile duct dilatation. casts. The onset can be early or late (within or
after 4 weeks from transplant). Diagnosis relies
Sclerosing cholangitis in children is usually on MRCP, with ERCP playing only a therapeutic
related with an underlying disorder, and approxi- role.
mately 14 % of children with sclerosing cholan- The role of EUS is well established in adult GI
gitis have underlying inflammatory bowel and pancreatobiliary diseases. There is, instead,
disease. The diagnosis of sclerosing cholangitis poor literature regarding the use of EUS in pedi-
is usually established by magnetic resonance atric patients because usefulness of EUS in chil-
MRCP. The typical finding is pruning of the dren has been only recently appreciated, and
peripheral biliary tree with stenosis and dilation. published papers often report few patients and
ERCP allows cytological sampling of the ste- single center experiences. Even if the pathology
nosis and therapeutic intervention in case of may differ between the two populations, EUS
obstructive symptoms (Fig. 3.10). In case of dom- indications in children are similar to those
inant ductal strictures, according to the data of described in adults. Also the reported results
literature in the adult population, there is indica- show a great impact of EUS in the management
tion to endoscopic treatment with sphincterotomy of disease in the pediatric population, in particu-
and balloon dilation to relieve the obstruction. lar for what concerns pancreatobiliary disease
Choledocholithiasis is rare in the pediatric (Fig. 3.11).
population, and it is typically related with hemo- EUS could be used as a diagnostic tool to
lysis, infection, chronic liver disease, or chole- avoid more invasive procedure as ERCP in the
dochal cyst. A review including 382 pediatric evaluation of the common bile duct or the pancre-
patients with gallstones found sickle cell disease, atic duct. In children with clinical signs of CBD
parenteral nutrition, and cardiac surgery as the obstruction, EUS avoided diagnostic ERCP in
most common risk factors with the highest fre- the majority of cases. Also in pancreatic disease,
quency in infants, often without symptoms. The EUS altered patient management or was used as
incidence of gallstones rises in girls during a therapeutic tool in EUS-guided treatment.
puberty. Ultrasonography does not always iden- There are few reports on interventional diag-
tify small stones in the biliary system. Thus, nostic or therapeutic pancreaticobiliary EUS in
3 Diagnostic and Therapeutic Endoscopy 59

a b

c d

Fig. 3.10 Radiological (a, b) endoscopic (c) and MRI (d) findings of plastic biliary stents placed in a child with
chronic pancreatitis associated to jaundice and choledochal dilation

the pediatric population. The principal described etiology was blunt abdominal trauma in five,
indications have been EUS-FNA and pancreatic hereditary pancreatitis in one, and idiopathic
fluid collection drainage. Despite the small sam- pancreatitis in one. Both technical and treatment
ple size, in the pediatric population results of success rates were 100 %. Two patients under-
fine needle aspiration were similar to those went repeat EUS-guided drainage due to lack of
achieved in adults in terms of success rate and adequate resolution of pancreatic fluid collection
diagnostic accuracy. In particular, the use of on follow-up computed tomography. No imme-
EUS-FNA could diagnose an autoimmune pan- diate or delayed complications were reported. At
creatitis or could be useful in case of chronic a median follow-up of 1033 days, all of the chil-
fibrosing pancreatitis for a differential diagnosis dren were doing well with no recurrence of the
from malignant masses. EUS-guided pseudocyst collections. EUS-guided rendezvous or ductal
drainage has been used with high success rate in drainage has been occasionally reported. A case
the pediatric population. In a case series pub- of pancreatic duct drainage by the rendezvous
lished in 2013, a total of seven children under- technique has been reported in a child and EUS-
went EUS-guided drainage of PFCs. The guided biliary drainage in a 13-year-old patient
60 G. Di Nardo et al.

a b

Fig. 3.11 Endoscopic (a) and EUS (b) appearance of esophageal duplication cyst. EUS-guided FNA of a pancreatic
mass (c)

with metastatic rhabdomyosarcoma obstructing diagnosis of esophageal stenosis, EUS with mini-
the biliary tract and involving the duodenum. probes can diagnose the nature of the stenosis,
This technique is rarely used even in the adult thus guiding the further treatment. Subepithelial
population. lesions or duplication cyst can be distinguished in
Pediatric mediastinal masses represent a diag- the upper gastrointestinal tract by endoscopic
nostic and therapeutic challenge. They are a het- ultrasound. Rectal ultrasound has been used in
erogeneous group of potentially life-threatening patients with anal fistulas and underlying Crohns
diseases. Transesophageal EUS with FNA allows disease.
assessment and biopsy of posterior and middle
mediastinal lesions. The reported cases in litera-
ture are principally mediastinal nodes in which 3.6.3 Patient Preparation and Sedation
EUS-FNA was used for cytological diagnosis.
There are several reports about the use of EUS The preparation and sedation of a patient under-
for the evaluation of esophageal, gastric, duode- going ERCP/EUS is similar to that used for
nal, or rectal disease. The technique and results upper gastrointestinal endoscopy. In the case of
are comparable to the ones in the adult popula- pediatric setting, an adequate explanation of the
tion with a significant impact of EUS on the man- procedure should be provided to the little patient
agement of the patients. In the differential and parents. If an adult endoscopist is perform-
3 Diagnostic and Therapeutic Endoscopy 61

ing the procedure, a close collaboration with a the bile duct is generally impossible because of
pediatric team should be implemented in order the small duct diameter.
to provide an adequate care. Deep sedation with In children older than 1 year and adolescents,
an anesthesiologist is highly recommended, the rate of successful cannulation is more than
since children cannot fully cooperate during pro- 95 %, comparable to reports in adults. In neo-
cedures performed under conscious sedation. nates and young infants, the rate of successful
Post-procedure monitoring is not different than cannulation of the common bile duct is often
other endoscopic procedures requiring sedation. lower than in adults.
ERCP and EUS can be performed on an ambula- In EUS examination, the maneuvers are simi-
tory basis when performed for diagnosis only. lar with the exploration of pancreatic head and
Therapeutic ERCP has a greater potential risk uncinate accomplished from the duodenum while
for serious complications, and overnight obser- pancreatic body and tail visualized from the
vation in the hospital may be indicated. Because stomach. The experience of the endoscopists may
ERCP is associated with a higher risk for bacte- account for a large part of the variability.
remia than diagnostic endoscopy, in selected
cases, an antibiotic prophylaxis should be
considered. 3.6.6 Complications

Complications of ERCP are pancreatitis, infec-

3.6.4 Equipment tion, hemorrhage, and perforation. A series of
329 ERCP for biliary or pancreatic indication
For ERCP, a pediatric duodenoscope, with a reported a total of 32 complications (10 %),
diameter of 7.5 mm is mandatory in neonate mostly pancreatitis with no deaths. The rate of
and infants younger than 12 months and is pre- post-ERCP pancreatitis seems to be higher in
ferred for children younger than 3 years. In the patients undergoing pancreatic duct stent
older children and adolescents, a standard adult placement (7 of 28 procedures, 25 %). There is
duodenoscope with a diameter of 11 mm can be a very limited experience with EUS in the pedi-
used. atric population. The complication rate not
For EUS, thinner instruments are preferred in seems to differ from the adult series being very
small patients. In children, 3 years of age or older low especially for diagnostic examination
a standard EUS equipment can be used. [1720].

3.6.5 Technique 3.7 Polypectomy

ERCP is usually performed with the patient in the 3.7.1 Introduction

prone or semiprone position. The duodenoscope
is inserted into the second portion of the duode- Polypectomy is the most common endoscopic
num and then is straightened in short route therapeutic intervention performed in children.
with a slow withdrawn. When it is not possible to In more recent decades, endoscopic polypectomy
perform this maneuver, the approach to cannula- has endorsed continuous advances because of
tion of the papilla is performed with the long improvements in the endoscopic technology and
route. In this case, the instrument stands along techniques.
the greater curvature of the stomach. Cannulation Polypectomy is difficult to learn, requiring a
technique in children is the same as in adults, but baseline level of skills in instrument handling
it is necessary to consider the narrower lumen of including the ability to precisely and efficiently
the childrens duodenum that can add some dif- control the instrument tip and therapeutic
ficulty. In neonates, deep selective cannulation of devices.
62 G. Di Nardo et al.

3.7.2 Technique Pedunculated polyps should be sufficiently

manipulated to assure the colonoscopist that the
Polyp shape and location both influence the suc- snare is near the polyps head but not around a
cess and technique of endoscopic polypectomy. portion of the head or normal tissue in order to
Pedunculated polyps are much easier to remove leave a sufficient stalk for regrasping if immediate
than sessile and flat polyps, although they are bleeding occurs. Once snared, the lesion should
still associated with a risk of postpolypectomy be lifted away from the colonic wall to minimize
hemorrhage. The right colon, especially the contact with the opposing colonic wall avoiding
cecum, is thinner walled than the left with conse- contralateral electrocautery injury. After transec-
quent higher rates of complications after remov- tion, the stalk should be observed briefly to ensure
ing polyps from this colonic region. Polyps that no immediate bleeding is occurring. In such a
draped over the ileocecal valve are the most dif- case, bleeding can be treated by regrasping the
ficult to remove and are associated with the high- stalk and holding it for 510 min. Alternatively,
est need for surgery. Rectal polyps are probably injection of diluted adrenalin or application of
the easiest to resect, particularly if located in the clips has been reported as useful methods to stop
lower half of the rectum that is extraperitoneal, immediate postpolypectomy bleeding. For large
minimizing the consequences of full-thickness pedunculated lesions, additional strategies such as
electrocautery. epinephrine injection (1:10,000) and attachment
Different polypectomy snares are available of a detachable loop snare (Fig. 3.12a, b) or of a
with variable shape (oval, crescent, hexagonal), metal endoclip (Fig. 3.12ce) to the stalk prior to
size (standard, mini, macro), and reusable vs. dis- polypectomy should be considered to prevent
posable. Before polypectomy, the snare should postpolypectomy bleeding.
always be checked to make certain that the tip Sessile polyps can be removed by standard
closes at least 1.5 cm into the plastic sheath. The monopolar electrocautery using principles simi-
point on the handle at which the snare has closed lar to those for pedunculated polyps. Transection
so that the snare has just entered the plastic sheath in a single piece is generally feasible even for
should also be marked, as this indicates when large polyps with a diameter within 2 or 3 cm.
mechanical closure is complete and approxi- After grasping, the polyp is lifted or tented into
mately the amount of tissue enclosed in the snare. the lumen in order to create an artificial stalk. In
All kind of polyps should be captured in the the right colon, it is advisable to partially deflate
six oclock position because the snare enters the lumen. Large sessile polyps represent a par-
the field roughly at this orientation; this can usu- ticular challenge to endoscopists because of the
ally be accomplished by rotation of the colono- risks of hemorrhage, perforation, and inadequate
scope relative to the polyp or changing the polypectomy.
patients position. Because the optical element is The submucosal injection technique has
located above the working channel of the endo- been proposed to make removal of large sessile
scope, attempting to capture polyps at other ori- colonic polyps easier and safer. Injection of flu-
entations may result in losing the visual field ids into the submucosa under the polyp
against a fold prior to capture of the polyp. It is increases the distance between the base of the
often easier to remove a polyp during the with- polyp and the serosa, thus reducing the risk of
drawal phase of the examination because in this bleeding, thermal injury, and perforation. The
phase loops are removed and the polyp may be most commonly used fluid is saline (normal or
more easily snared because both torque and tip hypertonic), with or without epinephrine. With
deflection are more responsive when the colono- time, this fluid will be reabsorbed; thus, other
scope is straightened. Additionally, advancing fluids have been used in an attempt to prolong
proximal to the lesion, deploying the snare, and the effect, including 10 % glycerol/5 % fruc-
dragging it over the polyp often facilitate place- tose, 50 % dextrose, sodium hyaluronate, and
ment of the snare. hydroxypropyl methylcellulose. Sometimes
3 Diagnostic and Therapeutic Endoscopy 63

a b

c d e

Fig. 3.12 Detachable loop snare (a, b) and metal endoclip (ce) applied to the stalk of two giant pedunculated polyps
to prevent postpolypectomy bleeding

few drops of methylene blue can be added to also be caused by a prior attempt at polypec-
enhance visualization of polyp margins. Fluid tomy with healing and scarring of the layers,
is injected using a standard sclerotherapy nee- preventing this separation by fluid injection or
dle. The needle may be placed into the submu- by the needle penetration out of the colon wall,
cosa at the edge of a polyp, or if the polyp is and so the fluid is being injected into the
large and flat, multiple injections may be given peritoneum.
around the periphery and directly into the cen- Most (over 8090 %) of the polyps encoun-
ter of the polyp. The desired elevation may tered during routine endoscopy are less than
require 34 mL of solution, although larger vol- 10 mm; therefore, techniques to remove these
umes can be injected safely. It is preferable to lesions must be optimized due to its important
inject the proximal (far) aspect of the polyp clinical consequences. These polyps can be
first. If the distal aspect is injected first, the resected using a number of different techniques,
polyp can be tilted away from the colonoscope, including hot or cold biopsy (with or without
making subsequent resection more difficult. If a cautery), hot or cold minisnare, or cold biopsy
bleb does not immediately form, slowly with- followed by fulguration with a bipolar electrode.
draw and lift the needle slightly while injecting Cold snaring is the best technique for virtually all
until bleb formation is observed. However, if small (<10 mm) and most diminutive (<5 mm)
the polyp fails to elevate (the non-lifting polyps. Cold snaring allows efficient resection of
sign), it may be an indication of infiltration of polyp tissue in a single piece, with a margin of
the lesion into the submucosa and muscularis normal tissue to ensure complete eradication.
propria. Alternatively, this phenomenon may Occasionally, polyps less than 10 mm are
64 G. Di Nardo et al.

narrow-based and bulky or pedunculated. In vatively and/or endoscopically. More rarely, they
these occasional situations, hot snare resection could be life threatening and/or require surgery.
may be warranted because of the higher risk of Risk factors for complications in this setting
immediate bleeding with a more vascular include multiple polypectomies, increased size,
pedicle. right colon location, and inexperienced
The technique of cold snaring is fundamen- endoscopist.
tally different from snaring with electrocautery. Bleeding, either immediate or delayed (usu-
With cold snaring, the endoscopist advances the ally within 1 week, but possible in up to 34
snare sheath, opens the snare, and encircles the weeks), is the most frequently observed
polyp. The snare is then slowly and progressively complication.
closed, with the aim of capturing 12 mm of nor- For small polyps, the immediate bleeding rate
mal tissue around the polyp, until complete clo- is 0.52.2 %, while delayed bleeding is rare (0.3
sure is achieved and the polyp is guillotined. 0.6 %). Most of the bleeding discovered in this
Suction can help the snare to capture the polyp setting is either self-limiting or easily treated in
and surrounding tissue. The polyp can then be the same endoscopic session, with clip placement
readily suctioned and retrieved. or adrenaline injection (1:10,000). Some of the
proposed methods of preventing bleeding, such
as prophylactic use of hemostatic clips or pro-
3.7.3 Retrieval of Multiple Polyps phylactic argon plasma coagulation, on the
polypectomy scar do not seem to be useful for
Retrieval of multiple polyps or multiple frag- preventing delayed bleeding in this setting.
ments of a big polyp could be a difficult chal- Pedunculated polyps have an increased risk of
lenge. A single snared polyp could be retrieved bleeding. Epinephrine injection to both the stalk
with the standard polypectomy snare; alterna- and the polyp head, as well as looping and clip-
tively, a prolonged grasping device or wire basket ping techniques, has been successfully deployed
may be used. In addition, dedicated Roth Net to prevent the risk of bleeding after hot snare pol-
snare with a special net has been introduced for ypectomy. Even though injection of epinephrine
the removal of multiple fragments in one shot and may only prevent immediate but not delayed
has been proved to be safe and useful. The bleeding, this is the most widely used preventive
retrieval net could be particularly useful after method.
piecemeal resection of large polyps in the proxi- Perforation (immediate or delayed) is the sec-
mal colon to avoid repeated introduction. Polyps ond most common complication of polypectomy.
as large as 78 mm in diameter could be aspirated For small and diminutive polyps, the risk of per-
and retrieved through the colonoscope using the foration is nil when cold polypectomy is per-
commercially available filtered polyp suction formed. Perforation in polypectomy has in fact
trap. A useful trick for forced aspiration of larger been mostly associated with electrocautery, so
polyp fragments is to remove the suction bottom this technique is no longer advisable. On the
valve, cover the opening with a finger, and wait. other hand, removal of large lesions is associated
with higher perforation rates (01.5 %). Lesions
larger than 50 mm, located at the proximal colon
3.7.4 Complications especially the cecum, are other important risk
factors for perforation, since the colonic wall is
Endoscopic polypectomy could be associated thin, while rectal location is a protective factor
with complications, such as bleeding, perfora- against perforation since the wall is thicker and
tion, and postpolypectomy coagulation syn- retroperitoneal. Patients suffering from severe
drome. Most of these complications are persistent pain that is not diminished by the pas-
self-limiting or could be readily managed conser- sage of flatus should undergo X-ray examination
3 Diagnostic and Therapeutic Endoscopy 65

to seek the presence of extraluminal air. A CT tropathy. Esophageal and gastric varices could
scan should also be considered. When the also have endoscopic characteristics that are
endoscopist is sure that perforation has occurred associated with a high rebleeding rate and will be
by virtue of seeing the peritoneal cavity or other discussed in a dedicated section. Colonic lesions
organ, then immediate surgical exploration is amenable to endoscopic therapy include bleeding
required. ulcers, vascular malformations, polyps, and
Postpolypectomy coagulation syndrome is a bleeding polyp stalks. Colonic varices, either
rare manifestation of peritoneal irritation because caused by portal hypertension or hereditary, are
of electrocautery but without evidence of perfo- less amenable to endoscopic therapy than their
ration on computed tomography scan. It occurs in upper tract counterparts because of their diffuse
1.33.7 % of patients undergoing excision of nature unless a discrete bleeding point is identi-
large lesions (usually >2 cm), but requires hospi- fied at the time of endoscopy.
talization in only 0.07 %. Fever, abdominal pain,
and increased inflammation markers characterize
it. Symptoms may occur up to 5 days after polyp- 3.8.2 Nonvariceal Gastrointestinal
ectomy, but this syndrome has an excellent prog- Bleeding
nosis and is managed conservatively with medical
therapy [2123]. Three endoscopic techniques could be used to
control nonvariceal gastrointestinal bleeding:
injective, thermal, and mechanical. The specific
technique used depends on equipment availabil-
3.8 Hemostasis Techniques ity, site and type of bleeding lesion, and experi-
ence of the endoscopist.
3.8.1 Introduction Standard pediatric gastroduodenoscopes have
a 2.0-mm operative channel, and consequently
Therapeutic endoscopy is indicated for patients they will accommodate needles for injection ther-
with active bleeding at the time of endoscopy and apy but will not allow the use of thermal and
for patients with high-risk stigmata or lesions mechanical devices. Standard adult gastroduode-
associated with a high rebleeding rate identified noscopes have a 2.8-mm operative channel suffi-
at endoscopy. High-risk stigmata associated with cient for all devices; however, the outer diameter
ulcers include an evidence of active bleeding, an (8.69.8 mm) of these endoscopes cannot be used
oozing from beneath an overlying clot, and a in children below 10 kg. Adult therapeutic gastro-
nonbleeding visible vessel at its base. A visible duodenoscopes have either one or two operative
vessel usually appears as a red, blue, or white channels ranging in sizes from 2.8 to 3.8 mm, but
plug or mound. their outer diameter (11.312.9 mm) usually pre-
Gastroduodenal vascular malformations and cludes their use in children below 2025 kg.
Dieulafoy lesions (an isolated blood vessel pro- Pediatric colonoscopes have a 2.83.8-mm
truding through a small nonulcer mucosal defect), channel allowing the use of all hemostatic
although are a rare source of upper gastrointesti- devices.
nal bleeding, have a high risk of bleeding with a
high complication rate if left untreated. The com- Injection Technique
plication and rebleeding rates of these lesions This is an inexpensive and easy-to-learn method
significantly decrease with effective endoscopic usually performed by injection of a liquid agent
therapy. at three or four sites around an exposed bleeding
Diffused mucosal bleeding from duodenitis or vessel and then directly at the site of the vessel.
gastritis is usually not responsive to endoscopic The rationale for this technique is that a visible
intervention, except for portal hypertensive gas- vessel is not an end artery and that for effective
66 G. Di Nardo et al.

Table 3.7 Selected endoscopic accessories for injective hemostasis

Min endoscopic channel Representative products and
Type Diameter/size required (mm) manufacturers
Injection needle 23G, 25G 2.0 Various
21G 2.8
Injection-coagulation catheter 7 F (25G) 2.8 Injection gold probe/Boston
10 F (25G) 3.7 Scientific
Injection-polypectomy snare 3.0 mm (25G) 3.7 iSnare/US Endoscopy
Adapted by Ref. [24]

Table 3.8 Sclerosant agents for nonvariceal bleeding

Volume/number of injections/ Max total
Solution Concentration location volume Comments
Hypertonic 3.6 % 3 mL 34 injections at base of 912 mL Repeat
saline-epinephrine saline + 1:20,000 bleeding vessel prophylactic
combination epinephrine or 7.2 % injections if
saline + 1:20,000 visible vessel
epinephrine present 2448 h
after first
Epinephrine with 1 mL 1:1000 0.52.0 mL injected in multiple 10 mL Larger volumes in
normal saline epinephrine + 9 mL sites around bleeding vessel and range for spurting
normal saline into bleeding point itself vessels
Epinephrine 510 mL epinephrine Inject epinephrine into Epinephrine May substitute
followed by 1:10,000 submucosa directly around 510 mL bipolar
polidocanol Polidocanol 1 % 5 mL blood vessel to achieve Polidocanol coagulation for
hemostasis by compression/ 5 mL polidocanol
vasocostriction, then obliterate
vessel with polidocanol
Thrombin in 100 IU thrombin in Inject into bleeding vessel 1015 mL
normal saline 3 mL normal saline 1015 mL total volume
Epinephrine with 1 mL 1:1000 1.02.0 mL per injection 30 mL Goal is lack of
normal saline for epinephrine + 9 mL injected in multiple sites (34) vascular markings
polypectomy normal saline around polyp to be raised up within injection
Adapted by Ref. [24]

hemostasis tamponade of the feeding vessel is for safe passage through the working channel
required. Injection is most easily performed by of the endoscope. When the catheter is placed
injection of the proximal site of the lesion first near the target lesion, the needle can be
and distally thereafter; this avoids that injection extended out of the end of the sheath to a preset
over the distal site of the lesion as creation of the distance, and a syringe attached to the handle
submucosal bleb may lift the bleeding site away is used to inject liquid agents. A combined
from the view. Hemostasis results from a combi- injection needle/multipolar probe and a com-
nation of vasoconstriction, mechanical tampon- bined injection needle/snare are available to
ade, and cytochemical mechanisms. allow for sequential injection and coagulation
Injection needles consist of an outer sheath (Table 3.7).
(plastic, Teflon, or stainless steel) and inner Table 3.8 lists the most commonly used solu-
hollow-core needle (1925 gauge). Using a tions, their concentrations, appropriate volumes,
handle on the end of the needle sheath, the and recommended injection site. Except under
operator can retract the needle into the sheath unusual circumstances, injection therapy should
3 Diagnostic and Therapeutic Endoscopy 67

be confined to a single solution (single agent or a devices, current is transmitted from one electrode
combination agent) during an injection episode on the probe to another electrode. Energy is
to minimize the risk of ulcer extension or delivered when any pair of electrodes is in con-
perforation. tact with the bleeding target. MPEC probes may
The main criticism of injective technique is have six points through which current can be
that it may only provide temporary control of passed; contact between any two is sufficient,
hemorrhage. For this reason, it is generally used allowing for tangential contact. The maximal
to stop or slow down active bleeding prior to temperature achieved with this method is signifi-
application of conclusive therapy such as thermal cantly less than that of monopolar coagulation,
or mechanical technique. resulting in less tissue injury and also greater effi-
Complications are usually related to the sub- cacy for vessels <2 mm. As with the heater probe,
stance injected (e.g., arrhythmias and hyperten- the correct technique is to compress the bleeding
sion after adrenaline, bowel ischemia, and vessel first and then to coagulate. Pulses should
perforation after sclerosing agent injection in the be applied as short, multiple pulses (2 s long) or
thinner walled duodenum or right colon) and a single pulse as long as 610 s. In adults, up to
rarely to inappropriate technique (e.g., increased 40 s total of electrocoagulation may be required.
bleeding, rebleeding). Increased bleeding after bipolar coagulation
has been reported in cases with a visible vessel; Thermal Techniques usually this bleeding is controllable with further
Thermal devices generate heat either directly bipolar coagulation, but on occasion surgery has
(e.g., heater probe [HP]) or indirectly by passage been required. MPEC seems to be equally effec-
of electrical current through tissue (e.g., multipo- tive to heater probe in terms of hemostasis, inci-
lar electrocautery [MPEC] probes, argon plasma dence of rebleeding, transfusion requirement,
coagulator [APC]). and need for emergency surgery.
Heater probe consists of a Teflon-coated hol- In addition to sequential combination therapy,
low aluminum cylinder with an inner heating a combination probe is available that allows for
coil. A thermocoupling device at the tip of the sequential injection and coagulation without the
probe maintains a constant temperature. Probe use of a dual-channel endoscope or catheter
activation results in delivery of a preselected exchange.
amount of energy in joules to the probe tip. Once The APC is a noncontact electrocoagulation
the pulse has been initiated, the duration of acti- device that uses high-frequency monopolar alter-
vation is predetermined. The probe is water per- nating current conducted to target tissues through
fused to prevent tissue adherence. Coagulation ionized argon gas (argon plasma).
should be around the bleeding point or stigmata The probes, consisting of a Teflon tube with a
first and then directly upon it. If a twin-channel tungsten monopolar electrode contained in a
instrument is used, the endoscopist is able to tam- ceramic nozzle close to the distal end of the probe,
ponade the bleeding with the probe while simul- are 2.3 or 3.2 mm in outer diameter and are avail-
taneously suctioning in the region of the ulcer able in lengths of 220 or 440 cm. Probes are avail-
base. The number of joules per pulse should be able to direct plasma either parallel or
reduced, especially in right-sided colonic lesions. perpendicular to the axis of the catheter (Fig. 3.13).
In 13 % of cases, perforation may occur after Gas flow rates can be varied from 0.5 to 7.0 L/
heater probe application for gastrointestinal min, the power settings vary from 0 to 155 W, and
bleeding because of the variable depth and extent the generator voltage ranges from 5000 to
of tissue injury after application. Precipitation of 6500 V. Argon gas passes through the coagulation
bleeding has been reported in up to 5 % of cases probe with an electrode at its tip. The foot switch
after heater probe application. activates the electrode, resulting in a flow of elec-
Because of these limitations, the bipolar probe trically activated ionized gas from the probe to the
or MPEC is more commonly used. In these tissue causing tissue desiccation at the interface.
68 G. Di Nardo et al.

a b e

Side oriented probe End oriented probe

c d

Circumferential oriented probe

Fig. 3.13 Schematic representation of the available different oriented probe for Argon Plasma Coagulator (APC) appli-
cation (ad). Endoscopic view of APC treatment of a diffuse gastric bleeding (e)

If the catheter is not near target tissue (28 mm), sure whenever the foot switch is activated during
there is no ignition of the gas, and depression of the procedure, because failure to do so can result
the foot pedal results only in flow of inert argon in overdistension of the stomach or bowel, espe-
gas. After desiccation, the electrical resistance of cially in smaller patients. Appropriate modifica-
the treated area increases, prompting the current tions will be required in pediatric patients, with
to move to the untreated area of lower resistance. current generators having minimum gas flow rates
The depth of coagulation is dependent on the of 0.5 L/min and in right-sided colonic lesions
power setting, the gas flow rate, the duration of that could be elevated with a saline cushion before
application, and the distance between the probe treatment to reduce the risk of perforation.
tip and the target tissue. The surface to be treated Applications for the APC include hemostasis
should be cleared of fluids, limiting the usefulness of vascular ectasias, treatment of bleeding ulcers,
of the APC in cases of active bleeding. If the over- treatment of residual adenomatous tissue, and
lying surface is not clear, then a coagulated film ablative therapy. The primary pediatric indication
may develop and the tissue beneath the surface is likely to be treatment of symptomatic gastroin-
may not be adequately treated. The correct tech- testinal vascular lesions (Fig. 3.13).
nique is to put the probe to an optimal operating Complications have been reported in 024 %
distance and to move the endoscope shaft to paint of patients in various adult series and include
the confluent area to be coagulated. The noncon- gaseous distension, pneumatosis intestinalis,
tact nature of the technique makes it possible to pneumoperitoneum, pneumomediastinum, sub-
treat large areas rapidly, in comparison with the cutaneous emphysema, pain at the treatment site,
heater probe or MPEC. The probe tip should not chronic ulceration, stricture, bleeding, transmural
contact the tissue because this is a monopolar burn, and perforation.
probe and deep tissue injury may occur with con-
tact, although the safety of the technique is not Mechanical Techniques
forfeited by occasional inadvertent tissue contact. Endoscopic clips consist of a metal double- or
Care must also be taken to continuously aspirate triple-pronged preloaded clip, a delivery deploy-
the argon gas, which is flowing under steady pres- ment catheter, and a handle used to operate and
3 Diagnostic and Therapeutic Endoscopy 69

deploy the clip. Clips are available in a variety of Clipping and other mechanical techniques
jaw lengths and opening angles, they require a have been shown to be more efficacious and are
2.8-mm endoscope channel for deployment, and associated with a lower rebleeding rate than non-
triple-pronged clip requires a 3.2-mm endoscopic mechanical therapies for patients with Dieulafoy
channel. A double-pronged clip with reopening lesion, Mallory-Weiss tears, and colonic bleeding
and repositioning capability up to five times after biopsy, after polypectomy, from hemor-
before deployment is available. rhoids, or from solitary rectal ulcer syndrome.
The preferred technique is to identify and clip Complications after clipping are extremely rare
the bleeding point first and then to apply addi- but include a case wherein a clip inadvertently
tional clips around the bleeding point if necessary. perforated a gastric ulcer and was applied to the
Because this is a mechanical technique, secure splenic artery, and a case of colonic perforation
clip deployment is achieved with maximal cap- thought to be due to clip placement for postpol-
ture of tissue around the bleeding vessel. Optimal ypectomy bleeding.
clip positioning is best achieved with the clip Detachable loops consist of a circular- or
extended a relatively short distance from the elliptical-shaped nylon loop preloaded onto a
endoscope tip. This allows for more precise clip delivery system that includes a hook wire to
application and allows for exertion of downward which the loop is attached within a Teflon sheath
force on the clip during its placement. The correct and an opening handle. The outer diameter of
technique is to position the clip slightly away 2.6 mm requires a 2.8-mm operative channel.
from the arterial base, allowing for an en face or Both reloadable and single-use preloaded devices
tangential approach, and to push the open clip are available. The loop is used in a manner simi-
downward while simultaneously applying suc- lar to the technique of polypectomy snare place-
tion. The clip should be slowly closed and, if opti- ment. The maximal loop opening size is 30 mm.
mally positioned, deployed. Reopening clips can The loop is tightened with advancement of a sili-
be repositioned before deployment if required. con rubber stopper. The loop is then detached
The limitations of clip application relate to the after hemostasis is achieved without transecting
location of the lesion and to size criteria. The the lesion. The primary indication for loop place-
proximal lesser curvature and gastric cardia may ment is for the prevention or management of
be difficult to approach for clipping directly or in postpolypectomy bleeding. When the loop is
the retroflexed position, and in some cases it is applied before polypectomy snare placement,
easier to carefully expose the clip before retroflex- care must be taken to avoid entanglement of the
ion. Duodenal ulcers involving the posterior wall loop in the polypectomy snare. Before polypec-
of the duodenal bulb, fibrotic ulcers, and arterial tomy, detachable loop placement should result in
vessel larger than 2 mm in diameter may be diffi- change of the color of the polyp head without
cult to clip. In most cases, the clips dislodge spon- transection. If the loop is applied too tightly,
taneously within 24 weeks and pass in the stool, amputation of the polyp may occur with resultant
although some have been in place for >1 year. bleeding; if it is too loose, bleeding may occur
Although no adverse effects have been after polypectomy. Hemostatic loop placement
reported, magnetic resonance imaging may be has also been effective in the management of
contraindicated if clips are present. Clipping for bleeding Dieulafoy lesions and has been used for
acute nonvariceal hemostasis is associated with bleeding gastric varices.
primary hemostasis rates in the range of
84100 %, with low rebleeding rates, comparable
with those achieved with injection, thermal, and 3.8.3 Variceal Bleeding
combination therapies. As with thermal therapy,
hemostatic clipping has been used as part of com- Currently endoscopic variceal ligation (EVL) is
bination therapy in conjunction with epinephrine the primary choice for the endoscopic manage-
injection. ment of variceal bleeding in children. However,
70 G. Di Nardo et al.

a b

c d

Fig. 3.14 Schematic representation of endoscopic variceal banding ligation (EVL) technique (ad) and endoscopic
view at the end of the procedure (e)

this treatment cannot be applied to small children in most patients. The effectiveness of sclerotherapy
due to technical limitations, and sclerotherapy is has been studied for both prevention and subse-
still recommended as an alternative approach in quent bleeding episodes. Considerably, whereas a
these cases. Primary endoscopic prophylaxis is band ligation device can only be used with an adult
only indicated in some children (i.e., patients endoscope, an injection needle can be applied to
who live in remote areas far from emergency every scope. Hence, sclerotherapy can be applied
medical care), and secondary prophylaxis is rec- even to a neonate. It is also a very inexpensive
ommended for cirrhotic children, whereas a method and is not technically difficult.
meso-Rex shunt operation is the first choice for Although endoscopic sclerotherapy has been
prophylaxis in children with extrahepatic portal widely used with effective treatment of bleeding
vein obstruction (EHPVO). Many of the current in neonates and children, side effects from the
recommendations for the management of vari- sclerosants can be significant, such as perfora-
ceal bleeding have been adopted from case series tion, bleeding, ulceration, and stricture formation
in children and RCTs in adults. at the injection site. The range of complications
An extensive experience with emergency associated with sclerotherapy has prompted the
sclerotherapy exists in children. A variety of agents development of alternative endoscopic methods
have been used (sclerosants, chemically irritating such as band ligation.
compounds such as ethanolamine/tetradecyl sul- EVL can stop variceal bleeding through rubber
fate). These sclerosants are injected either intra- or band ligation of the variceal vessel and consequent
para-variceal, until bleeding has stopped. In the set- mechanical strangulation (Fig. 3.14). After con-
ting of emergency sclerotherapy, it is important to firming the target varices that require ligation, the
be aware of the significant incidence of associated scope is advanced under direct vision until the
bacteremia and to consider antibiotic prophylaxis banding cylinder is in full 360 contact with the
3 Diagnostic and Therapeutic Endoscopy 71

varix (Fig. 3.14a). After full contact is made, suc- rate of complications and band ligation shows a
tion is applied by depressing the endoscopic aspi- lower rate of therapeutic success and higher rate
ration control valve, which draws the varix and of rebleeding than vascular occlusion in these
surrounding mucosa into the banding chamber cases. The intravariceal injection of N-butyl-2-
(Fig. 3.14b). Once the chamber is completely cyanoacrylate causes rapid occlusion of the vari-
filled by the varix, which is evident by a complete ces when it makes contact with blood. To prevent
red out and loss of endoscopic visibility, the trip damage in the working channel when applying
wire is pulled (Fig. 3.14c) to push the elastic band this method, the radiographic contrast agent lipi-
over the varix. The engorged varix is strangulated odol is mixed with the N-butyl-2-cyanoacrylate
at the mucosal junction (Fig. 3.14d, e). Treatment to delay permanent hardening and enable
begins with ligation of the most distal variceal col- radiologic observations after the procedure. If
umns in the esophagus just above the gastroesoph- the N-butyl-2-cyanoacrylate is too dilute to
ageal junction, commencing with the bleeding travel through the vessels due to slow hardening,
varix, if one is present. Subsequent ligations of the there is a risk of a fatal cerebral or pulmonary
remaining varices are performed at increasingly embolism developing. Small aliquots are thus
higher levels, proceeding upward in a spiral fash- recommended for these injections. Even though
ion to avoid circumferential placement of bands at this technique may be considered in children,
the same level. Large varices should have addi- only a pilot study involving eight patients
tional bands placed more proximally within the younger than 2 years old and weighing less than
distal 10 cm of the esophagus. A 2-cm mucosal 10 kg who had gastroesophageal varices has
bridge between adjacent bands is essential to mini- been performed. Although glue injection
mize mucosal necrosis, rebleeding, and dysphagia. (0.52 mL injected) was successful in all infants
After banding, patients eat soft food for 2 days. with immediate control of bleeding and a low
Repeated treatments are performed at intervals of rebleeding rate of 37.5 % requiring a second
2 or 4 weeks. On average 69 bands are applied at treatment with cyanoacrylate, this data is too
the initial session and progressively fewer at sub- small to properly evaluate this treatment modal-
sequent session. EVL may be a preferable ity in pediatric cases [2426].
approach because it is easier and safer. Direct
comparisons of endoscopic sclerotherapy and var-
iceal ligation both in adult and pediatric patients 3.9 Dilation Techniques
demonstrated similar rate of control of active
bleeding and recurrence of hemorrhage with sig- Stricture dilation may be indicated when there is
nificantly lower overall complications and mortal- associated clinical impairment or a need to access
ity rate for EVL. In addition, variceal ligation beyond the stricture for diagnosis or therapy.
appears to lead to obliteration in fewer sessions. Dilators used in gastrointestinal endoscopy can
Potential concerns of this technique in children be allocated into two categories: fixed diameter
includes the impossibility to perform this tech- push-type dilators (bougie dilators) and balloon
nique in small children due to the scope and asso- dilators.
ciated ligature attachment size as compared to the Bougie dilators are available in a variety of
childs size (youngest described case was 4 years designs, calibers, and lengths and are usually
old) and the possible entrapment of the full thick- reusable. They exert both radial and longitudinal
ness of the esophageal wall (esophageal wall is forces when advanced through a stenosis and are
thinner than adults) by the rubber band with subse- used primarily in the treatment of esophageal
quent risk of ischemic necrosis and perforation. and rectal strictures. Users should refer to the
For the endoscopic treatment of gastric vari- manufacturers instructions for guidance on
ceal bleeding in adults, vascular occlusion with reprocessing.
N-butyl-2-cyanoacrylate injection is recom- Nonwire-guided bougie dilators (Hurst and
mended because sclerotherapy has shown a high Maloney dilators) are flexible push-type dilators
72 G. Di Nardo et al.

that do not accommodate a guidewire. They are 3.9.1 Patients Preparation

available in a variety of diameters and are inter- and Techniques
nally weighted with tungsten for gravity assis-
tance. Hurst dilators have a blunt, rounded tip, Patient preparation will depend upon the main
whereas Maloney dilators have an elongated, cause and site of stricture. Patients with achalasia
tapered tip. may require prolonged fasting and removal of
Wire-guided bougie dilators (Savary-Gilliard food rests using a nasoesophageal tube. Adequate
and America dilation system dilators) are flexi- colon cleansing is needed for the treatment of
ble, tapered, polyvinyl chloride, and latex-free lower GI tract stricture, and laboratory tests may
cylindrical solid tubes with a central channel to be warranted in patients with blood dyscrasias or
accommodate a guidewire. Tucker dilators are those taking anticoagulant therapy. Prior to
small (413.3 mm) silicone bougies tapered at endoscopy, all patients have to provide written
each end; loops on each end can be pulled ante- informed consent, also with written information
gradely or retrogradely across strictures. A gas- about the risk of perforation, and the possible
trostomy is required for use. These may be useful need for surgery. General anesthesia is needed to
in the treatment of tortuous strictures secondary perform dilation in children. After the procedure,
to caustic ingestion. patients should be observed for 24 h. Radiographic
Balloon dilators are available in an array of contrast examination is not performed routinely
designs, and lengths; calibers are marketed only before dilation, but it is performed after dilation
for single use. They exert only radial forces of achalasia or complex strictures to exclude per-
when expanded within a stenosis and can be foration. Antibiotics are not used routinely before
used in the treatment of all accessible strictures dilation. Anticoagulants should be discontinued.
throughout the GI tract including small bowel PPI therapy is recommended after esophageal
strictures. They are designed to pass through the dilation for peptic stricture.
endoscope with or without wire guidance so that Dilation can be performed with or without
dilation can be observed. Balloon dilators are endoscopic, fluoroscopic, and/or wire guidance.
made of low-compliance inflatable thermoplas- Selection of different types of dilators depends on
tic polymers that allow uniform and reproduc- operator preference, type, and site of the stricture.
ible expansion to their specified diameter at Selection of the appropriate size is critical for safe
maximum inflation. The majority of balloon and effective dilation. Techniques may need to be
dilators allow for sequential expansion to multi- modified for complex strictures (e.g., length
ple diameters. Dilating balloons are expanded by >2 cm, lumen diameter <12 mm, tortuous) and/or
pressure injection of liquid (e.g., water, radi- specific disease states and locations in the GI tract.
opaque contrast) by using a handheld accessory Wire-guided bougie dilators (Savary and
device. The hydraulic pressure of the balloon is American dilators) are passed over a guidewire
monitored manometrically to gauge radial endoscopically placed and subsequent endoscope
expansion force. Inflation with radiopaque con- removal (Fig. 3.15a). Nonwire-guided bougies
trast enhances fluoroscopic observation. (Hurst and Maloney) are passed blindly into the
Achalasia balloon dilators are large-diameter esophagus. These may have a higher rate of per-
(30, 35, and 40 mm) polyethylene balloon dila- foration in the presence of large hiatal hernias or
tors specific for achalasia. All currently available complex strictures.
achalasia balloon dilators are wire guided, single Balloon dilators in the GI tract may be passed
use and do not pass through the endoscope. They with or without wire guidance. The balloon is
are positioned across the esophagogastric junc- positioned across the stenosis and inflated under
tion by using fluoroscopic guidance with visual- direct endoscopic visualization. Nonwire-guided
ization aided by the radiopaque markers on the balloons are used in a similar fashion but are
balloon. Balloon insufflation with air is moni- passed across the stenosis by using endoscopic
tored manometrically. visualization only (Fig. 3.15b).
3 Diagnostic and Therapeutic Endoscopy 73

Fig. 3.15 Schematic representation of esophageal dilation performed with Wire-guided Savary dilator (a), with a
nonwire-guided balloon (b) and with a large diameter wire-guided balloon in a case of Achalasia (c)

Pneumatic balloon dilation of the lower placed and under fluoroscopic guidance initially
esophageal sphincter with a large-diameter wire- using a 30-mm balloon. Although nonfluoroscop-
guided balloon is the mainstay of endoscopic ically guided dilation using endoscopic visualiza-
therapy for achalasia (Fig. 3.15c). Dilation is tion alone has been reported. A brief 6-s dilation,
generally performed over a wire endoscopically sufficient to obliterate the balloons waist, was
74 G. Di Nardo et al.

shown to be as effective as the standard 60-s strictures immediately before or after dilation has
dilation. been advocated to improve outcome by decreas-
Although the choice of dilatation device is left ing the need for repeat dilations. This technique
to the individual endoscopist, the rule of three has also been successfully used to prevent stric-
has been the standard for bougie dilation. ture recurrence after balloon dilation in children
Specifically, the initial dilator chosen should be with stenotizing Crohns disease (Fig. 3.16).
based on the known or estimated stricture Interruption of strictures (e.g., esophageal
diameter; serial increases in diameter are then webs, Schatzki rings) with biopsy forceps or
performed. After moderate resistance is encoun- needle-knife electrocautery, either as the sole
tered with the bougie dilator, no greater than three treatment or in conjunction with dilation, has
consecutive dilations in increments of 1 mm been successfully demonstrated.
should be performed in a single session. Although
this rule does not apply to balloon dilators, most
balloons allow a three-step inflation process, each 3.9.2 Complications
of 1 mm, practically paralleling the rule of three.
Current AGA recommendations for manage- Perforation is the major complication associated
ment of peptic esophageal stricture include con- with endoscopic dilation (0.11 %). It appears
sideration that steroid injection into benign that perforations are common using a single

a b

c d

Fig. 3.16 Endoscopic view of ileocolonic stricture (a) balloon dilation (b, c) followed by intralesional steroid injection
(d) in a child with Crohns disease
3 Diagnostic and Therapeutic Endoscopy 75

nonwire-guided bougie size dilator particularly Table 3.9 Indications and contraindications for PEG
in children with complex stricture or with a Indications Underlying disorders
large hiatal hernia. Other possible complica- Inability to swallow Neurological disorders
tions include chest pain, bleeding, and Multiple congenital
bacteremia. Oropharyngeal dysmotility
The risk of perforation with balloon dilation in Epidermolyis bullosa
achalasia is in the range of 34 % with a mortality Others
rate of <1 %. Other complications associated Inadequate caloric Cystic fibrosis
with achalasia dilation include prolonged pain intake Congenital heart disease
Chronic respiratory failure
and intramural hematomas. Open surgical repair Oncologic disease
with myotomy of early recognized endoscopic Special feeding Unpalatable formula in multiple
perforation offers an outcome similar to that of requirements food allergies, metabolic
elective open myotomy. However, if endoscopic diseases, or renal failure
perforation occurs after pneumatic dilation, lapa- Continuous enteral Short bowel syndrome
feeding Malabsorption
roscopic myotomy is usually not technically fea-
sible. In patients with failed myotomy, pneumatic Contraindications
dilation could be safely performed. Absolute
Colonic interposition
Perforation after dilation usually occurs at the Severe and uncorrectable bleeding disorder
site of the stricture, but it could happen also in Gastric varices
different site mainly related to the inappropriate Severe ascites
use of nonwire-guided dilators and consequent Pharyngeal or esophageal obstruction
creation of false track through the intestinal wall.
Some experts recommend endoscopic inspection Ascites
immediately upon completion of the dilatation Previous abdominal surgery
procedure as the appearances may raise the pos- Scoliosis
sibility of perforation and prompt early treat-
ment. Perforation should be suspected if severe Adapted by Ref. [30]
or persistent pain, dyspnea, tachycardia, or fever
develops. Physical examination may reveal sub-
cutaneous crepitus of the chest or cervical region ing. Gastrostomy could be used not only as an
in cases of esophageal perforation. Although a enteral tube feeding but also for gastric decom-
chest or abdominal radiograph could show a per- pression and or to administrate medications.
foration, a normal study result does not exclude The most common indications for percutane-
this diagnosis and a water-soluble contrast esoph- ous endoscopic gastrostomy (PEG) placement
agram or computed tomogram of the chest/abdo- are listed in Table 3.9 and could be listed in four
men may be necessary to disclose a perforation main groups: inability to swallow, inadequate
[2729]. caloric intake, special feeding requirements, and
continuous enteral feeding.
There are a number of relative but few abso-
3.10 Percutaneous Endoscopic lute contraindications to PEG placement (see
Gastrostomy Table 3.9). Uncorrectable coagulopathy and
unfavorable anatomy resulting in lack of transil-
3.10.1 Indications and Contraindications lumination with inability to bring the anterior
gastric wall in apposition to the abdominal wall
In children unable to take adequate oral nutrition are considered the main absolute contraindica-
reliably and safely for more than 13 months, tions for PEG placement. Careful patient selec-
placement of a gastrostomy should be considered tion and care in performing the procedure are
to avoid complications of nasogastric tube feed- known to reduce morbidity and mortality, which
76 G. Di Nardo et al.

are generally higher in patients with acute states junction of the costal margin and left midclavicu-
of severe illness, such as heart failure. lar line.
Some operators may first insert a needle so
that the endoscopist can confirm the correct loca-
3.10.2 Technique tion (Fig. 3.17d). The assistant now performs the
puncture by holding the trocar perpendicular to
PEG placement should be carried out in an oper- the abdominal wall and pushing it through into
ating room under general anesthesia. Prophylactic the inflated stomach. The endoscopist confirms
use of antibiotics (a single dose of broad-spectrum entry of the trocar and its overlying plastic sheath
antibiotic administered before the procedure) is (Fig. 3.17e). The trocar is withdrawn while leav-
recommended to prevent local or systemic infec- ing the sheath in situ to provide a secure track for
tion. An endoscopist together with an appropri- the guidewire. The guidewire is passed through
ately trained assistant, who is responsible for skin the plastic sheath (Fig. 3.17f), the endoscopist
puncture and insertion of the guidewire, is war- grasps it with the forceps (Fig. 3.17gi), and the
ranted for PEG placement. Available PEG place- sheath is then withdrawn as the guidewire is
ment kits typically contain a gastrostomy tube slowly drawn into the stomach. The entire assem-
with internal and external retaining devices, a skin bly including endoscope, forceps, and guidewire
trocar, a guidewire, and a plug adaptor for the is then withdrawn. The guidewire now passes
tube. Gastrostomy tubes are made from polyure- through the abdominal puncture, into the stom-
thane or silicone rubber and are available in a ach, and out through the mouth. The proximal
range of sizes from French gauge 924, with sizes end of the guidewire is tied to a loop on the end
1215 being suitable for most of the children. of the gastrostomy tube (Fig. 3.17l). The distal
The most popular technique of insertion is the end of the guidewire is gently pulled, drawing the
pull technique because it has many advantages tube and its internal bolster through the mouth,
over the other techniques especially in young chil- down the esophagus, into the stomach, and out
dren. The patient is placed in the supine position, through the puncture site, until the internal retain-
and the anterior abdominal wall is cleaned using ing device comes to lie on the anterior gastric
an operative skin disinfection protocol. An endo- wall (Fig. 3.17m). Sometimes it is necessary to
scopic examination of the esophagus and stomach make a small incision at the puncture site to facil-
is then performed. The duodenum is not examined itate passage of the gastrostomy tube out through
so as to minimize intestinal air distension. the skin.
The stomach is inflated however, so as to bring The distal end of the tube, still attached to the
the anterior gastric wall in close contact with the guidewire, is now cut off. An outer retaining
abdominal wall. The endoscopists assistant now device such as a disk is passed over the external
identifies the correct skin puncture site (Fig. 3.17). tube, and this holds the tube at the abdominal
The best option is to enter the stomach close to wall so that it cannot slip back into the stomach.
the junction of the gastric antrum and body. The It is important to ensure that this external retain-
site is located by using endoscopic transillumina- ing device is not so loose as to be ineffective or so
tion (a bright point of light should be seen on the tight as to cause pressure damage. Local anes-
abdominal wall). If a clear point of transillumina- thetic may be injected around the incision point
tion cannot be identified, the assistant should not to reduce postoperative discomfort.
proceed with the puncture because this suggests The tube is now cut to the desired length and
the colon lies interposed between the stomach the adaptor plug is inserted. A small amount of
and the abdominal wall. When a good transillu- iodinated disinfectant may be applied to the
mination can be identified (Fig. 3.17c), the assis- external retaining device. A dry dressing is
tant applies digital compression at the proposed applied to the site for removal after 2448 h.
insertion site, and the endoscopist confirms that Finally, the endoscope should be reinserted to
this is a suitable entry point in the stomach confirm that the inner retaining device is posi-
(Fig. 3.17a, b). The correct insertion point is usu- tioned correctly and to ensure that there is no
ally midway between the umbilicus and the bleeding (Fig. 3.17n).
3 Diagnostic and Therapeutic Endoscopy 77

a b c

d e f

g h i

m n

Fig. 3.17 Schematic representation and endoscopic view including endoscope, forceps, and guide wire is then
of the different PEG placement phases. (ac) The endos- withdrawn. (l) The proximal end of the guide wire is tied
copists assistant identifies the correct skin puncture site. to a loop on the end of the gastrostomy tube. The distal
(d) The assistant now performs the puncture by holding end of the guide wire is gently pulled, drawing the tube
the trocar perpendicular to the abdominal wall and push- and its internal bolster through the mouth, down the
ing it through into the inflated stomach. (e) The endosco- oesophagus, into the stomach and out through the punc-
pist confirms entry of the trocar and its overlying plastic ture site, until the internal retaining device comes to lie on
sheath. (f) The guide wire is passed through the plastic the anterior gastric wall (m). (n) Finally, the endoscope
sheath. (gi) The endoscopist grasps it with the forceps should be reinserted to confirm that the inner retaining
and the sheath is then withdrawn as the guide wire is device is positioned correctly and to ensure that there is no
slowly drawn into the stomach. The entire assembly bleeding
78 G. Di Nardo et al.

Children should be admitted overnight to Pneumoperitoneum is a frequent postopera-

ensure adequate pain control and safe initiation tive finding identified radiologically in 550 % of
of feeds. In the immediate postoperative period, patients. It is usually of minor clinical conse-
the patients general condition is monitored and quence, but could be a sign of iatrogenic bowel
the abdomen is examined for signs of peritonitis injury and hence should not be dismissed in the
or significant pneumoperitoneum. Most of the relevant clinical context.
children require some analgesia during the first 2 Colonic injury or gastrocolic fistula is uncom-
days. PEG should be used after 24 h starting with mon, but owing to the displacement of the trans-
saline solution for few hours and then with desig- verse colon over the anterior gastric wall, it can
nated liquid formula. lead to puncture of the colon during the blind
For 1 week, daily aseptic cleaning of the site is insertion of the needle/trocar. Risk factors include
recommended and a sterile dressing can be under- or overdistension of the stomach, a left
applied. Subsequently, simple washing is suffi- diaphragmatic hernia, and significant kyphosco-
cient and a dry dressing may be placed over the liosis. This complication could be detected early
outer collar. Occlusive dressings are not recom- or late, frequently after many months, and even
mended as they increase the risk of local only during exchange of the PEG tube with gas-
infection. trostomy button (Fig. 3.18). Clinical signs include
After a period of 23 months or more, once the the presence of undigested feed in stools, diar-
gastrostomy tract has healed, a more suitable device rhea immediately after feeding, feculent vomit-
known as gastrostomy button can replace the gas- ing, or discharge from the gastrostomy track.
trostomy tube. This device consists of a shorter Small bowel injury is most common in chil-
(0.54.5 cm in length) and wider (e.g., 1416 dren who have undergone prior abdominal sur-
French) tube, just sufficient to traverse the fixed gery and occurs owing to adhesions that have
track, with some form of internal retaining device. fixed small bowel loops anterior to the liver, mak-
Their fixed length requires measurement of ing them highly susceptible to injury during tro-
the formed track before insertion of the new car insertion.
device. This can be done with a graduated mea- Stoma leak is common after PEG placement
suring device before selection of the correct and may only need gentle tightening of the exter-
length of device. nal fixation device to ensure close apposition of
They can be inserted and removed quite eas- the internal bumper to the gastric wall. More per-
ily, usually without need for sedation or general sistent leaks may however lead to peritonitis.
anesthesia. Only the first insertion of this device Hemorrhage is an extremely rare complica-
should be performed under endoscopic control to tion resulting from gastric, peritoneal, retroperi-
be sure that the balloon is correctly placed in the toneal, and abdominal wall injuries. Hypotension
stomach and not in the colon as in the case of without evidence of intraluminal bleeding is sug-
gastrocolic fistula. The only disadvantages are gestive of parenchymal lesions (mainly liver and
that they need to be changed every 46 months. spleen) and should be promptly recognized and
treated surgically. Puncture of abdominal wall
vessels may present with bleeding from the PEG
3.10.3 Complications tract itself. Tightening the external and internal
bumper may assist with hemostasis.
Complications may be classified as early and Late complications include local infection,
late. granulation tissue, and buried bumper syndrome.
Early complications as a direct result of PEG Peristomal wound infection is one of the most
placement occur within 30 days of insertion and common complications of PEG (3040 %).
include pneumoperitoneum, colonic injury or Prophylactic antibiotics are able to reduce stomal
gastrocolic fistula, small bowel injury, hepatic/ infection rates. If discharge occurs around site or
splenic injury, bleeding, and stoma leak. erythema is present, the site could be swabbed
3 Diagnostic and Therapeutic Endoscopy 79

c d

Fig. 3.18 Schematic (a) representation of a gastrocolic fistula as a complication of PEG. Radiographic study (bd)
with water-soluble contrast solution shows tip of tube in the lumen of trasverse colon

and evidence of colonization and antibiotic sensi- easily; it tends to discharge continuously and
tivities obtained. The site is almost always colo- may cause local pain. Treatment options include
nized without causing tissue infection, although silver nitrate, topical corticosteroids, cryother-
pain around the site and tissue swelling suggest apy, or surgical debridement. Silver nitrate does
bacterial invasion. Depending on clinical status, not cause any pain if applied only to the granula-
the child may need topical or systemic antibiot- tion tissue and is helpful to shrink down exces-
ics. Less than 5 mm of erythema around the outer sive granulation tissue.
stoma site is common and is likely owing to local Buried bumper is most common in the second
irritation by movement of the external bumper or year after insertion and occurs in approximately 2 %
minimal leakage. of children. The internal flange migrates through the
Overgranulation at the gastrostomy site is gastric wall and potentially into the peritoneal
seen as red/pink tissue at the stomal border that space. Signs include difficulty in infusing fluid and
extends above the surrounding skin. This is a feeds, with an increasing difficulty in moving and
common complication that is usually owing to an rotating the PEG during the weekly cares. This may
ill-fitting device, wherein excessive movement or be minimized by ensuring a correctly fitting device
leakage leads to an excessive healing response. at regular review, particularly to ensure increasing
The granulation tissue has a tendency to bleed tube length in line with weight gain.
80 G. Di Nardo et al.

If suspected, an upper endoscopy is warranted. the stomach by 12 cm and then rotated once a
Feeds should be discontinued until a diagnosis is week from day 7 postinsertion.
made, as complications include sudden peritoni- Teaching of all peoples involved in the care of
tis and the formation of intraperitoneal or abdom- the PEG begins before PEG placement and at the
inal wall abscesses. In some cases, it is possible time of the decision to proceed to insertion.
to pass a guidewire through the tube lumen under Teaching initially includes the demonstration of
endoscopic control, gently dilate the tract with a different devices and explanation of the planned
dilator, and use the patent tract to insert a button. surgical procedure. However, in addition to
teaching the child and family, support for staff PEG Care involved in caring for each patient in the com-
It is quite normal to experience some clear or col- munity may be necessary. There are several key
ored discharge from around the site for the first aspects of PEG use and care that should be taught.
710 days post placement while the site is heal- The family and caregivers should have the fol-
ing. The site should be cleaned daily with warm lowing competencies assessed to confidently be
soapy water; after cleaning, it is essential to ensure able to manage their childs PEG tube [30, 31].
the area is fully dry. The use of creams and pow-
ders around the tube should be avoided as this
may contribute to irritation and softening of the References
skin, which can lead to superficial skin infection.
In addition to the observation of the site for 1. ASGE Standards of Practice Committee; Lightdale JR
infection, a PEG requires daily care. One should et al (2014) Modifications in endoscopic practice for
pediatric patients. Gastrointest Endosc 79:699710
also check and document any erythema, skin
2. ASGE Technology Committee; Barth BA et al (2012)
breakdown, granulation tissue, and pain, swell- Equipment for pediatric endoscopy. Gastrointest
ing, or offensive discharge. Endosc 76:817
Baths can be given once the incision site has 3. Cote CJ et al (2006) Guidelines for monitoring and
management of pediatric patients during and after
healed. This is normally a minimum of 48 h after
sedation for diagnostic and therapeutic procedures: an
the gastrostomy has been placed. Swimming is update. Pediatrics 118:25872602
permitted, but should not be encouraged for 2 4. Samer Volonaki E et al (2012) Gastrointestinal endos-
weeks following gastrostomy placement. copy and mucosal biopsy in the first year of life: indi-
cations and outcome. J Pediatr Gastroenterol Nutr
Dressings that cover, sit under, or occlude the
gastrostomy are not recommended and usually 5. Leichtner AM et al (2013) NASPGHAN guidelines
not required. In specific circumstances, dressings for training in pediatric gastroenterology. J Pediatr
may be helpful, such as silver dressings for the Gastroenterol Nutr 56(Suppl 1):S1S8
6. Turner D et al (2010) Evidence-based recommenda-
treatment of excessive granulation tissue forma-
tions for bowel cleansing before colonoscopy in chil-
tion and antimicrobial dressings in the presence dren: a report from a national working group.
of minor, superficial infection. Endoscopy 42:10631070
Flushing of the gastrostomy tube is essential 7. Di Nardo G et al (2014) Bowel preparations for colo-
noscopy: an RCT. Pediatrics 134:249256
to maintain tube patency, prevent tube blockages,
8. Di Nardo G et al (2012) Investigation of small bowel
and reduce bacterial overgrowth. Commonly, in pediatric Crohns disease. Inflamm Bowel Dis
20 mL of water is recommended, with smaller 18:17601776
volumes used in certain circumstances, for exam- 9. Oliva S et al (2015) Capsule endoscopy followed by
single balloon enteroscopy in children with obscure
ple, if a child is fluid restricted and to avoid fluid
gastrointestinal bleeding: a combined approach. Dig
volume overload. Caregivers should be instructed Liver Dis 47:125130
not to pull on the tube and to avoid any persistent 10. Oliva S et al (2014) Small bowel cleansing for capsule
tension as this may lead to progressive migration endoscopy in pediatric patients: a prospective random-
ized single-blinded study. Dig Liver Dis 45:5155
of the bumper into the abdominal wall, leading to
11. Oliva S et al (2014) Capsule endoscopy in pediat-
buried bumper syndrome. To prevent this com- rics: a 10-years journey. World J Gastroenterol
plication, PEG should be carefully pushed into 20:1660316608
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12. Barth BA (2011) Enteroscopy in children. Curr Opin 23. Carpenter S et al (2007) Polypectomy devices. ASGE
Pediatr 23:530534 Technology Status Evaluation Report. Gastrointest
13. Annese V et al (2013) European evidence based con- Endosc 65:741749
sensus for endoscopy in inflammatory bowel disease. 24. Kay MH et al (2007) Therapeutic endoscopy for non-
J Crohns Colitis 7:9821018 variceal gastrointestinal bleeding. J Pediatr
14. ASGE Standards of Practice Committee; Fisher L, Gastroenterol Nutr 45:157171
Lee Krinsky M, Anderson MA et al (2010) The role of 25. Conway JD et al (2009) Endoscopic hemostatic
endoscopy in the management of obscure GI bleed- devices. ASGE Technology Status Evaluation Report.
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Endosc 75:8086 Gastroenterol Hepatol Nutr 16:19
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North Am 42:443458 Gastroenterol Nutr 60:131141
Anesthesia in Pediatric Digestive
Andrea Gentili, Valeria Landuzzi,
and Maria Cristina Mondardini

4.1 Introduction Digestive surgery comprises different pathol-

ogies involving the gastrointestinal tract, liver,
Anesthesia for digestive surgery is not a subspe- and abdominal wall defects and also the esopha-
cialty, but some aspects are typical to this type of geal tract, which has characteristics of surgery
surgery. and of anesthesia typical of thoracic surgery.
Abdominal surgery in the pediatric patient
may be performed for a wide variety of congeni-
tal, neoplastic, traumatic, and infectious diseases. 4.2 Anatomic and Physiological
An optimal approach to the planning of anesthe- Characteristics of the
sia for digestive surgery requires not only a good Digestive System in
knowledge of the technical features and an under- Neonates, Infants, and
standing of the physiological alterations associ- Children
ated with the anesthetic and surgical procedure
but also of the patients underlying status. Major differences exist between the gastrointesti-
In addition some physiological modifications nal system characteristics of preterms, neonates,
associated with digestive surgery are influenced infants, and very young children and those of
by particular surgical approaches such as lapa- adults. Some of them have special features useful
roscopy or liver resections, by the anesthetic from the point of anesthesia and intensive care:
agents administered, by the patients underlying
myocardial and respiratory function, and by the The esophagus has a tender thin mucous
patients age: many critical pathologies need membrane, well supplied with blood vessels.
quick surgical correction in neonatal age. Glandules of an esophagus in newborns are
Regarding the age in which the pathologies may completely absent; muscular and elastic tis-
be corrected, it is necessary to consider the poten- sues are poorly advanced. The position of the
tial neurotoxicity of the anesthetic drugs [13]. proximal entrance of the esophagus in new-
borns is high, at the third to fourth cervical
vertebras, while in the adult, it is at the seventh
vertebra. The length of the esophagus is calcu-
A. Gentili (*) V. Landuzzi M.C. Mondardini lated by Bischoffs formula: 1/5 lengths of
Department of Pediatric Anaesthesia and Intensive body + 6.3 cm.
Care, S. Orsola-Malpighi University Hospital, The stomach in infants is set horizontally. The
Via Massarenti 9, Bologna, Italy cardia area of the stomach is undeveloped;
e-mail:; valeria.landuzzi@; therefore, regurgitation is possible. The

Springer International Publishing Switzerland 2017 83

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_4
84 A. Gentili et al.

pyloric part is well developed, and an overde- immaturities of the infant gastrointestinal
velopment of pylorospasm is observed. The tract, and the lack of adequate nutrition.
capacity of the stomach in newborns is
3035 ml, in 1-year-olds 250300 ml, and in
8-year-olds 1000 ml. Low production of gas- 4.3 Preoperative Evaluation
tric juice and low acidity are marked. The
muscular layer is undeveloped, and the gastric The preoperative history and physical examina-
air bubble is enlarged. tion are directed at identifying acute and chronic
The small intestine is long and highly mobile; problems and underlying medical conditions, as
therefore, invaginations are frequently possible. well as previously undiagnosed diseases that may
Secretor insufficiency and high permeability place the child at an increased risk during the
promote penetration into the blood of undi- perioperative management [4].
gested components of nutrition, toxins, and The preoperative history must include insights
microorganisms, causing sensitization. The about intestinal malabsorption, gastroesophageal
immaturity of the ileocecal valve promotes the reflux, digestive tract infections, and triggers of
entrance of bacterial flora from the colon. hepatic failure, such as infectious, toxic, meta-
The colon is situated higher and has a length bolic, infiltrative, and ischemic/vascular prob-
proportional to the body height of the child. lems. Clinical serious conditions may accompany
Haustration under 6 months is absent. The set- such diseases and, in addition to the specific
tling in the intestine of normal microflora symptoms, may include fatigue and weight loss.
begins in the first hours of life and usually In neonatal age, in pathologies such as esophageal
comes to an end by 710 days; therefore, tran- atresia and abdominal wall defects, an evaluation
sitional dysbacteriosis is observed. of the prenatal and maternal history is mandatory
The liver in children is quite large, 4 % of as well as a search for undiagnosed illnesses, dis-
body mass in newborns, and 2 % in adults. The orders, or anomalies, specifically genetic syn-
parenchyma of the liver is poorly differenti- dromes and congenital heart diseases.
ated, and the lobular structure is typical only The physical examination also focuses on the
by the end of the first year of life. The liver is gastrointestinal and hepatobiliary system but
sanguineous and easily enlarged in infectious begins with the pathology, the global assessment,
diseases, intoxication, and circulatory insuffi- and the clinical status of the child.
ciency. In children hemorrhagic syndrome in The preoperative examination of poor esopha-
liver diseases develops more often. geal function, of a full stomach, and bowel
The gastrointestinal tract presents the largest obstruction attempts to identify previous prob-
surface area of the body exposed to antigens lems, which may place the patient at increased
and microbes. The intestine must therefore risks during anesthesia induction, such as an
have intricate mechanisms to allow the entry inhalation syndrome.
of nutrients and other beneficial molecules In patients with a neurological disease, it is
while preventing potentially harmful microbes important to evaluate the respiratory tract, identi-
and other agents from gaining entry into the fying phenomena of dysventilation, atelectasis, or
inner milieu. Several factors lead to a hostile respiratory infections. In the presence of active
gastrointestinal environment that predisposes bronchospasm, a preoperative treatment may be
the neonate and infant to disease. These necessary, and intraoperative anesthetic techniques
include the introduction of feeding tubes into may be required to prevent the exacerbation of
the stomach or more distal intestine, the rou- bronchoconstriction of the small airways [5].
tine use of broad-spectrum antibiotics that In patients with esophageal atresia, it is impor-
select for resistant pathogens that thrive in the tant to assess possible inhalation of saliva or gas-
unusual microbial environment of the neona- tric content into the respiratory tract and to
tal and pediatric intensive care unit, intrinsic evaluate the gastrointestinal distension.
4 Anesthesia in Pediatric Digestive Surgery 85

When a laparoscopy is about to be performed, A rating for antibiotic needs

the respiratory system and cardiocirculatory func- An analgesic perioperative plan
tion should be examined paying attention to all
the determinants of myocardial performance. Par- Risk evaluation and informed consent are
ticularly, preload evaluation is mandatory if an essential elements in preoperative assessment.
abdominal mass compresses the inferior vena cava. The American Society of Anesthesiologists
Laboratory and instrumental evaluations are developed and modified later the classification
often important in the preparation of anesthesia of physical status (ASA) to define a correlation
for abdominal surgery. Among the preoperative of clinical condition and tolerance to surgery.
laboratory tests, particular attention should be The correct information about all possible
given to the complete blood count, which may anesthetic techniques (a pamphlet should be
indicate anemia as a reflection of chronic malab- given before the anesthesiological visit) and in
sorption, and the white blood cell count and the particular of the benefit/risk of the purpose tai-
indexes of infection, which may indicate the pres- lored procedures must be provided before
ence of active abdominal infection, and the plate- acquiring written consent for anesthesia. A
lets, which can be associated with a splenic specific risk such as difficult airway manage-
sequestration. In addition, an investigation involv- ment, or cardiac, respiratory, neurological, and
ing tests of hepatic function and coagulation is metabolic conditions, should be annotated on
recommended in patients with liver compromise: the anesthesiological chart and on the opera-
children who have liver diseases, portal hyperten- tory list.
sion, or splenic diseases are at increased risk for
intraoperative and postoperative bleeding.
Radiological screening (chest radiographs, 4.4 Premedication
computed tomographic scans, magnetic reso- and Preoperative Fasting
nance imaging) is essential to assess the abdomi-
nal anatomy and any additional information At the end of the global evaluation (clinical his-
concerning alterations associated with findings tory, physical examination, laboratory tests,
that may influence the anesthetic and surgical imaging, cardiorespiratory tests), a pharmaco-
management (Table 4.1). logical medication is considered. Sedative pre-
Echocardiography is performed to check for medication is not always necessary, but when
cardiovascular anomalies, right and left ventricle useful, midazolam 500 mcg/kg, orally, is cur-
performances, and pulmonary pressure. rently the most frequently used drug. Midazolam
Lung function testings have been widely used can also be administered by nasal route
in children 68 years of age or greater. Simple (200 mcg/kg). Atropine in clinical practice is
spirometry is easiest to obtain. The results of administered after vein placement only in the
such tests are generally used as indicators of the presence of clinical need. A local anesthetic
complexity of perioperative management. emulsion (lidocaine 25 mg + prilocaine 25 mg)
In patients about to be submitted to digestive or medicated plaster (lidocaine 70 mg + tetra-
surgery, the following procedures are indicated: caine 70 mg, for children over 3 years) is applied
on a detectable peripheral vein. Preoperative
An effective optimization of preoperative fasting is indicated for elective surgery and
therapy healthy patients, to avoid inhalation syndrome at
An appropriate assessment of the need for anesthesia induction. Recent guidelines also
blood products consider the correct preoperative administration
An assessment of the presence and ultimate of drugs to decrease the risk for pulmonary aspi-
need for intravenous access with consider- ration in selected patients [6]. Parents are
ation of temporary or long-term central venous allowed to be present in the operating room at
catheter induction of anesthesia.
86 A. Gentili et al.

Table 4.1 Correlation between gastrointestinal/hepatic problems and potential anesthetic implications
Gastrointestinal/hepatic problems Potential anesthetic implications
Vomiting, diarrhea Electrolyte imbalance, dehydration, full stomach
Gastroesophageal reflux Treat like a full stomach
Increased abdominal volume Diaphragmatic cephalic displacement
Decreased lung compliance
Decreased systemic oxygenation
Ab ingestis inhalation Aspiration pneumonia
Pulmonary infiltrates Decreased lung compliance
Increased V/Q mismatch
Increased pulmonary shunt effect
Decreased systemic oxygenation
Prolonged fasting Dehydration, hypovolemia
Malabsorption Anemia, malnutrition
Black stools Anemia, hypovolemia
Jaundice Drug metabolism/hypoglycemia
Liver dysfunction Drug metabolism/toxicity

4.5 Anesthesiological Approach tor permits the variation of all respiratory items
including frequency, tidal volume (inspiratory
Studies in the literature consider it very important and expiratory), minute volume, peak pressure,
in these patients to achieve a level of anesthesia and mean airway pressure.
which allows a safe execution of the surgical pro- Monitoring also includes body temperature,
cedure. The entire staff, involving different pro- urine output, and inspiratory and expiratory con-
fessional figures, should be trained and educated centration of volatile anesthetics. In many
in order to improve safety, ensure treatment of patients, the neuromuscular blockade is moni-
possible side effects, and guarantee the manage- tored by stimulating the ulnar nerve using the
ment of emergencies [7]. train-of-four pattern of stimulation.
Temperature measurement is a must in pediat-
ric abdominal surgery and in particular in neo-
4.5.1 Monitoring nates. The temperature is tested with the
esophageal probe during major surgery. The use
Standard intraoperative monitoring is both inva- of pre-warmed fluids and active warming sys-
sive and noninvasive and is well described in the tems (mattress, convective warm air blanket,
guidelines for safety in the operating room. radiant heater) is necessary. Anesthesia interferes
Cardiovascular function is monitored by ECG with the thermoregulatory response in all ages.
(heart rate and rhythm), noninvasive systolic A new approach is oriented to measure cere-
blood pressure (SBP), and diastolic blood pres- bral oxygenation (using near-infrared spectros-
sure (DBP); if necessary, a radial arterial catheter copy technology) to reduce potential risks of
is cannulated not only for invasive monitoring but neurolesive events caused by conventional intra-
also for intraoperative and postoperative blood operative ventilation that influence intracranial
gas analysis and laboratory tests. When clinical pressure, cerebral blood flow, and cerebral perfu-
conditions and the fluid requirements are difficult sion pressure [8, 9].
to evaluate, a central venous catheter (CVC) is
placed by a superior cava approach for invasive
monitoring of central venous pressure (CVP). 4.5.2 Vascular Access
The respiratory function is monitored by
peripheral arterial oxygen saturation (SpO2) and Vascular access is necessary in all types of
end-tidal CO2 (ETCO2). The mechanical ventila- surgery.
4 Anesthesia in Pediatric Digestive Surgery 87

Adequate peripheral access is essential intra- and adjuvant drugs, if necessary. Anesthesiological
operatively and also for fluid replacement in the management, today, foresees combined general-
postoperative period. One or two peripheral veins regional anesthesia.
may be necessary. Balanced anesthesia is the most common GA
Clinical conditions and the type of surgery indi- applied, in which a mixture of small amounts of
cate the placement of a single- or double-lumen several drugs, administered by different routes
central venous catheter, appropriate for the size of (inhalation + intravenous), permits a correct anes-
the patient. This vascular access is required both thetic plan for the surgery. Recently, total intrave-
for monitoring and for rapid and safe infusions of nous anesthesia (TIVA) is chosen for pediatric
fluid, plasma expanders, and blood derivatives. The patients. In all pediatric ages and in particular in
upper cava vein approach is mandatory for the liver neonates, many drugs cannot be legally used. The
and oncologic abdominal surgery, particularly bispectral index is designed to observe the anes-
when it has been extended to or into the inferior thetic plan and drug consumption although
cava vein (rarely until the right atrium), and surgery results do not differ from those of conventional
may foresee vein clamping. The use of ultrasono- clinical practice (Table 4.2) [14].
graphic guidance during CVC placement has been
demonstrated the better percutaneous procedure Inhalation Agents Sevoflurane is a halogenated
for decreasing the complications rate [10]. general inhalation anesthetic drug and to date the
most frequently drug employed in pediatric anes-
thesia. It is administered by vaporization vehicled
4.5.3 Intraoperative Fluids by O2/medical air at different FiO2. The mini-
mum alveolar concentration (MAC) in neonates
Intra-surgical crystalloid infusion was 20 ml/kg (3.3 %) and children until 3 months (3.2 %) is
during the first hour in patients under 3 years and similar, but older infants and children have a
15 ml/kg for older patients; in the hours that fol- lower MAC of approximately 2.5 %. During
lowed, the infusion dosage was 810 ml/kg/h for mask induction, the incidence of agitation is near
all patients. 14 %, but laryngospasm and bronchospasm are
Extravascular or interstitial sequestration of present in around 1 or 2 %. It is quite clear that
fluid (the so-called third-space fluid loss) can the concomitant use of opioids requires a lower
occur during digestive surgery. Estimated third- halogenated concentration. Inhalation anesthesia
space fluid deficits are replaced with isoosmotic consents a rapid recovery, but agitation is fre-
fluids, at rates according to the type of surgery quently present and is considered an adverse
(approximately 4 ml/kg). The infusion used was effect [1517].
0.81 % dextrose in polyelectrolyte solution or in
quarter-strength normal saline solution (0.2 % Intravenous Agents Although in the past years
NaCl) and lactated Ringers solution [1113]. sodium thiopentone, belonging to the
pharmacological class of barbiturates, was con-
sidered the most commonly used intravenous
4.5.4 Anesthetic Techniques agent for anesthesia induction, propofol is now
the most frequently employed induction agent
General anesthesia is increasingly associated (1.53 mg/kg) in pediatric age. The current and
with regional anesthetic techniques, to optimize recent literature contains many reports of good
anesthesia and analgesia results throughout the results in particular for anesthesia induction in
perioperative period. procedural deep sedation [1820]. In preterm
neonates and in the first 10 days of life, there is a General Anesthesia (GA) risk of propofol accumulation if given both for an
Anesthetic management can be performed by intermittent bolus and infusion. It would seem
inhalation or intravenous hypnotics, associated sensible at present to limit its use to single-bolus
with neuromuscular blocking agents, opioids, administration [2124].
88 A. Gentili et al.

Table 4.2 Drugs used during digestive general anesthesia in pediatric age
Drug Induction doses Maintaining doses
Anesthetic agents
Sevoflurane* 18 % 23.5 %
Thiopental 36 mg/kg
Propofol 2.53 mg/kg 912 mg/kg/h
Fentanyl 12 mcg/kg 13 mcg/kg/h
Alfentanil 715 mcg/kg 0.51.5 mcg/kg/min
Remifentanil 0.51 mcg/kg 0.31 mcg/kg/min
Neuromuscular blocking agents
Atracurium besylate 0.30.5 mg/kg 0.20.4 mg/kg/h
Cisatracurium besylate 0.150.25 mg/kg 0.10.3 mg/kg/h
Vecuronium 0.080.1 mg/kg 0.060.08 mg/kg/h
Rocuronium 0.6 mg/kg 0.30.6 mg/kg/h
Sevoflurane is a halogenated gas. Its administration is related to minimum alveolar concentration (MAC) Regional Anesthesia (RA) permits the needle location to be identified, and
It is generally accepted that RA provides safe and reduces the amount of local anesthetic adminis-
effective pain relief, as it provides the block of tered [31].
sensory transmissions [25, 26]. Regional anes- The drugs used are local anesthetics and opi-
thetic techniques also in pediatric patients pro- oids for both top-up boluses and continuous infu-
vide safe and effective pain relief during and after sion. It should be noted that the binding of local
surgery with different techniques [27]. anesthetics with plasmatic protein (albumin and
A recent study of the ADARPEF revealed a -glycoprotein) is reduced in both newborn and
low incidence of complications related to regional infants and can result in an accumulation of the
anesthetic techniques and concludes that RA has drugs themselves, especially if a continuous infu-
a good efficacy and safety [28]. The application sion is planned, with potential toxic risks.
of pediatric regional anesthesia blocks has Currently, selected local anesthetics for pedi-
increased in recent years; neuraxial blocks are atric techniques are left-handed enantiomers
applied in all ages and peripheral blocks are rap- (levobupivacaine and ropivacaine), and this
idly expanding especially in children aged 5 makes the technique safer. The association of
years or older. In pediatrics RA is performed local anesthetics with opioids allows the use of
under GA or deep sedation to reduce potential low doses of both. Morphine, which was once the
damages from a loss of behavioral control during most widely used opioid, owing to the increased
the procedure and to keep hypnosis during sur- incidence of respiratory depression, vomiting,
gery. However, RA reduces intraoperative anes- and itching, is now often replaced by fentanyl.
thetic requirements, supporting recovery and
early ambulation and shortening the time to reha- Neuraxial Blocks Central neuraxial bock is
bilitation [29, 30]. A necessary condition to suggested for patients undergoing major abdomi-
obtain the most benefits from RA is the knowl- nal surgery. In the spinal approach, drugs are
edge and expertise of the specialist who chooses administered intrathecally into the cerebrospinal
and applies the techniques and appropriate and fluid, in epidural approach into the fatty tissues
adequate equipment and devices. Ultrasound surrounding the dura [32]. Absolute contraindi-
guidance is the best clinical practice both for cations are local infection at injection site, hypo-
neuraxial and peripheral blocks. Ultrasonography volemia, shock, coagulopathy, high intracranial
could augment the success rate, since it allows pressure, allergy to local anesthetics, and parent
anatomical structures and nerves to be visualized, refusal. Relative contraindications include sepsis,
4 Anesthesia in Pediatric Digestive Surgery 89

neurological dysfunction, and anatomic abnor- less than 20 years ago, when Anand published his
malities. Neurological injury, infection, isch- work [38].
emia, seizures, hypotension, and cardiac arrest
are the risks of neuraxial anesthesia. It should be Peripheral Nerve Blocks Peripheral nerve
remembered that there are some anatomical dif- blocks are a valid alternative to the neuraxial tech-
ferences between adults and children in the lum- nique, with good sensory block and without the
bosacral region [33]. major complications of central block. Sympathetic
block and hemodynamic changes are minimal as
Caudal Epidural Block Epidural block by caudal well as motor block and urinary retention. The use
route, the most popular technique in pediatrics, is of neurostimulation and ultrasonography is rec-
suggested in herniorrhaphy and other pathologies ommended although, in the latter case, evidence
with surgical under umbilical approach. The cau- is not strong. The length of block depends on the
dal space is easy to find in patients less than 7 pharmacokinetics of the local anesthetic, long-
years of age, when block is commonly performed. acting anesthetics such as levobupivacaine or
The sacral hiatus is found by searching for a tri- ropivacaine are preferred, while adjuvants such as
angle with the base formed by a line joining the clonidine may extend the duration.
right and left sacral cornea and the apex at the
lower IV sacral vertebrae. The sacral hiatus is Ilioinguinal-Iliohypogastric Nerve Block This
situated higher in children than in adults. The block may be used for surgical procedures in the
dedicated needle passes, at a nearly 45 angle, inguinal region such as herniorrhaphy. Using a
through the sacrococcygeal ligament, and after landmark technique, the puncture site is about
loss of resistance, the local anesthetic is injected. 1 cm medial to the anterior superior iliac spine,
This block is more frequently used as a single but this traditional technique is burdened with
shot. Adjuvants may be added to prolong the high failure rates. The point of injection by ultra-
duration of analgesia. Over the past several years, sound is more lateral, and the transversus abdom-
caudal catheters were introduced upward even to inis/internal oblique fascial plane needs to be
thoracic level especially in neonates and infants, identified, where the nerves could be found [39].
but this technique is no longer recommended,
because of the risk of fecal soiling [34, 35]. Rectus Sheath Block A rectus sheath block pro-
vides effective pain relief and muscle relaxation
Lumbar Epidural Block In contrast to the caudal for laparoscopic surgery and other small midline
block, lumbar epidural block is rarely used as a incisions. It is performed bilaterally, between the
single injection, and usually a catheter is inserted. rectus abdominis muscle and the posterior rectus
Catheter placement is based on surgical incision sheath. The unpredictable depth of the posterior
location corresponding to segmental levels to tar- rectus sheath in children is a good argument for
get analgesia. This technique should be performed the use of ultrasound together with the advantage
by experienced anesthesiologists. In very small of allowing visualization of the bowel, which
infants, epidural needles are inserted below L4 so, may decrease accidental puncture [40].
to achieve the desired segmental level, the cathe-
ters should be threaded for a long segment, moni- Transversus Abdominis Plane (TAP) Block TAP
toring the efficacy of the pain relief. Currently, the block is effective in laparoscopic procedures and
indication is to decrease the distance of insertion open surgery. Its use is limited by the need for
to as short as 34 cm inside the epidural space. bilateral blocks when the incision crosses the
Central blocks have a history of more than 100 midline. This, like the other abdominal wall
years in adults, but in pediatrics RA was rarely blocks described above, is effective for somatic
applied/described [36, 37] and became an essen- pain but not for visceral pain. TAP block may be
tial integrated, safe, and effective analgesic sys- useful when epidural analgesia is contraindi-
tem producing excellent intraoperative analgesia, cated. Local anesthetic should be placed between
90 A. Gentili et al.

the internal oblique and transversus abdominis ileus, earlier postoperative mobilization, shorter
muscles; the triangle of Petit is used as landmark periods of disability, shorter hospital stays, and
for injection; a relatively large volume of anes- better cosmetic results in favor of laparoscopic
thetic is required [41]. videosurgery [4345]. Other benefits, compared
to traditional open operative techniques,
Local Wound Infiltration Local wound infiltra- include the avoidance of large incisions, less fluid
tion is a component of multimodal postoperative loss, heat, and forced retraction of tissues.
analgesia. The single-shot infiltration of local An optimal approach to the planning of anes-
anesthetics in laparoscopic working ports is more thesia for laparoscopy depends on a knowledge
commonly performed than continuous wound of the technical requirements and an understand-
infiltration for fear of complications. Also intra- ing of the physiological alterations associated
peritoneal instillation was rarely performed, with the procedure.
although a systematic review and meta-analysis Physiological changes during laparoscopic
of its effectiveness in adults have given promis- surgery are related to the changes associated with
ing results [42]. the increased abdominal pressure associated with
insufflation of the abdomen, the patients pos-
tural modifications (head-up or head-down), and
4.5.5 Intraoperative Ventilation the CO2 absorption and its general effects [46].
The magnitude of the physiological perturba-
The aim of intraoperative ventilation techniques tions associated with laparoscopy is influenced
is to maintain normal levels of oxygenation and by the patients age, the patients underlying
normocapnia. The aim to facilitate the digestive myocardial and respiratory function, and the
intervention and the advice to avoid high pres- administered anesthetic agents.
sure in the airway should be remembered. Tension pneumoperitoneum causes an eleva-
Pulmonary mechanical ventilation for these tion in intra-abdominal pressure (IAP) which
patients reflects the traditional intraoperative produces important effects on cardiovascular,
ventilation techniques. Patients were mechani- pulmonary, renal, and metabolic function.
cally ventilated using an oxygen/air mixture with
oxygen inspired fraction (FiO2) between 0.35 and
0.50; tidal volume was adjusted between 9 and 4.6.1 Effects on Respiratory System
10 ml/kg, and respiratory rate (RR) was regulated
on the basis of the patients age. The ratio of Pneumoperitoneum and increase in IAP cause
inspiratory time to expiratory time was usually cephalic displacement of the diaphragm, resulting
1:2. Positive end-expiratory pressure (PEEP) was in the reduction in lung volumes including vital
set at 34 cm H2O. capacity, total lung volume, and functional resid-
ual capacity (FRC). This phenomenon is exacer-
bated by cephalic shift of the abdominal contents
4.6 Laparoscopy in Digestive in the head-down position. Pulmonary compliance
Surgery is reduced and airway resistance is increased, pro-
ducing a higher airway pressure for any given tidal
Laparoscopic videosurgery is becoming increas- volume with an increased risk of hemodynamic
ingly more important in pediatric abdominal sur- changes and barotrauma during intermittent posi-
gery for both the diagnosis and surgical treatment. tive pressure ventilation (IPPV). Restriction in dia-
Several authors who have compared this tech- phragmatic mobility promotes uneven distribution
nique to traditional surgery for the treatment of of ventilation to the nondependent part of the lung,
some pathologies have reported reduced surgical resulting in ventilation-perfusion mismatch with
trauma, less postoperative pain, reduced periop- hypercarbia and hypoxemia. This preferential ven-
erative morbidity, shorter period of postoperative tilation is increased further by supine position,
4 Anesthesia in Pediatric Digestive Surgery 91

inhalational anesthetic agents, and neuromuscular increases in left ventricular end-diastolic volume
blockade [47, 48]. (EDV), left ventricular end-systolic volume
Another important respiratory implication is (ESV), and left ventricular end-systolic meridio-
represented by CO2 insufflation. Insufflated CO2 nal wall stress (LVESWS). Before, during, and
is rapidly absorbed across the peritoneum and after intra-abdominal insufflation, systolic func-
can lead to an increase in the total body CO2 con- tion indexes, left ventricular fractional shortening
tent. If ventilation is controlled and not changed (LVFS), and left ventricular ejection fraction
in response to this increase, then the arterial pCO2 (LVEF) underwent slight, insignificant changes.
will rise. During the surgical procedure, LVFS and LVEF
remained within a range above 25 % and 55 %,
respectively. Furthermore, there were no varia-
4.6.2 Effects on Cardiocirculatory tions in the LVESWS/LVFS ratio. In this study,
System pneumoperitoneum induction determined the
increase in both EDV and ESV. The EDV is rec-
In recent years, important knowledge has been ognized as a good indicator of preload; the
obtained about the cardiovascular changes increase is mostly due to a drainage effect on the
induced by pneumoperitoneum in children. splanchnic circulation, with an increase in venous
Routine clinical measurements, such as heart rate return to the right heart. The increase in ESV
and blood pressure, have been used to assess the could be partly the result of slightly impaired
hemodynamic changes induced by laparoscopy. contractility, probably affected negatively by
Studies so far have shown most effects on blood anesthetic drugs, and partly of an acute increase
pressure, which often increases, while there are in afterload, more correctly expressed as aortic
no or only slight effects on heart rate [47, 48]. impedance. The myocardial left ventricular per-
Experimental studies on the intraperitoneal insuf- formance remained stable in all patients of the
flation of young animals have also shown an study, as shown by the absence of any modifica-
increase in venous return, peripheral arterial tion in the LVFS and LVEF. A parallel increase in
resistance with impaired splanchnic circulation, ESV explains why LVFS and LVEF did not
cardiac output, and cardiac index [49]. In pigs change significantly. These results could repre-
weighing 38 kg, the presence of hypercarbia sent the balanced effect of the increase in both
during peritoneal insufflation increased heart preload and afterload induced by elevated intra-
rate, left ventricular stroke work, and cardiac abdominal pressure, through a combined action
index, without changes in total peripheral resis- on venous return and aortic impedance [52].
tance or central venous pressure [50]. A study Pneumoperitoneum in children has a major
concerning the hemodynamic effects of pneumo- impact on cardiac volumes and function, mainly
peritoneum in healthy infants, by continuous through the effect on ventricular load conditions.
esophageal aortic blood flow echo Doppler, dem- The acute increase in IAP affects both preload
onstrated that abdominal insufflation with a pres- and afterload, while the systolic cardiac perfor-
sure of 10 mmHg resulted in a significant mance remains unchanged. The final advice of
decrease in aortic blood flow and stroke volume these studies was to remain prudent before sub-
and in a significant increase in systemic vascular jecting a child with cardiopathy to laparoscopy.
resistance [51]. To date, the literature has reported many experi-
Another study examined cardiovascular ences of laparoscopy in children with cardiac dis-
changes associated with intra-abdominal insuf- ease, offering reassuring messages about this
flation (10 mmHg) using echocardiography with procedure and its outcome. Today, the culture
transthoracic approach. Systolic blood pressure and experience exist to improve or complete the
and diastolic blood pressure increased during mosaic of pediatric heart diseases, relating the
intra-abdominal insufflation. Heart rate remained cardiocirculatory changes of laparoscopy to the
regular. Pneumoperitoneum was associated with various pathophysiological and clinical profiles
92 A. Gentili et al.

of homogeneous groups of children with similar An inability to pass a nasogastric or orogastric

heart lesions [53]. suction catheter is almost always diagnostic.
A preanesthetic plan included an evaluation of
associated anomalies, present between 30 and
4.6.3 Management of Intra- 50 % of babies. The most common are the con-
abdominal Pressure genital heart diseases, particularly tetralogy of
Fallot, pulmonary atresia, atrial or ventricular
It is important not to exceed an intra-abdominal septal defects, patent ductus arteriosus, and aortic
pressure of 6 mmHg in newborns, 8 mmHg in coarctation. Echocardiography is performed rou-
infants, and 12 mmHg in older children so as to tinely on these babies preoperatively. Vascular
minimize the negative effects on cardiocircula- anomalies and upper airway problems such as
tory function and cardiac output. The IAP read- laryngo- or tracheomalacia may be present.
ing should be clearly visible to the anesthetist and Severe tracheomalacia is not unusual and may
documented on the record [46, 47]. require prolonged intubation or even tracheos-
After starting the pneumoperitoneum, the tomy. Cleft lip and palate may be found in asso-
position of the tracheal tube needs to be checked ciation with esophageal atresia, as may vertebral,
again to exclude an endobronchial position which renal, and anorectal defects.
can result from the diaphragm and lungs being The term VACTERL has been used to describe
shifted upward relative to the tube. a syndromic complex with usual associated
anomalies: V vertebral, A anorectal, C cardiac, T
tracheoesophageal fistula, E esophageal atresia,
4.7 Esophageal Atresia R radial or renal, and L limb. The term CHARGE
describes another syndrome represented by C
4.7.1 Preoperative Management coloboma, H heart disease, A atresia choanae or
esophageal atresia, R retarded growth, G genital
Esophageal atresia (EA) and tracheoesophageal anomalies, and E ear anomalies.
fistula (TEF) are congenital anomalies that com- To diagnose and manage this anomaly, it is
monly occur together with an incidence of imperative to carefully pass an orogastric tube
1:30004500 live births. Surgical repair should into the proximal pouch, typically meeting resis-
be performed within the first few days of life. tance at 810 cm. Awake prudent aspiration of
Careful preoperative management is manda- the proximal pouch is performed in the preopera-
tory for a good surgical result of this pathology. tive period.
The essential components that need to be imple- To avoid inhalation in the respiratory tract, the
mented after birth as early as possible are: neonate should be kept with the head of the bed
elevated to 3545. A chest radiograph confirms
Diagnosis the diagnosis, revealing the tip of the tube in a
Investigation of associated anomalies dilated, air-filled proximal atresic pouch. Distal
Suction of the upper pouch bowel gas confirms the presence of a tracheo-
Prevention and treatment of gastric and bowel esophageal communication, most commonly a
distension distal fistula.
A typical presentation of newborn with esoph-
Prenatally, esophageal atresia is often not ageal atresia is variable impairment in respiratory
identified and only suspected in the presence of function. Often there is no respiratory distress,
polyhydramnios, cardiac malformation, or chro- but it must be remembered that its presence may
mosomal abnormalities. In the absence of prena- have different origins, sometimes associated:
tal suspicion, the postnatal presentation typically inhalation in the respiratory tract of saliva through
includes respiratory distress with initial feedings the upper airway or gastric juice from the fistula,
associated with excessive drooling or salivation. prematurity, failure in severe cardiac malforma-
4 Anesthesia in Pediatric Digestive Surgery 93

tion, significant deformity of the rib cage, and

excessive gastric distension.
In preoperative treatment it should not be
underestimated that excessive crying can help
increase the flow of air into the stomach through
the distal fistula. A sedation with midazolam at
low doses (0.50.8 mcg/kg/h) may be necessary.
Similarly, aggressive abdominal palpation should
be avoided, as this could lead to reflux of gastric
content into the fistula and direct aspiration into
the airway.
The onset of respiratory distress with the need
of intubation and excessive gastric distension are
clinical situations that can accelerate the surgical Fig. 4.1 The rigid bronchoscopy

4.7.2 Intraoperative Management Anesthesia
The anesthesiological approach of esophageal
atresia with tracheoesophageal fistula aims to
avoid on the one hand an excessive gastric disten-
sion determined by positive pressure ventilation
and, on the other hand, an acid reflux into the
The literature suggests an induction of anes-
thesia maintaining spontaneous respiration, with
topical administration of lidocaine (35 mg/kg),
without application of a positive pressure via face
mask. For this purpose, inhalation anesthesia is
often indicated in several studies. Fig. 4.2 Esophageal atresia type III. Tracheoesophageal
fistula in the carina: trifurcation Airway Endoscopy
A preliminary procedure to surgery consists in From a diagnostic standpoint, the endoscopy
the airway endoscopic evaluation, which is in allows the identification of the EA type, the char-
fact the most reliable method for the recognition acteristics and size of the fistula, as well as the
of tracheoesophageal fistula (TEF), and allows an anatomic relationship with the esophageal
exact classification of esophageal atresia. pouches. From an operative point of view, the
The literature contains various descriptions of endoscopy allows the fistula themselves to be
airway endoscopy used for the recognition of incannulated, which, in the case of distal TEF
TEF, performed both with flexible and rigid (Fig. 4.2), gives access to the stomach, which can
instruments [54]. The use of the rigid endoscopy then be drained, reducing the risks of aspiration
(Fig. 4.1) is reported in numerous studies and pneumonia and improving the mechanical venti-
allows us to assure an open airway and assists lation. The identification of the precise anatomic
operative management: in the presence of TEF, position of the TEF allows the tip of the endotra-
the airway endoscopic procedure was in fact cheal tube to be adjusted in order to achieve the
diagnostic and operative at surgery [55, 56]. optimal ventilation. Large or carinal fistula may
94 A. Gentili et al.

bring about potential complications during anes- presence of the upper fistula and plan correctly
thesia if the endotracheal tube happens to slip the therapeutic strategy: the presence of upper
into them. The presence of the catheter or set of fistula led us to revise the diagnosis of two EAs at
balloon catheters through the fistula (Figs. 4.3 first considered of type III to EA of type IV
and 4.4) prevents gastric insufflation, reducing (Fig. 4.5) and one EA of type I, without fistula, to
the risk of pulmonary aspiration, and guides the EA of type II.
surgical dissection during minimally invasive or The rigid ventilating tracheobronchoscopy,
open surgery [57]. performed by experienced specialists, improves
The recognition of an upper fistula is particu- perioperative management of newborns affected
larly difficult because the fovea is smaller, or by EA and appears to be a safe and effective
hardly visible, compared to lower TEF. This ana- procedure.
tomical condition explains the need sometimes
for a second endoscopy to better identify the Thoracoscopic Implications
Esophageal atresia repair also foresees the thoraco-
scopic technique, which in newborns requires the
lung to collapse, at least partially. There are two
methods of achieving this. The first is lung exclu-
sion which, using bronchial blocker with one-lung
ventilation, allows the lung to collapse passively,
and the second is lung compression by carbon
dioxide insufflation. It should also be noted that the
pathology and age of the patient often influence
lung exclusion achievement. In neonatal age it is
often impossible to perform lung exclusion.
Both methods are associated with serious
respiratory and cardiocirculatory physiopatho-
logical problems that have been extensively stud-
Fig. 4.3 Esophageal atresia type III: distal tracheoesoph- ied in adult patients, but to a lesser extent in the
ageal fistula with placement of catheter neonatal and pediatric age.

Fig. 4.4 Esophageal atresia type III: in rigid bronchos-

copy the catheter, through the tracheoesophageal fistula, Fig. 4.5 Esophageal atresia type IV: double tracheo-
is placed in the stomach esophageal fistula, distal and upper with catheter
4 Anesthesia in Pediatric Digestive Surgery 95

Lung exclusion presents extreme difficulties birth of these children can be programmed. Many
in newborns, although some cases are reported in of these babies are of low birth weight, especially
literature [58, 59]. The difficulty in finding a suit- those with gastroschisis.
able bronchial blocker for the newborn and the In the preoperative evaluation of the newborn,
poor tolerance of prolonged lung ventilation are it is important to evaluate the common anoma-
elements that favor the use of pleural insufflation. lies associated, more frequent with omphalo-
While during one-lung ventilation a marked cele. Other gastrointestinal malformations or
decrease in oxygenation results from an increased genitourinary and craniofacial anomalies may
intrapulmonary shunt due to the unventilated and be present, including harelip and cleft palate.
collapsed lung, with pleural insufflation, the rise Important syndromic abnormalities include
in pleural cavity pressure brings about notable Beckwith-Wiedemann syndrome (macrosomia,
hemodynamic effects that greatly decrease the macroglossia, and hypoglycemia), imperforate
preload, stroke volume, cardiac output, and mean anus, chromosomal anomalies (trisomies 13, 18,
arterial pressures. Cardiovascular function is 21), as well as cardiac malformations including
penalized in direct proportion to the intrapleural the pentalogy of Cantrell, characterized, in addi-
insufflation values, while generally the respira- tion to omphalocele, by short sternum, anterior
tory parameters are only slightly compromised diaphragmatic hernia, left ventricular diverticu-
and hemogasanalytic changes are unremarkable. lum, and deformity of the rib cage. Some patients
The pleural CO2 insufflation always brings about have a very narrow dog-type chest with under-
a fall in cardiocirculatory performance, which is lying hypoplastic lungs and may die early with
generally well tolerated in the euvolemic patient respiratory failure or later with cor pulmonale.
with normal cardiac function. An insufflating The large surface area of exposed bowel out of
pressure limitation, a slow artificial pneumotho- the abdominal wall predisposes the patient to
rax, and a cardiovascular function optimization fluid and electrolyte disturbance due to gastroen-
(by fluid administration or possible use of inotro- teric loss and increased evaporation, heat losses,
pic agents) can be useful to limit negative cardio- infections, and decreased mesenteric blood flow
circulatory effects [6062]. with risk of ischemia of the intestinal loops. The
preoperative goals to appropriately resuscitate
the newborn are:
4.8 Abdominal Wall Defects
Predispose warming measures, including the
4.8.1 Preoperative Management increase of ambient room temperature, use of
heating lamps and forced-air warming blan-
Abdominal wall defects are constituted by kets, and infusion of heated fluids.
omphalocele and gastroschisis. The first is a her- Ensure an effective hydration, even with sup-
niation within the umbilical cord, and the second plementation of blood and its derivatives, if
is a defect of the abdominal wall lateral to the necessary. Fluid resuscitation with isotonic
umbilicus, usually on the right side. Omphalocele, solutions such as 12 % dextrose in polyelec-
with an incidence of 1 in 500010,000 live births, trolyte solution, normal saline, or Ringers
is more common than gastroschisis, which has an lactate is recommended for the newborn with
approximate incidence of 1 in 30,000 live births. marked hypovolemia. Volume resuscitation is
Surgical repair should be performed prefera- usually continued until the infants urine out-
bly within the first day of life; in gastroschisis the put normalizes and/or blood gases indicate
wait can be just a few hours. Timely and appro- normal acid-base balance.
priate preoperative treatment is mandatory for a Prevent infections by antibiotic therapy and
good surgical result of this disease. placement of a plastic bag that encloses the
These conditions are very readily diagnosed entire infant below the nipples, including all
antenatally by ultrasonography, and often the externalized viscera.
96 A. Gentili et al.

Ensure a good splanchnic perfusion by cardio- The anesthetic technique must provide a good
vascular function optimization with fluid analgesia, obtained by opioids and a large use of
administration or possible use of inotropic muscle relaxants, to obtain the most effective
agents. For this purpose, the position of the help for the closing of the wall defect with
baby is important because it does not have to replacement of the viscera in the abdomen. In
lead to a kinking or twisting of the bowel addition to anesthetic support, surgical strategies
loops. Infants with gastroschisis should be to achieve primary repair include stretching of
positioned on their right side in a lateral decu- the abdominal wall, evacuating the contents of
bitus position to enhance venous blood return the stomach and small bowel, irrigating
from the gut. meconium from the intestines, and enlarging the
Predispose a gastroenteric decompression defect by leaving a fascial hernia.
by naso-/orogastric tube, placed to intermit- The determination of objective criteria that
tent suction. Decompression is important would predict safe, primary closure of abdominal
because it helps to prevent partial or total wall defects is based mainly on intraoperative
obstruction of blood flow and oxygenation to measurement of intra-abdominal pressures that
the bowel. should be kept less than 20 mmHg to prevent
adverse hemodynamic consequences to other
Stabilization and the decision about the most organs and tissues. However, during surgery, it is
appropriate time for the surgical repair must take also necessary to consider changes of other intra-
into consideration many factors, including ther- operative hemodynamic parameters such as cen-
moregulation, fluid volume status, gastric disten- tral venous pressure, cardiac output, arterial
sion and intestinal compromise, infection, blood pressure, and heart rate as well as of the
respiratory status, and preparation for surgery. urine output and of respiratory parameters such
Stability of the aforementioned factors is neces- as oxygenation, ETCO2, and airway pressure dur-
sary before the impending surgical repair to opti- ing mechanical ventilation [64].
mize the infants outcome [63].

4.8.2 Intraoperative Management
1. Nasr VG, Davis JM (2015) Anesthetic use in newborn
infants: the urgent need for rigorous evaluation.
The treatment of choice for omphalocele and gas-
Pediatr Res 78(1):26
troschisis defects in newborn is primary repair, 2. Sanders RD, Hassell J, Davidson AJ, Robertson NJ,
whenever possible. Primary closure carries the Ma D (2013) Impact of anaesthetics and surgery on
risk of placing the abdominal contents under neurodevelopment: an update. Br J Anaesth
excessive pressure and producing reduction of
3. McCann ME, Soriano SG (2012) Perioperative cen-
cardiac output, hypotension, bowel ischemia, tral nervous system injury in neonates. Br J Anaesth
anuria, and respiratory failure. Sometimes there 109(1):6067
is a chance that this clinical situation will develop 4. Serafini G, Ingelmo PM, Astuto M, Baroncini S,
Borrometi F, Bortone L, Ceschin C, Gentili A,
into a full-blown abdominal compartment
Lampugnani E et al (2013) Preoperative evaluation in
syndrome. infants and children: recommendations of the Italian
When primary closure cannot be achieved, Society of Pediatric and Neonatal Anaesthesia and
either because of the large size of the defect or Intensive Care (SARNePI). Minerva Anestesiol
because it compromises respiratory and cardio-
5. Rajesh MC (2015) Anaesthesia for children with
vascular function, the alternative approach is a bronchial asthma and respiratory infections. Indian
staged repair utilizing a pouch. This staged repair J Anaesth 59(9):584588
carries an increased risk of infection as well as 6. ASA Committee on Standards and Practice Parameters
(2011) Practice guidelines for preoperative fasting
the need of multiple anesthetic and surgical
and the use of pharmacologic agents to reduce the
procedures. Risk of pulmonary aspiration: application to healthy
4 Anesthesia in Pediatric Digestive Surgery 97

patients undergoing elective procedures: an updated 23. Allegaert K, De Hoon J, Naulaers G, Van De Velde M
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7. Gregory GA (2012) Gregorys pediatric anaesthesia, Anaesthesiol Belg 59:283288
5th edn. Churchill-Livingstone, New York 24. Skinner AV (2010) Neonatal pharmacology. Anaesth
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9. Ing C, Chui I, Ohkawa S, Kakavouli A, Sun L (2013) Neonatal regional anaesthesia: alternative to general
Incidence and causes of perioperative endotracheal anaesthesia for urologic surgery. Urology
reintubation in children: a review of 28208 anesthet- 41(4):362365
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10. Sang P, Yoon HK, Sang YS et al (2013) Ultrasound- cal surgery. Int Anesthesiol Clin 31(1):5766
guided subclavian catheterization in pediatric patients 27. Dalens B (2006) Some current controversies in pedi-
with a linear probe: a case series. Korean J Anesthesiol atric regional anaesthesia. Curr Opin Anaesthesiol
64(6):541544 19(3):301308
11. Lindahal SG (1988) Energy expenditure and fluid and 28. Ecoffey C, Locroix F, Giaufre E (2010) Epidemiology
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M, Baroncini S (2000) Cardiocirculatory changes
Intensive Care in Digestive Surgery
Andrea Gentili, Rosina De Rose, and Elisa Iannella

5.1 Introduction 5.2 Intensive Monitoring

Postoperative admission to the pediatric intensive Monitoring is one of the main prerogatives of
care unit (PICU) is foreseen for all pediatric intensive perioperative hospitalization, which
patients undergoing major digestive surgery and may involve pathologies with clinical controls
all children with a basic critical illness, often unre- and rapid autonomization or others requiring
lated to the abdominal problem that leads to sur- long and complex assistance.
gery, which requires monitoring and/or intensive Particular importance is given to respiratory
treatment. Hospitalization in intensive care monitoring, with attention to the type of mechan-
increases the security of critical patients in the ical ventilation, the respiratory weaning, and the
delicate phase that follows the surgery, character- techniques of noninvasive respiratory assistance,
ized by the need to maintain a proper respiratory, and to the cardiovascular, metabolic and electro-
cardiovascular, and metabolic function and stabili- lyte, temperature, and neurological monitoring
zation of these features, together with the need for carefully tailored to the level of consciousness
analgesia and sedation, appropriate fluid therapy and sedation of the patient.
and electrolyte compensation, neurological moni- The respiratory monitoring involves simple
toring, and prevention/treatment of infections. and noninvasive instrumentation ranging from
It should also be pointed out that for some dis- pulse oximetry and capnography to the reading of
eases, often typical of the neonatal age, such as volumes, pressures, and compliance curves pres-
esophageal atresia, abdominal wall defects, and ent during mechanical ventilation. An important
necrotizing enterocolitis, the surgery is part of an control is that of the arterial blood gases, which
intensive treatment, which begins at birth and offers the opportunity to further monitor oxygen-
which also involves an important phase of preop- ation parameters such as alveolar-arterial gradi-
erative treatment and stabilization. For these clin- ent oxygen (A-aDO2), oxygenation index (OI),
ical conditions, the more correct term is arterial-alveolar ratio (a/AO2), and PaO2/FiO2
perioperative intensive care [1]. ratio, useful in the evaluation of the postoperative
alveolar recruitment in many challenging dis-
eases such as esophageal atresia, omphalocele,
A. Gentili (*) R. De Rose E. Iannella and gastroschisis. The traditional control of the
Department of Pediatric Anaesthesia and Intensive chest with imaging through X-ray until the com-
Care, S. Orsola-Malpighi University Hospital, puted tomography is now usefully supplemented
Via Massarenti 9, Bologna, Italy by the use of ultrasound lung, easily repeatable
e-mail:; rosina.derose@; and usable in the control/treatment of conditions

Springer International Publishing Switzerland 2017 99

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_5
100 A. Gentili et al.

such as pneumothorax, pleural effusion, and pul- respiratory failure. Early respiratory weaning and
monary atelectasis [2, 3]. extubation are safe and feasible in many patients,
Hemodynamic monitoring focuses on param- but in a significant minority, this might not be
eters of the conventional type such as ECG, inva- possible. A number of factors have been shown to
sive or noninvasive blood pressure, and central contribute to delayed weaning from the ventila-
venous pressure as well as on parameters obtained tor. These include perioperative factors such as
through the method of pulse contour analysis and known chromosomal and neurological abnormal-
transpulmonary thermodilution, which allow the ities, the age of the patients, the presence of air-
continuous evaluation of cardiac output, periph- way problems and pulmonary disease, the
eral vascular resistance, and stroke volume, in complexity of the operation, postsurgical compli-
addition to the measurement of preload in volu- cations, and myocardial dysfunction.
metric terms and the estimation of the intratho- The main objectives of such support are the
racic blood volume (ITBV) and the amount of insurance of an adequate alveolar ventilation,
extravascular lung water (EVLW). with CO2 removal associated with a satisfactory
Furthermore, it is possible to obtain the evalu- oxygenation, improving the relationship of venti-
ation of the perfusion of tissues such as the brain, lation/perfusion (VA/Q), encouraging alveolar
renal, and splanchnic through the near-infrared recruitment, and reducing the work of breathing
spectroscopy (NIRS). Finally, again through (Table 5.1).
ultrasound method, the monitoring of the filling The first measures are constituted by methods
fluid challenge can be obtained through the mea- of noninvasive ventilatory (NIV) assistance,
surement of the size of the vena cava. combining oxygen therapy with the possible
Monitoring in PICU includes control of the application of positive airway pressure and/or of
main laboratory tests and evaluation at regular a ventilatory support (high-flow nasal oxygen,
intervals of daily input and output of fluid in NIV equipment), with the use of different inter-
order to accurately assess the volume status of faces depending on the age of the patient (nasal
the patient. prong, masks, or helmets) (Figs. 5.1 and 5.2) [4].
The children admitted require careful moni- If the newborn and children require intuba-
toring to prevent infectious complications. The tion, the possibilities of ventilatory assistance can
monitoring follows a strict protocol of surveil- range from techniques of controlled ventilation
lance involving culture tests such as throat swabs, (mainly controlled pressure) to assisted methods,
rectal samples, biological tracheobronchial secre- used in the weaning of patients such as synchro-
tions, gastric and urinary content, and material nized intermittent mandatory ventilation (SIMV),
conducted by any drainage. The surveillance pressure support (PS), and continuous positive
begins at the induction of anesthesia in the oper- airway pressure (CPAP) [5, 6].
ating room or at the time of admission to the
PICU. It should also examine all the types of Table 5.1 Objectives of mechanical ventilation
principal invasive devices and drainage at the Support or manipulate pulmonary gas exchange
time of their removal. Blood cultures are pro- Normalize alveolar ventilation (PaO2, PaCO2, and
grammed if the patients clinical condition and pH)
the biohumoral markers suggest severe sepsis. Achieve and maintain PaO2 > 90 mmHg and
peripheral Sat O2 > 95 %
Increase lung volume and maintain adequate functional
residual capacity (FRC)
5.3 Respiratory Treatment Obtain lung expansion and prevent or treat
After major digestive surgery, often the main Improve oxygenation and lung compliance
treatment in PICU is instrumental support of the Reduce the work of breathing in the presence of high
respiratory function, which provides a gradation airway resistance and/or reduced compliance, when
of interventions depending on the severity of the spontaneous breathing becomes ineffective
5 Intensive Care in Digestive Surgery 101

Fig. 5.3 Parameters of respiratory assistance with high-

frequency oscillatory ventilation (HFOV)

adjusted ventilatory assistance (NAVA) based on

neural respiratory control [7, 8]. By NAVA, the
Fig. 5.1 Noninvasive ventilatory (NIV) assistance with electrical activity of the diaphragm (Edi) is cap-
helmet in neonatal age tured with an appropriate catheter, equipped with
an array of nine miniaturized electrodes, which
must interface in the lower esophagus at the level
of the diaphragm, in order to obtain the best elec-
trical signal from diaphragmatic fibers. The cath-
eter sends the signals to the ventilator and is used
to assist the patients breathing [9, 10]. Since the
mechanical ventilator and the diaphragm work
with the same signal, the mechanical coupling
between the diaphragm and the mechanical ven-
tilation is virtually instantaneous (Fig. 5.4).
The ventilation in neonatal and pediatric age
during the postoperative course after surgery
requires a solid basic understanding of respira-
tory system mechanics (pressure-volume rela-
Fig. 5.2 Ventilator for noninvasive ventilatory (NIV) tionship of the respiratory system and the concept
of its time constants) and cardiopulmonary phys-
iology. Furthermore, careful attention has to be
A particular method of ventilation is controlled paid to avoid damaging the lungs by potentially
high-frequency oscillatory ventilation (HFOV) injurious mechanical ventilation. Optimizing
characterized by very small volumes (less than ventilator settings during controlled and assisted
the dead space) and extremely high respiratory ventilation must lead to a progressive and gentle
rates between 5 and 15 Hz (300 and 900 breaths/ lung recruitment, avoiding the damage caused by
min). Oscillatory ventilation produces a series of strong and repetitive opening/collapse of distal
oscillations (positive and negative) in the airways, airways and excessive alveolar hyperinflation.
with an active expiratory phase, and during the Especially in neonatal age, in the presence of
entire respiratory cycle, lung volume is main- a still immature lung, and in association with
tained almost constant (Fig. 5.3). problems such as pulmonary infections, sepsis,
An interesting ventilatory approach, very use- aspiration of saliva or gastric juice, and severe
ful for the weaning of patients, is the neurally heart diseases, excessive mechanical ventilation
102 A. Gentili et al.

Lower Longitudinal muscle

esophageal Circular muscle
External Internal
Costal part
Crural part

Phrenoesophageal Esophagus
ligament Sling fibers
Squamocolumnar junction

Fig. 5.4 The electrical discharge of the diaphragm captured through the introduction in the lower esophagus, at the
level of the diaphragm, of a NAVA catheter equipped with an array of nine miniaturized electrodes

can lead to lung injury, emphasizing phenomena 5.4 Cardiocirculatory Treatment

of volutrauma and barotrauma, which can result
in a biotrauma, characterized by alveolar dam- The cardiac output (CO) is the result of the heart
age, with increased microvascular and epithelial rate multiplied by the stroke volume; it under-
permeability, fluid filtration, and pulmonary goes changes according to the variation of the
edema. two parameters.
This clinical condition can approach an acute Modifications of the heart rate are able to
respiratory distress syndrome (ARDS), character- result in major reductions in cardiac output: bra-
ized by the absence of secretion or abnormalities dycardia in children, especially at an early age,
in the action of surfactant, resulting in decreased causes an important reduction of CO, as the sys-
lung compliance and significant hypoxemia. tolic ejection volume does not increase in propor-
Administration of surfactant, associated with tion to the decrease of the heart rate, because of
HFOV, may represent an effective method of poor ventricular compliance, due to the immatu-
lung recruitment and alveolar recovery in acute rity of the cardiac muscles.
pulmonary injury and in ARDS. Bronchoscopic Tachycardia, up to 200 beats/min, seems bet-
instillation offers the theoretical advantages ter tolerated, as it is accompanied by a propor-
that the surfactant may be distributed directly tional increase in CO.
to the desired regions of the lung, with a more Likewise, limitations in stroke volume also
economical use of the drug and with the oppor- involve a significant lowering of cardiac output.
tunity to lavage leaked serum proteins prior to Supporting cardiovascular disease in young
instillation. patients with digestive surgery must include both
5 Intensive Care in Digestive Surgery 103

principal actions for the overall improvement in evidence strongly suggests that fluid overload
stroke volume and specific interventions with may be detrimental to critically ill patients.
antiarrhythmic therapy. Relatively, little attention has been paid to the
consequences of fluid overload such as respira-
tory failure, increased cardiac demand, and
5.4.1 Increase of Stroke Volume peripheral edema. Recent studies on patients
with acute lung or kidney injury have reported
The increase of the CO is achieved, thanks to an that fluid overload has been associated with
increase in the volume of systolic ejection. It adverse outcomes [13, 14].
depends on and is influenced substantially by The treatment of choice for the optimization
three mechanisms: of myocardial contractility appears to be the
correction of all unfavorable factors (hypoxia,
Increase in the preload acidosis, hypoglycemia, hypocalcemia, drugs,
Increase in myocardial contractility and toxic substances). Positive inotropic
Reduction of the afterload (vascular resistance agents, pressor drugs, and vasodilators are
against which the ventricle pumps the blood indicated as appropriate [15]. Sympathomimetic
volume) amines are compounds used in optimizing
The volume expansion contributes to the Dopamine is a catecholamine most used in
increase in preload; it should benefit from the use neonatal and pediatric age. Its action takes place
of crystalloid, colloid, and blood and its deriva- on both beta and alpha receptors at a dose of
tives. At first contributions of 1020 ml/kg iso- 510 mcg/kg/min, respectively. The positive ino-
tonic polyelectrolyte solutions are likely to tropic effect is still mainly due to the release of
improve the clinical condition with the recovery endogenous norepinephrine. Its positive inotro-
of peripheral perfusion, decreased heart rate, and pic effect is modest overall. In patients with renal
the recovery of a viable diuresis. These quantities impairment, it is the drug of choice because at a
are usually well tolerated hemodynamically. dose of 32 mcg/kg/min, in continuous
Secondly, volume resuscitation of a patient administration, it ensures a vasodilatation of the
with hypovolemic or septic shock is an essential splanchnic and renal vascular system. Such
component of initial patient care. Massive action however is discussed for renal and intesti-
amounts of intravenous fluid are usually admin- nal protection.
istered to replace intravascular volume deficit Dobutamine increases myocardial contrac-
and to minimize complications attributed to tility, systolic ejection volume, and cardiac out-
hypovolemia such as tachycardia, hypotension, put; it decreases the systemic and pulmonary
acute kidney injury, and multiorgan failure. resistance when used in cardiac failure. Even at
Goal-directed therapies focused on the restora- high doses, it has little effect on heart rate and
tion of normal blood pressure and organ perfu- does not cause an increase in peripheral resis-
sion have been advocated in the management of tance. It is therefore particularly indicated for
critically ill patients. Early goal-directed ther- patients with severe heart failure. Its action is
apy, which is instituted in the initial phase of predominantly beta-adrenergic. This drug is
management of patients with severe sepsis or normally used in continuous infusion at a dose
septic shock, has been shown to improve overall of 510 mcg/kg/min. It has no specific action
survival [11, 12]. on renal and mesenteric circulation and is
In contrast to the notion of aggressive and therefore often used jointly with low-dose
liberal volume resuscitation, a growing body of dopamine.
104 A. Gentili et al.

Epinephrine is the drug of choice in cardio- used, even only to reduce an excessive increase
pulmonary resuscitation (CPR). It possesses in heart rate.
potent inotropic and chronotropic effects, asso- Supraventricular tachycardia (SVT) is the
ciated with action on the alpha and beta recep- most common rhythm disturbance in children.
tors of the systemic vascular resistance. In Adenosine is considered the drug of choice to cor-
moderate doses it proves to be a real inotropic rect the SVT. If administered quickly, at a dose of
support in critically ill patients, even when other 0.1 mg/kg through a central venous catheter, it
medicines have not been fruitful; the risk of a causes an immediate reduction in the frequency of
response in generalized vasoconstriction is real the sinoatrial node and the conduction velocity of
only at high doses. the atrioventricular node. The doses may be
In other cases, it is necessary to resort to a reduc- repeated and the dosage increased up to 0.2
tion in the afterload; the decrease in systemic vascu- 0.3 mg/kg, with a maximum total dose of 12 mg.
lar resistance decreases afterload and increases the Ventricular tachycardia, fortunately infre-
volume of systolic ejection, without being accom- quent in children, requires immediate treatment.
panied by increased myocardial oxygen demand. In the acute phase lidocaine (1 mg/kg), amioda-
Sodium nitroprusside is a vasodilator with rone (5 mg/kg) and procainamide (515 mg/kg)
effects on vascular resistance (arteries) and intravenous are recommended. Electrical cardio-
capacitance (veins). Arteriolar dilation produced version is indicated when the patient remains
by this drug reduces the afterload; increased vas- unstable despite drug treatment.
cular capacitance requires proper support of the
preload. It is normally used at a dosage of 0.5
10 mcg/kg/min; its administration requires con- 5.5 Fluid Management
tinuous monitoring of cyanide and thiocyanate
metabolites [16]. Fluid management of the pediatric surgical patient
Nitroglycerin dosage of 120 mcg/kg/min has represents an important aspect of clinical care,
an action prevailing on vascular capacitance with particularly for the initial treatment of the sick
an effective reduction of the preload. child. An understanding of the physiology of fluid
Amrinone is an inhibitor of phosphodiester- requirements is essential for care of these chil-
ase, which has positive inotropic action and is a dren. Infants and children are sensitive to small
powerful vasodilator. It is administered slowly in degrees of dehydration, and commonly used pro-
boluses of 0.751 mg/kg, followed by continuous tocols for pediatric fluid therapy do not consider
infusion of 510 mcg/kg/min. the rapidly changing perioperative physiology in
this patient population. Standard formulas for
fluid therapy can be modified to account for these
5.4.2 Heart Rate and Rhythm rapid changes in physiology (Table 5.2).
Normalization Control and distribution of body fluids in neo-
nates, infants, and children are carried out in large
Tachyarrhythmias have recently been reported part through the kidney and vary according to the
in childhood but can be related to the increased different age groups: the total water of a prema-
presence of circulating catecholamines, elec- ture infant represents approximately 85 % of body
trolyte abnormalities, metabolic acidosis,
hypoxia, and hypercapnia. Pheochromocytoma
and hyperthyroidism are the endocrine disor- Table 5.2 Postoperative fluid management
ders that most frequently are associated with Patient weight Daily fluid intake
tachyarrhythmias. Often beta-blocker drugs, <10 kg 85100 ml/kg
especially propranolol at a dose of 0.01 1020 kg 1000 ml + 50 ml every kg > 10 kg
0.1 mg/kg/day, constitute the drugs mainly >20 kg 1500 ml + 20 ml every kg > 20 kg
5 Intensive Care in Digestive Surgery 105

weight, with a redistribution percentage between Much evidence confirms that pain and stress
the extracellular fluid volume (ECV) and intracel- must be treated in order to prevent short- and
lular fluid volume (ICV) of 55 % and 30 %, long-term adverse outcomes [1820].
respectively; in term infant the total water consti- Not rarely a correct analgosedation manage-
tutes 78 % with an ECV equals to 45% and an ment is hard to achieve and overtreatment and
ICV to 33 %. Only at 1-year-old (total H2O = 65 %) undertreatment are both harmful. The complexity
is the reversal of the percentages of the two com- and the clinical difficulties due to the age of the
partments witnessed (ICV = 40 % and patients sometimes induce therapeutic priorities
ECV = 25 %), which is the characteristic of adults to preserve cardiocirculatory stability or to ensure
(total H2O 60 %, ICV 40 %, and ECV 20 %). neurological evaluation, giving up analgesic and
Two aspects are most relevant in designing a fluid sedative drugs and underestimating the conse-
therapy in all ages: fluid intake and volume replace- quences of an inadequate pain control and pro-
ment. Intravascular fluid guarantees tissue perfu- longed stress.
sion; therefore, paying attention to it must have the Therapeutic necessities of a patient should be
highest priority. Fluid replacement is necessary to set up in advance on dedicated and shared inter-
maintain the hydroelectrolytic homeostasis and nal protocols, integrated into local context and
acid-base balance. Fluid distribution is regulated by appropriate to the needs of specific situations, in
osmotic pressure: hypothalamic nucleus is sensitive order to prepare later and progressively an effi-
and responds to very low variations, and this condi- cient and personalized analgosedation therapeu-
tion causes a hormonal response, involving the tic plan, according to real needs of the patient.
secretion of ADH and aldosterone. The dehydrated
patient produces more ADH to preserve the H2O. It
should be taken into account that during the intraop- 5.6.1 Pain and Sedation
erative period, ADH secretions may increase due to Measurement
factors other than the osmotic ones (pain, stress,
drugs). For a correct fluid postoperative planning, Analgesia must be regularly assessed and docu-
consideration must be given to the metabolic require- mented using validated age-related scales.
ments, intraoperative administration, third-space Self-report scales are preferred instruments
sequestration, blood loss related to surgery, and par- for pain assessment in patients with adequate
ticular conditions such as the use of radiant lamps cognitive development. There are several propos-
for neonates/preterms [17]. als for different ages: the Faces Pain Scale
Fluid requirements depend on the metabolic (>3 years), the visual analog scale (VAS), and the
expenditure, which is higher in neonatal age. numerical rating scale (NRS) (>7 years).
Under normal conditions, 100 ml is required to Observational scales must be applied in
metabolize 100 Kcal, according to the calculation patients aged less than 3 years or unable to com-
of Holliday and Segar. municate and therefore are the most used in
intensive care; some of them, multidimensional,
also include the registration of physiological
5.6 Analgosedation parameters such as heart rate, blood pressure,
Management and SpO2.
Observational scales recommended for neona-
Effective and adequate therapy to control pain and tal age are the Premature Infant Pain Profile
stress is essential in the management of children (PIPP) and the Crying, Requires increased oxy-
in perioperative digestive surgery treatment. gen administration, Increased vital signs,
Analgosedation must meet different require- Expression, and Sleeplessness (CRIES) scale; for
ments: adequacy, appropriateness, effectiveness, children the Face, Legs, Activity, Cry, and
and safety. Consolability (FLACC) and the Childrens
106 A. Gentili et al.

Hospital of Eastern Ontario Pain Scale (CHEOPS) Regional techniques must always be consid-
are used. ered in cases of localized pain such as procedures
Pain measurement must be carried out at regu- and surgery. Epidural analgesia is effective for
lar intervals like other vital signs to monitor acute pain after surgery or trauma to the chest,
changes in pain intensity over time and the effec- abdomen, pelvis, or lower limbs, although its
tiveness of the treatment. Intervals of 46 h may safe management requires expertise and good
be sufficient if pain control is adequate. skill level.
Sedation must be regularly assessed and docu- The aims of sedation are reduction of distress,
mented using adequate monitoring scales. The fear, and agitation, improvement of patient-
COMFORT scale, validated also for the neonatal ventilator synchrony, and decrease in self-
age, is the most utilized tool [21]. removing of invasive devices. Sedation cannot be
pursued without an adequate analgesic treatment,
since persistent not treated pain hampers the
5.6.2 Drugs for Analgosedation sedation strategy.
Midazolam is the most frequent benzodiaze-
Measurement of pain and the identification of its pine used for sedation in pediatric intensive care.
underlying causes lead to the choice of analgesic Its administration by continuous intravenous
drug, which must be of adequate power and tar- infusion varies between 0.5 and 4 mcg/kg/min.
geted to causal mechanisms. Midazolam is not recommended in premature
Acute pain is the form most frequently met in infants because of the high incidence of neuro-
PICU, but complex patients with prolonged stay logical adverse events related to continuous
in intensive care may present with persistent, infusions.
chronic forms of pain, for which a multimodality Propofol is a sedative/amnestic agent with no
approach may be necessary (Table 5.3). analgesic properties. Although initially intro-
Acetaminophen in neonates and acetamino- duced into anesthesia practice, its rapid onset,
phen and nonsteroidal anti-inflammatory drugs in rapid recovery time, and lack of active metabo-
children above 3 months of age are recommended lites led to its evaluation as a drug for intensive
for treating mild pain (Table 5.4). care sedation. Its use for prolonged periods of
Opioids are the drugs recommended for treat- time may cause adverse effects such as
ing moderate-to-severe pain (Table 5.5). hyperlipidemia, hypercarbia, and the propofol
In some patients, adding nonsteroidal anti- infusion syndrome, characterized by metabolic
inflammatory drugs or acetaminophen to opioids acidosis, rhabdomyolysis, arrhythmias, and car-
is useful. diac failure [22].
Fentanyl is indicated in the presence of car-
diocirculatory instability and in neonates with
persistent pulmonary hypertension. 5.6.3 Tolerance and Withdrawal

Table 5.3 Postoperative pain management. Multimodal- Long-term treatments can be complicated by tol-
ity approach erance. Drugs and patient-related factors take
Acetaminophen part in developing tolerance, defined as the phar-
Nonsteroidal anti-inflammatory macodynamic reduction of the secondary effects
Opioids to long-term therapy.
Regional anesthesia Symptoms of withdrawal may develop during
Local infiltration of the trocar insertion in laparo- and therapy discontinuation: hypersympathetic
thoracoscopy activity, neuroexcitability, and gastrointestinal
Local wound infiltration impairment. Symptoms are not specific, and
Nonpharmacological techniques withdrawal syndrome may pass underdiagnosed
5 Intensive Care in Digestive Surgery 107

Table 5.4 Doses and method of postoperative administration of acetaminophen, main nonsteroidal anti-inflammatory
drugs (NSAIDs), and tramadol used in children
N times
Drugs Administration Dose (kg/day) (day) Continuous
Acetaminophen Oral, rectal 6090 mg 46
Acetaminophen Intravenous 6090 mg 46
Ibuprofen Oral, intravenous 2040 mg 34
Ketoprofen Oral, intravenous 57.5 mg 3
Ketorolac Oral, intravenous 11.5 mg 3
Naproxen Oral, intravenous 1020 mg 2
Acetylsalicylic acid Oral, intravenous 4080 mg 4
Tramadol Oral, intravenous 23 mg 23 0.10.25 mg/kg/h

Table 5.5 Postoperative pain management. Drug doses, onset, duration, and potency of opioid narcotics
Drug Potency Doses (mcg/kg/h) Onset (min) Duration (h) depression
Morphine 1 1050 2030 34 +++
Fentanyl 100 0.54 35 0.51 +++
Alfentanil 20 315 1.53 0.20.3 +
Remifentanil 250 0.051 (mg/kg/min) 12 0.10.2 +

or not recognized, since such symptoms may be needs in normal terms and assesses the changes
frequently ascribed to other pathologic condi- related to the clinical status. Almost always it is
tions seen in PICU. good to take as a reference point the actual
Risk factors have long been identified and weight, considering the ideal weight only in cases
must always be evaluated: length of the therapy that deviate significantly from normality.
(>5 days) and cumulative dose (fentanyl in neo- Enteral and/or parenteral nutrition should aim
nates > 1.6 mg/kg, in infants > 2.5 mg/kg, mid- at covering the nutritional needs of the patient in
azolam > 60 mg/kg). Even if the incidence of the terms of basal metabolic rate and physical activ-
withdrawal syndrome is variable in different epi- ity and correction of preexisting malnutrition,
demiological studies, it seems clear that the syn- growth, and disease states.
drome develops mainly when analgosedation Excessive nutritional intake can cause hyper-
drugs are too rapidly reduced or abruptly with- glycemia, increased fat, fatty liver disease, disor-
held [2325]. ders of the lipid, and protein metabolism. By
contrast, a reduced intake can cause weight loss,
malnutrition, impaired immune response, delayed
5.7 Nutritional Support tissue repair, and growth retardation.
The World Health Organization (WHO)
Clinical nutrition is a therapeutic act that helps indicates the adequate daily intake in pediatric
meet the nutritional needs of patients unable to age.
feed adequately in a natural way. Objectives of Tolerance of caloric intake is limited by the
clinical nutrition are reduction of the damage capacity to metabolize substrate calories, depend-
produced by pain and surgical stress, preventing ing on the route of administration, the activity,
the onset of a condition of malnutrition, and/or the age, and the pathology of the patient.
the reduction of its implications if they were A newborn subjected to parenteral nutrition
already present. (PN) requires a lower caloric intake compared to
The quantitative and qualitative composition a similar neonate subjected to enteral nutrition
of the nutrition begins with the identification of (EN), since the consumption determined by the
108 A. Gentili et al.

dynamic-specific action, related to intestinal artificial feeding, of which there are two modes
absorption, is absent. of administration: enteral and parenteral nutri-
Early nutritional support is always necessary tion. On the basis of the age and the presence of
in newborns, especially in premature with endogenous reserves of nutrients, which are
reduced gestational age, such as very-low-birth- scarcer the lower the age of patients, it is neces-
weight (VLBW) infants, whose birth weight is sary to program an artificial nutrition plan, which
below 1500 g and that, because of their limited should not be delayed beyond 24 h in neonates
nutritional reserves, need a higher protein and and infants and beyond 4872 h in later age
calorie intake than a normal-weight newborn. bands. In the postoperative period following
An important aspect of postoperative stress in digestive surgery, parenteral nutrition is most fre-
pediatric surgery is that, after surgery, energy quently adopted.
expenditure reaches a maximum value of 24 h The start and progressive increase of nutrients
after operation, returning to baseline within 24 h. up to the desired values is called the induction
The amount of energy expenditure is related to phase of the parenteral nutrition (PN). Nutrients
the severity of the surgery and remains higher in must be administered with well-calibrated incre-
premature infants and in the first 48 h of life. ments, respecting a constant relationship between
Pain, stress, and trauma surgery greatly influ- protein intake and energy intake (provided by
ence a correct nutrition through hormonal imbal- nonprotein calories which are the sum between
ance initially characterized by reduced insulin calories of carbohydrates and lipids). This ratio
secretion and increased release of the hormones has to be carefully balanced (nitrogen grams/
with opposite action, such as catecholamines and nonprotein calories = 1/150250). In this phase
glucagon. This early phase is characterized by a the metabolic indexes should be checked fre-
reduced utilization of metabolic nutrients. quently to test the tolerance of the patient to
Subsequently, it develops into a tendency toward a PN. In the following days, with the PN at a stabil-
hypermetabolic state, with an increased demand ity condition, if well tolerated by the patient, the
for protein and calories, which are drawn from the biochemical controls may be weekly. With the
energy reserves of the organism, with a redistribu- achievement of the phase of stabilization, moni-
tion among deposit tissues, such as fat, toward toring of the auxological parameters, such as
organs with high metabolic needs such as the ner- nitrogen balance, visceral protein (retinol, preal-
vous tissue and viscera, including the liver and bumin, transferrin), weight, height, and head cir-
kidney. This altered nutritional, metabolic, and cumference, is particularly useful [26].
hormonal condition, if not supported by a gradual As soon as bowel function is recovered, the PN
and controlled administration of nutrient intake, can be suspended with a gradual reduction of the
can lead to a state of catabolism and protein/caloric volume and amount of nutrients (weaning phase).
malnutrition, which in turn is responsible for: Table 5.6 shows the nutritional needs during
total parenteral nutrition.
Increased susceptibility to infection
Slowing the healing of surgical wounds (gas- 5.8 Abdominal Compartment
trointestinal anastomosis) Syndrome
Increase of decubitus ulcers
Increased presence of altered gastrointestinal 5.8.1 Introduction
Reduced intestinal absorption and nutrient Abdominal compartment syndrome (ACS) is
loss with feces defined as the adverse physiologic consequences
resulting from an increased intra-abdominal pres-
After a major surgery, necessitating a state of sure (IAP). The organ systems most affected
starvation, it is mandatory to intervene through include the cardiovascular, renal, and pulmonary
5 Intensive Care in Digestive Surgery 109

Table 5.6 Nutritional needs during total parenteral nutrition

Age and weight Protein (g/kg/day) Carbohydrates (g/kg/day) Lipids (g/kg/day)*
Premature 34 121416 23
Neonate 3 18 23
310 kg 2.53 1618 2
1015 kg 2.5 1214 2
1520 kg 2 1012 1.5
2030 kg 1.52 <12 1.5
>30 kg 1.5 <10 1
Critically ill children 1.53 7.5 12
Lipids in TPN
Lipid intake 2535 % of nonprotein calories
Minimum 0.25 g/kg/day to prevent EFA deficiency
Maximum 23 g/kg/day in neonates and infants
Administration continuously over about 24 h

systems. If untreated, ACS can cause clinical 5.8.3 Clinical Presentation

deterioration and rapidly lead to crucial organ
failure and death. On the other hand, abdominal Cardiovascular
decompression usually leads to a prompt reversal With advancing ACS, the patient presents a pro-
of the adverse pathophysiologic modifications. found shock often unresponsive to fluid resusci-
tation and vasoactive drugs. Reduced cardiac
output results primarily from decreased venous
5.8.2 Etiology and Pathophysiology return because of compression of the inferior
vena cava and the portal vein as well as from
In pediatric age, ACS has been associated with increased intrathoracic pressure, which markedly
several etiologies including abdominal injury reduces cardiac preload.
with postoperative bleeding, abdominal heman- Increased thoracic pressure, related to dia-
gioma, trauma, bowel necrosis, mesenteric vein phragmatic elevation, was shown to decrease left
thrombosis, omphalocele, gastroschisis, intesti- ventricular compliance and a very high IAP to
nal graft-versus-host disease, intestinal perfora- decrease myocardial contractility. Hemodynamic
tion, peritonitis, necrotizing enterocolitis, hepatic function is further impaired by increased systemic
veno-occlusive disease, shock, and burns requir- vascular resistances induced by increased IAP.
ing massive fluid resuscitation.
Intra-abdominal pressure under normal condi- Respiratory
tion is usually 0 mmHg and is slightly positive in Respiratory failure is a major component of the
patients submitted to mechanical ventilation, ACS and is characterized by elevated peak venti-
because of transmission of intrathoracic pressure latory pressure, hypoxemia, and hypercarbia. The
in the abdomen. Initially, IAP rises slowly as elevated IAP causes upward displacement of the
abdominal contents and girth increase. However, diaphragm and compresses the lungs, resulting in
at a certain critical level, compliance of the progressively stiffer chest with extremely low
abdominal wall reaches its limits, and any further compliance.
distension results in a rapid rise in abdominal
pressure, decreased organ perfusion, and devel- Renal
opment of clinical ACS. Oliguria progressing to anuria, both of which can be
As intestinal ischemia leads to bowel disten- unresponsive to fluid therapy and diuretics, is the
sion, bowel wall edema, and capillary leak, it can hallmark of the ACS. Elevated IAP results in mark-
set up a vicious cycle by further increasing IAP edly increased renal venous pressure and impaired
and may eventually lead to both bowel necrosis renal venous drainage: this is thought to be the most
and ACS [27]. important mechanism of renal dysfunction.
110 A. Gentili et al. Gastrointestinal Volume resuscitation with repeated fluid

Increased IAP was shown to significantly reduce challenges is the mainstay of cardiovascular
splanchnic perfusion. At an IAP of 20 mmHg, support, aiming and improving the decreased
significant decreases in blood flow to all seg- preload that causes the reduced cardiac output.
ments of the bowel, the liver, the kidneys, and the This should be increased by inotropic support
spleen were demonstrated. Impaired intestinal (dopamine, dobutamine, epinephrine) if
perfusion results in anaerobic metabolism, lactic response is inadequate.
acidosis, and free radical production. Most patients will require mechanical ventila-
tion, and, as abdominal pressure rises, higher air- Cerebral way pressures and FiO2 will be required to
Increased intracranial pressure (ICP) is a recog- maintain gas exchange.
nized component of ACS. In recent years several These measures, however, will at best result in
case reports described prompt reductions in ele- temporary improvement, because they do not
vated ICP following abdominal decompression. alleviate the underlying problem and may actu-
ally result in further deterioration as more fluids
leak into the abdominal third space.
5.8.4 Intra-abdominal Pressure
Determination Surgical Care
The key to successful management of ACS is an
Intra-abdominal pressure can be determined by early diagnosis and prompt surgical decompres-
measuring intragastric pressure, inferior vena sion of the abdomen.
cava pressure through a long femoral venous In patients whose ACS is caused by intra-
catheter, or urinary bladder pressure. This last abdominal accumulation of fluid, such as ascites,
procedure is simple and practical in which an peritoneal tap and continuous drainage may
age-adjusted amount of saline is injected through resolve the problem.
a urinary catheter connected to a pressure trans- Following decompression, primary abdominal
ducer (Table 5.7). closure without excessive pressure is usually
impossible, and the abdominal cavity is left open
with the use of various temporary abdominal wall
5.8.5 Management closure techniques.
Several techniques are described depending Medical Care on the underlying disease, age, and severity of the
Critical care management of the patient with clinical condition: the use of only-skin closure,
ACS consists of supporting the failing organ sys- the Dacron mesh, and the external sterile plastic
tem until definitive therapy is instituted and the pack (vacuum pack) or of sterile 2-L intravenous
basic problem can be brought under control. fluid bag (Bogota bag).

Table 5.7 Grading of abdominal compartment syndrome by intra-abdominal pressure and percentage of organ fail-
ures, with recommendation for treatment
pressure Urine output PIP SVR >1000 DO2I >600 O2/min/
Grade (mmHg) <0.5 ml/kg/h >45 mmHg dyn/s/cm5 m2 Recommendations
I 1015 0% 0% 0% 0% Maintain
II 1625 0% 40 % 20 % 20 % Hypervolemic
III 2635 65 % 78 % 65 % 57 % Decompression
IV >35 100 % 100 % 100 % 100 % Decompression and
PIP peak inspiratory pressure, SVR systemic vascular resistances, DO2I oxygen delivery index
5 Intensive Care in Digestive Surgery 111

5.9 Necrotizing Enterocolitis not be the optimal setting for a surgical proce-
dure, but moving an infant weighing <1000 g
Necrotizing enterocolitis (NEC), which typically in a serious and unstable condition to the oper-
occurs in the second to third week of life in pre- ating theater entails very high risks. In a short
terms, is characterized by variable damage to the space of time, various events may occur that
intestinal tract, ranging from mucosal injury to could irreversibly precipitate their condition:
full-thickness necrosis and perforation. NEC the loss of body temperature, the discontinua-
affects close to 10 % of infants who weigh less tion of the mechanical ventilation instituted,
than 1500 g, with mortality rates of 50 %. the modifications in posture during transfer,
In surgical NEC, the anesthesia is carried out which could lead to serious cardiocirculatory
in a clinical condition characterized by a drastic complications such as bradycardia and
and rapid deterioration, frequently involving hypotension.
complications such as acidosis, electrolyte imbal- The decision as to whether, and for how long,
ances, lethargy, abdominal compartment syn- it is possible to wait before undertaking the
drome, acute renal failure, coagulopathy, RDS, urgent intervention. The goal should be to
and cardiocirculatory failure. Often the clinical obtain, in a brief space of time, the best pos-
picture is further complicated by the occurrence sible clinical stabilization before undertaking
of toxic-septic shock with multiple organ dys- surgery (optimization of the fluid resuscitation
function syndrome (MODS) which is triggered in and inotropic and vasopressor drugs, correc-
an infant weighing <1000 g. tion of possible acidosis, anemia, or coagu-
Often, especially in extremely low-birth- lopathy) without further compromising the
weight (ELBW) infants, the anesthesiological general condition of the patient.
and intensive approach may become difficult The choice of which anesthetic drugs to use.
[2830]. Even though the pharmacokinetics is not fully
Some points, almost always interdependent, understood, smaller doses of anesthetic are
need to be raised [31]: usually required, and their effects last longer
due to low clearance and prolonged elimina-
The choice of surgical option. This is between tion half-lives. The literature is currently still
peritoneal drainage and laparotomy, depend- discussing the neurotoxic effect of anesthetic
ing on the clinical condition of the infant and drugs on the developing brain. It therefore
the extent of the disease. However, the opti- remains unclear what role anesthesia expo-
mum choice remains controversial. Peritoneal sure during infancy actually plays in deter-
drainage is a short procedure, requires a less mining neurobehavioral outcome. This could
risky anesthesia, but only offers a temporary have very worrying implications in ELBW.
decompression for the purposes of stabilizing Moreover, no important differences in neu-
the patient in expectancy of a more invasive rodevelopmental outcomes were observed
surgical intervention. Laparotomy foresees an between the surgical and medical NEC.
anesthesia with very high risk, its principal The choice of which intraoperative monitor-
objective being the removal of gangrenous ing might constitute an additional aid in such
bowel in order to check sepsis while preserv- small preterms in whom the scarce feasibility
ing as much bowel length as possible. The sur- of monitoring is well known during high-risk
gical options of laparotomy include interventions. Capillary blood-gas analysis
enterostomy alone or intestinal resection with could be useful. Other possibilities to be
enterostomy. investigated in ELBW could be the reliability
The decision about where to operate. This of central venous pressure in a peripherally
question is still open to debate, also consider- inserted central catheter of extremely small
ing that every hospital has its own logistic and caliber and the role of abdominal as well as
organizational characteristics. The NICU may cerebral near-infrared spectrometry (NIRS).
112 A. Gentili et al.

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Clinical Nutrition
Antonella Diamanti, Teresa Capriati,
and Daniela Giorgio

6.1 Introduction According to the ESPGHAN indications, EN

support includes both delivery of liquid formula-
Pediatric patients are particularly vulnerable to tions via tube and provision of specialized oral
the disease-related consequences of malnutrition nutritional supplements (ONSs) [2]. ONSs are
that may be prevented by clinical nutrition [1]. suitable to completely replace intake by normal
The clinical nutrition applies in clinical practice foods and they allow to avoid more invasive AN
the techniques of artificial nutrition (AN) that techniques. They have good taste and are avail-
include enteral nutrition (EN) and parenteral able as liquids or creams. When oral intake is
nutrition (PN) [2]. EN consists in administration inadequate or intake of normal food is inappro-
of complex nutrients into the gastrointestinal priate to meet the patients needs, EN by tubes
tract; PN delivers simple nutrients directly into should be approached. It is realized by the use of
the blood generally by central venous catheters or enteral formulations for the long-term use and
in some cases by peripheral veins [3, 4]. The subdivided as polymeric, based on cows milk
most appropriate nutritional intervention will be proteins (PFs); low molecular formulas, contain-
determined by assessing patients age, clinical ing oligopeptides derived from protein hydroly-
condition, gastrointestinal function, attitude for sates and high amount of medium-chain
oral intake, dietary habits, and costs [2]; however, triglycerides (MCTs) (HFs); and elemental feeds,
decisional algorithm starts from the gut function. based on free amino acids (AAs). EN support is
Following this assessment the patient may receive the first choice in patients with maintained gut
dietary advice, oral nutritional supplements, function. PFs are employed in about 50 % of the
enteral nutrition (EN) regimens, or parenteral overall EN candidates; they are inadequate in
nutrition (PN) [2]. some digestive diseases, in post-pyloric enteral
feeding, and in cows milk allergy [2, 5, 6].
When gut function is impaired, as in all forms
of intestinal failure (IF), PN should be approached
[2]. IF refers indeed to all states where the intes-
A. Diamanti, MD (*) tine has inadequate absorptive capacity to meet
Hepatology, Gastroenterology and Nutrition Unit, nutritional, fluid, and electrolyte needs to sustain
Bambino Ges Children Hospital, life and growth requirements of a child [7].
Piazza S. Onofrio 4, 00165 Rome, Italy
e-mail: The etiology of IF recognizes the short bowel
syndrome (SBS) where congenital or acquired
T. Capriati D. Giorgio
Artificial Nutrition Unit, Bambino Ges Childrens lesions have determined extensive loss of intesti-
Hospital, Piazza S. Onofrio 4, 00165 Rome, Italy nal mass, as the most frequent underlying disease

Springer International Publishing Switzerland 2017 113

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_6
114 A. Diamanti et al.

Intestinal obstr.

Intestinal failure:
Short gut
Abnormal gut function

Normal gut function
Oral intake >50% +dysphagia or
Oral intake <50% or
Daily length of overall meals >4-6 hours or
Veryimpaired growth

Normal gut function

No dysphagia or
Oral intake >50% or
Not very impaired growth

Fig. 6.1 Summary of clinical nutrition management in tizing enterocolitis, EN enteral nutrition, ONS oral nutri-
pediatric digestive diseases. PN parenteral nutrition, * tional supplements
paralytic or mechanical ileus, obstruction, NEC necro-

[8]. Malabsorption due to ineffective mucosal improve gut barrier function [11, 12]. Thus, few
surface (congenital enterocyte disorders, pheno- clinical conditions are now considered absolute
typic diarrhea, and autoimmune enteropathy) and contraindications to EN (see Fig. 6.1). We can
motility disorders with undamaged mucosal sur- ideally represent the nutritional approach to pedi-
face but wide motility dysfunctions (chronic atric digestive surgery as a pyramid, in which,
intestinal pseudo-obstructions, gastroschisis not proceeding from the base to the tip, increasingly
associated with small bowel resection, and invasive techniques are encountered (see
Hirschsprungs diseases) are further categories of Fig. 6.1).
IF [710].
However, complete enteral starvation should
be avoided whenever possible [2]. Therefore, 6.2 Clinical Nutrition and SBS
although PN should be firstly considered in IF,
EN should be also employed integrating the max- Nutritional management of SBS is of particular
imum tolerated amount of enteral intake with the interest because it provides a model of combined
ongoing support of PN. Even minimal quantities PN/EN management. This model may be applied
of nutrients in the gastrointestinal tract (so-called to several digestive diseases at neonatal onset.
trophic feeding) may promote intestinal perfu- Following neonatal small bowel resection, IF
sion, initiate release of enteral hormones, and occurs due to the residual reduced length of the
6 Clinical Nutrition 115

Type 3: >4thmonth
Increase ON trying to
suspend EN
Type 2: 2th-4thmonth If dependence on PN
Try to reduce/suspend PN persists: plan HPN
Optimize EN and ON (chronic IF)
Type 1: first month Prevent/treat IFALD that
Manage early fluids may occur
Begin/optimize PN
Begin EN

Fig. 6.2 Course of IF after neonatal small bowel resection. IF intestinal failure, PN parenteral nutrition, EN enteral
nutrition, ON oral nutrition, IFALD intestinal failure-associated liver disease, HPN home parenteral nutrition

gut, responsible for SBS. The course of IF SBS 6.2.2 Providing Adequate PN
related can be ideally subdivided into three
phases, with distinct clinical characteristics and Before approaching each PN program, a reliable
requiring different nutritional approaches. If vascular access should be warranted. The choice
long-term dependence on PN is expected (gener- of the access is dependent on the predicted length
ally more than 3 months), IF can be defined as of the PN support. Peripherally inserted central
chronic, and it requires to plan home parenteral lines are very effective means of providing PN
nutrition (HPN) programs (see Figs. 6.2 and 6.3) over a short to medium term, while more defini-
[13, 14]. tive central venous access is required for pro-
Overall the nutritional care of neonatal SBS longed PN. The expertise of a dedicated
onset includes (1) early managing of fluid and hospital-based nutritional team is required to tai-
electrolyte losses before starting PN and EN; lor PN to the single patient and to manage central
(2) providing adequate PN, for growth and nor- catheters; it is supported by official guidelines
mal development; (3) promoting intestinal published by the pertinent societies [1517].
rehabilitation by optimizing EN; (4) discharg- SBS is at risk for developing intestinal failure-
ing on home parenteral nutrition (HPN) the associated liver disease (IFALD) [18] due to
patients with protracted dependence on PN; IF-related factors, such as lack of enteral feeding,
and (5) preventing/treating complications disturbed enterohepatic bile flow, presence of
related to the patients underlying disease and inflammation, oxidative stress, immaturity of the
their PN. liver, and infections, but also PN-related factors
[18]. Therefore, in patients who are predicted to
require long-term treatments, PN should be
6.2.1 Early Managing of Fluid tailored to reduce the risk of liver injury [9, 19].
and Electrolyte Losses To prevent/treat IFALD, some aspects of PN
management can be modulated and in particular
SBS patients, at the early stages after bowel are the following:
resection, have increased losses of fluids and
electrolytes which can lead to significant electro- A. Choosing lipid emulsions (LEs)
lyte imbalance and dehydration. Early restoration B. Optimizing non-lipid intake
of fluid and electrolyte homeostasis is therefore
required, and it needs aggressive recovery with Choosing LEs
fluids [15]. Early fluid replacement is usually Historically, a French study delineated IFALD in
1 mL for every mL of fluid loss. This phase is adult HPN patients as a value of at least 1.5-fold
followed by PN beginning. the upper limit of normal on two of three liver
116 A. Diamanti et al.

a b

Start EN
EN 5/10 ml/h.
within 7-10
start bolus
days from
EN or ON

Start at 1-2
IF is not tolerated,
ml/Kg/h by
reduce PN in
continuous EN
isocaloric manner

Try to suspend
BF first option PN by
HFs is BF not maintaining
available ON
in daytime and
EN in nighttime

ation EN

Change formula
(switch to HFs/AAs in
BF/HFs fed

Test maximum
amount of ON,
suspend EN and
plan HPN

Fig. 6.3 Patterns of combined management of PN and erance to advancing EN. BF breastfeeding, HFs hydro-
EN after small bowel resection. PN parenteral nutrition, lyzed formulas, ON oral nutrition, AAs amino acid-based
EN enteral nutrition. (a) Pattern of EN beginning. (b) formulas, HPN home parenteral nutrition
Pattern of tolerance to advancing EN. (c) Pattern of intol-
6 Clinical Nutrition 117

function measures for cholestasis that persists for may not be able to provide enough energy to sus-
more than 6 months [20]. This study also showed tain growth. A mixed LE containing soybean oil
that chronic cholestasis predicts serious liver (SMOFlipid) compared with SO in a blinded ran-
problems and is associated with the use of soy- domized controlled trial in pediatric HPN patients
bean oil-based lipids (SO) at doses >1 g/kg/day resulted in mild changes in total bilirubin when
[20]. Several factors may explicate how LEs can administered four to five times per week at 2 g/
impact on the development of IFALD: kg/day and in normal growth pattern [25].
In North America, FO alone (Omegaven,
(a) Activation of hepatic macrophages (Kupffer Fresenius Kabi, Bad Homburg, Germany) is
cells) by excess of 6 polyunsaturated fatty available on the market, whereas in Europe, it is
acids (PUFAs) in SO that leads to the produc- possible to use LEs containing the mixture
tion of proinflammatory cytokines derived (SMOFlipid, Fresenius Kabi, Bad Homburg,
from linoleic and arachidonic acids [21]. Germany). That led to develop two different
(b) High intake of phytosterols (e.g., stigmas- approaches to optimize LE use in the United
terol and campesterol, equivalents of cho- States and Canada as compared with Europe.
lesterol in vegetable oils) derived from SO; Many institutions generally combine the use
they have structural similarity to bile acids of novel lipid preparations and reduced rates of
and may act as antagonists to nuclear bile administration of SO to prevent the development
receptors that are protective against cho- of liver disease [21]; e.g., if bilirubin exceeds
lestasis [21]. 34 g/L, lipid intake is reduced at 1 g/k/day,
(c) Overall content of vitamin E, especially of while if it goes over 50 g/L, the lipid source is
its most bioactive isoform -tocopherol, changed to FO alone at 1 g/kg/day.
which protects PUFAs from oxidative dam- Table 6.1 summarizes the composition of
age due to lipid peroxidation. The addition available LEs employed in PN.
of this component to SO has been shown to
reduce liver damage in a piglet model of Optimizing Non-lipid Intake
IFALD [21]. Excessive glucose intake causes increased lipo-
genesis and fat tissue deposition together with
Published surveys report that the use of a fish subsequent liver steatosis and enhanced produc-
oil-based LEs (FO) is able to reverse IFALD [22, tion of triglycerides by the liver [3]. The American
23]. These surveys, nevertheless, are used at a Society for Parenteral and Enteral Nutrition
markedly decreased dosage of FO (1 g/kg/d) if (ASPEN) [26], the European Society for Pediatric
compared to that of SO in the control historic Gastroenterology, Hepatology, and Nutrition
group (3 g/kg/day) [22]. That supports the [18], and the American Academy of Pediatrics
hypothesis that the overall decreased fat intake guidelines (ESPGHAN) [27] recommend limit-
rather than FO supplementation is important in ing the glucose infusion rate (GIR) at 1214 mg/
reversing IFALD [21]. Interestingly a recently kg/min (18 g/kg per day) in infants and young
published paper reports two cases of reverted children up to 2 years. Glucose intake should
cholestasis by switching from SMOF lipid usually cover 6075 % of nonprotein calories [3].
(Fresenius Kabi, Bad Homburg, Germany), an As reported above reduced LEs intake as strategy
emulsion containing a mixture of 30 % of SO, to prevent/treat IFALD may be required; in such
30 % of coconut oil, 25 % of olive oil, and 15 % of cases increased glucose intake, to better satisfy
FO at 2.03.0 g/kg/day, to FO at 1 g/kg/day [24]. the nutritional needs, resulted as well tolerated
That supports the hypothesis that the reduced [28].
amount rather than the type of LEs may be Furthermore, prophylactic cycling of PN may
hepatotoxic. reduce the incidence of IFALD [21]. Cyclical PN
Anyway FO monotherapy has now been is well tolerated and may be 36 months of age.
widely employed in clinical practice. FO alone In cyclical PN the maximal rate of glucose infu-
118 A. Diamanti et al.

Table 6.1 Composition of lipid emulsions available for parenteral nutrition

Emulsion (% fat) (manufacturer) Lipid source (%) 6:3 ratio Phytosterols (mg/L) -Tocopherol (mol/L)
Intralipid 20 % (Fresenius Kabi) SO 100 % 7:1 348 33 87
Lipofundin 20 % (B. Braun) SO 50 % 7:1 No data 502
MCT 50 %
ClinOleic-Clinolipid 20 % SO 20 % 9:1 327 8 75
(Baxter) OO 100 %
Lipoplus 20 % (B. Braun) SO 40 % 2.7:1 No data 562
MCT 50 %
FO 10 %
SMOF lipid 20 % (Fresenius Kabi) SO 30 % 2.5:1 47.6 500
MCT 30 %
OO 25 %
FO 15 %
Omegaven 10 % (Fresenius Kabi) FO 100 % 1:8 0 505
SO soybean oil, MCT medium-chain triglycerides, OO olive oil, FO fish oil

sion may exceed the advised GIR. The maximal quences [29]. The most pragmatic way to address
infusion rate should not exceed 1.2 g/kg per hour EN handling in IF should be to account that all
(20 mg/kg per min). A stepwise increase and patients regardless of the etiology of their IF may
decrease of glucose infusion rate at onset and at recover to a variable degree and that the strate-
discontinuation of the infusion should be consid- gies to promote EN should be reconsidered on a
ered to avoid hyper- and hypoglycemia, respec- day-to-day basis. The overall care of IF is based
tively. A reliable method for tapering is to halve on the judicious integration of two overlapped
the rate for 30 minutes and then to halve this goals: progressive advancement of enteral calo-
again for an additional 30 minutes. Glucose toler- ries and gradual weaning from the ongoing sup-
ance should be monitored during the first phases port of PN, maintaining a weight gain [15]. If
of the cycling PN [3]. tube feeding is used, the practice of inserting a
With regard to the choice of amino acid solu- gastrostomy early allows a more controlled
tion, there is evidence that supplementation of method of delivering feed with an opportunity to
TrophAmine may reduce the incidence of IFALD preserve and promote voluntary feeding without
in certain high-risk populations such as those the negative effects of the long-term presence of
with NEC [19]. a nasal tube [29]. If patients with motility disor-
Furthermore, copper and manganese serum ders but also with SBS show poor tolerance to
levels from PN solutions should be monitored gastric feeding, the post-pyloric EN approach
closely in patients who have developed IFALD should be tried [6]. Main aspects concerning EN
because they may exacerbate it [19]. management in SBS are:

A. Choosing the formula

6.2.3 Promoting EN B. Assessing methods of feeding
C. Assessing tolerance to EN
The provision of enteral nutrients is a critical D. Using enteral supplements
component of the therapy of IF; in SBS patients it E. Starting and handling complementary foods
represents the fundamental driver of adaptation
[15]. Early attempts of oral nutrition confer the Choosing the Formula
critical window of opportunity for establishing There is a paucity of evidence in favoring one
normal suck and swallow patterns; if this is not type of feed over the other in this setting; however,
attended, the child is at risk for oral aversion, breastfeeding (BF) should be used when toler-
which has many long-term negative conse- ated as it helps and promotes adaptation [30]. The
6 Clinical Nutrition 119

full advantages of BF include the optimal macro- Methods of Feeding

nutrient composition for human infant growth, EN should be started as soon as postoperative
with a full complement of macro- and micronu- ileus resolves [16, 41, 42], by the most physio-
trients [31, 32]. In addition, it contains trophic logical mode. This ideally should be in the form
factors such as epidermal growth factor, which of oral bolus feeding via the breast or bottle. In
likely augment the adaptive process [7]. infants unable to tolerate oral feeds, nasogastric
Furthermore, BF contains immunoglobulins and tube feeding is needed. Continuous tube feeding
natural antimicrobial properties which both is associated with increased feed tolerance by
enhance mucosal barrier function and prevent improved mucosal contact and decreased transit
dangerous overgrowth of bacteria within the time within the gut [16]. Bolus tube feeding
intestinal lumen. Finally it promotes intestinal helps gut motility and adaptation and provides
colonization by appropriate lactobacilli and periods of fasting, thus reducing persistent
related bacteria which are important elements of hyperinsulinemia. After establishing an appro-
healthy microbiome [33, 34]. Bovine colostrum priate base of enteral nutrients, the general pat-
also seems to confer beneficial effects on IF [35]. tern is to increase the provision of enteral
Finally BF supports physiological and psy- nutrients by a slow but steady increment, begin-
chological relationship between infant and ning at 1020 mL/kg/day (for the average new-
mother. If the mothers own milk is not available, born). After the infant can tolerate continuous
banked breast milk, even with pasteurization, has feeds of 5 mL/h, it is extremely useful to begin
nearly identical physiologic benefits [31]. Overall transition to oral feeds, providing in small quan-
BF should be the first choice in SBS patients. tities, three to four bolus oral feedings a day
If BF is not available, formula selection should (equal or less than the volume continuously tol-
be based on: erated per hour). After establishing a stable
feeding pattern, feeds are steadily increased on a
(a) Low allergenicity, because SBS infants are at daily basis [16]. In order to maximize overall
high risk for allergy [36] enteral intake, it is often helpful to have continu-
(b) Fat profile based on a combination of ous drips overnight. To correctly switch from
medium-chain triglycerides (MCTs) and PN to EN, it needs to consider that the net caloric
long-chain triglycerides (LCTs) (ratio of extraction from EN is not 100 % as from PN and
MCTs to LCTs of 30 %/70 %) that seems to that macronutrient absorption from EN is supe-
favor fat absorption in patients with signifi- rior than that of electrolytes and fluids.
cant intestinal resection, with or without a Therefore, PN should be decreased according to
colon in continuity [37] the calories provided by EN and not volume for
(c) Pre-hydrolyzed protein content that may be volume [41].
more suitable than the whole proteins to give
nitrogen source to an inefficient mucosal sur- Assessing Tolerance to EN
face [32] In SBS infants, increasing stool output, vomiting,
(d) Low osmolality (less than 310 mOsm/L) and irritability to the advancing EN may suggest
to minimize the risk for osmotic diarrhea poor tolerance to the current EN regimen. If stool
[38, 39] ] output is between 30 and 40 mL/kg body weight,
(e) Glucose polymer as main carbohydrate it needs to carefully increase EN. Doubled stool
source rather than lactose, due to the possible output or outputs >40 mL/kg/day are contraindi-
lactose intolerance, especially in SBS chil- cations to increase enteral feeds and indications
dren [16] to deal with a short-term reduction in feeding
volume that will be gradually reintroduced. Stool
Some HFs and AAs meet the above reported frequency greater than six times per day should
criteria. AAs have been shown effective in induce to cautiously increase EN [16].
decreasing PN length in small and uncontrolled Carbohydrate intolerance, which determines
series of SBS patients [18, 40]. frequent and liquid stools, is frequent in SBS
120 A. Diamanti et al.

Table 6.2 Markers of impaired EN tolerance and of evo- also via enteral route [10]. It is important to mon-
lution toward chronic IF
itor sodium balance, because sodium deficiency
Reference can limit growth in infants [7, 41]. The simple
spot measurement of the urinary sodium and, in
Anatomical 1. Residual small bowel [7, 8, 10,
selected cases, the calculation of the fractional
markers length (40 cm) 17, 42]
2. Residual small bowel excretion of sodium are rapid and effective ways
length assessed by GA to monitor the sodium loss. If the spot urine
(<10 %) sodium is <10 mEq/L, increased sodium intake,
3. Type of the remaining
both in EN and in PN, is required. The sodium
bowel (relevant loss of
ileus) content in PN should be titrated to keep urine
4. ICV and colon loss (?) sodium >30 mEq/L and to maintain urine sodium-
Clinical 1. Frequency of stools [17, 42, to-potassium ratio at least 1:1. Weekly monitor-
markers (>68/day) 43] ing of the urinary sodium is a preemptive way of
2. Impaired growth
3. Diaper rash due to liquid
assessing status, rather than waiting for the serum
feces level to drop, and long-term monitoring of this
4. Fecal or stoma output parameter is suggested [7].
>3040 ml/Kg When increasing in feeds does not result in
Biochemical 1. Plasma citrulline [7, 42, 43] appropriate weight gain, it should consider
markers concentration
(<1215 mol/L) supplementation with additional fat [15]. There
2. pH of feces (values <5 is good rationale for using long-chain triglyc-
indicates acid and not erides (LCTs) as supplemental vegetable oils,
absorbed stools) or olive oil, or emulsified preparations.
3. Urine electrolytes
(sodium <30 mEq/L and Additionally it may be reasonable to add MCTs
urine sodium-to- because they are absorbed directly across the
potassium ratio <1:1) enterocyte membrane, without requiring lym-
GA gestational age, ICV ileocecal valve phatic absorption. This occurs in the proximal
small bowel and even the stomach; therefore,
patients, and it can be suggested by the presence to add gradually increasing amounts of MCTs
of reducing substances on the stools and by the to the formula being used, especially if deliv-
stool pH <6. ered by tube feeds, may favorably increase the
The rise in plasma citrulline concentration fre- overall caloric intake. MCTs are nevertheless
quently accompanies the successful achieving of less effective than LCTs in promoting intesti-
enteral tolerance. Citrulline is a nonessential nal adaptation [43].
amino acid produced by the enterocytes of the
small bowel; its serum level has been shown to Starting and Handling
reflect intestinal mass in various gastrointestinal Complementary Foods
diseases. Citrulline concentration of The introduction of complementary, age-
1215 mol/L or greater following EN beginning appropriate foods between 4 and 6 months of
seems to predict a successful PN withdrawal age, as well as oral boluses of human milk/for-
[41]. In Table 6.2 we report the markers of mula as soon as tolerated, is helpful to stimulate
impaired EN tolerance useful in clinical practice. oral motor development and to prevent feeding
The combinations of several markers are associ- aversion [10].
ated with evolution toward chronic IF. Early weaning (17 weeks) has the advantage
of promoting feeding maturation with respect to Use of Enteral Supplements solids and a reduction in milk fluid volume which
IF patients can loss bicarbonate and sodium in may exacerbate a tendency to vomit or induce an
their stool or stoma which must be closely moni- increase in osmotically driven stomal losses [10].
tored and replaced, not only intravenously but Feeding therapy is usually required as these
6 Clinical Nutrition 121

infants are likely to have some degree of oral for HPN should be clinically stable. As soon as
aversion due to delayed introduction of oral feeds sufficient stability is reached, the child should be
as a result of prematurity, prolonged intubation, discharged under continued outpatient care with
and cardiovascular instability. a team experienced in intestinal rehabilitation. A
Patients without a colon tolerate better diets coordinated multidisciplinary approach is essen-
that are high in fat (3040 % of caloric intake), tial throughout, and the early training of parents
whereas those with intact colons experience ste- in the complexity of HPN care is essential. A spe-
atorrhea and magnesium and calcium loss with cialized nurse dedicated to the coordination of
high-fat intake. With calcium loss, oxalate the HPN service is essential, and once the fund-
absorption is enhanced in the colon and kidneys, ing and provision of a HPN service are put in
which can lead to the formation of oxalate renal place, early discharge home benefits the child
stones [41, 44]. Hence, it is necessary to restrict and family [10]. Transferring care of these chil-
oxalate intake in SBS patients with a colon to dren from hospital to home has a positive influ-
decrease the risk of oxalate renal stones. Oral cal- ence on CVC infections, social circumstances, as
cium supplements can also reduce the formation well as reducing the cost of treatment. At the
of oxalate stones. same time, it also puts a significant burden on the
Soluble dietary fiber (pectin or guar gum) family who has to spend a lot of time caring for
can slow gastrointestinal transit time allowing the child and has difficulty in maintaining gainful
for improved absorption (see above). The solu- employment [45].
ble fiber in the colon is fermented to short-chain
fatty acids, including butyrate which is an
energy source for colonocytes. In addition, the 6.2.5 Preventing/Treating
butyrate regulates colonocyte proliferation and Complications
improves water and sodium absorption by
upregulating the sodium-hydrogen exchangers The complications of IF SBS related [4654] can
[7]. However, excess pectin (>3 %) can lead to be subdivided into two main categories:
an osmotic diarrhea which can counteract its
benefits. A. CVC-related complications
In SBS children there is a potential for sig- B. IF-/PN-related complications
nificant malabsorption of carbohydrates, espe-
cially lactose. Therefore, feed with a glucose Main complications and suggested way of
polymer as a main carbohydrate source is likely prevention are summarized in Fig. 6.4.
to be better tolerated [16]. Solids rich in com-
plex carbohydrates, such as cereals and soluble CVC-Related Complications
fibers, lean meat, and unsweetened fruits, are Administration of long-term PN requires place-
well tolerated in patients with little or intact ment of indwelling central venous catheter. The
colon. Patients without a colon or with a stoma problems associated with central lines include
tolerate foods at high lipid contents and poor of infections, mechanical damage, blockages, and
carbohydrates. thrombosis. Infections are the commonest com-
plication with incidence being around 16 per
1000 days of PN [17]. Prevention of infections is
6.2.4 Discharging on HPN based on optimal catheter placement and strict
hand hygiene. Taurolidine, a derivative of amino
HPN represents the best care option in infants acid taurine, has been shown to have a role in
who do not need hospitalization but are depen- reducing catheter-related sepsis [55]. With
dent on long-term PN. It is indicated if the transi- advances in the type of catheters used and inser-
tion from PN to full EN, although possible, is tion techniques, there has been a significant
expected over a long period [45]. Patients eligible reduction in complications [17].
122 A. Diamanti et al.

Optimal CVC placement

Prevention CVC related sepsis Rupture

Warfarin if recurrent episodes Displacement

Occlusion (clot
or calcium
Optimal CVC placement,
Strict hand hygiene,
Use of taurolidine or ethanol lock (?) tamponade




Suspected in presence of blood stools Monitoring metabolic bone disease and pro
and iron deficiency -inflammatory status

Use WHO growth charts


Declining renal function
Appropriate calcium, phosphorum and vitamin D
Reduce food with high oxalate intake supplementation

Careful monitoring of potential nephrotoxic Monitor aluminumconcentrations


Maintain optimal hydration


Reduce carbohydrates intake Supplementation according to the guidelines

Antibiotics cycles Periodic monitoring

Fig. 6.4 Summary of short bowel syndrome complica- failure-associated liver disease, WHO World Health
tions. CVC central venous catheter, PN parenteral nutri- Organization, SBBO small bowel bacterial overgrowth
tion, IF intestinal failure, IFALD intestinal
6 Clinical Nutrition 123 IF-/PN-Related Complications among patients with bacterial overgrowth syn-

Trace element depletion is very common among drome [43].
patients with surgical short bowel syndrome if Provision of enteral water-soluble vitamins is
parenteral administration is inadequate. Adequate unnecessary while patients are on parenteral vita-
parenteral zinc supplementation is particularly min supplements, but if adaptation occurs and
important; its deficiency is generally associated patients are weaned off TPN, enteral provision of
with high output from the stoma but also with most water-soluble vitamins is advisable. Fat-
congenital diarrhea. As zinc is a cofactor for alka- soluble vitamin supplementation is delivered via
line phosphatase synthesis, an excellent surro- parenteral vitamins and parenteral lipid generally
gate marker for zinc deficiency is the serum preventing deficiency, but after weaning of TPN,
alkaline phosphatase level, which is likely enteral supplementation is advisable.
decreased in patients at risk for the clinical mani- Iron deficiency can occur in patients with
festations of zinc deficiency [7]. SBS, but it is frequently correctable with oral
D-lactic acidosis occurs among patients whose iron supplements because the efficiency of enteral
gastrointestinal tract is colonized by D-lactate- iron absorption is maximal in the duodenum
synthesizing organisms. Humans have the ability which is often maintained after neonatal surgical
to rapidly catabolize L-lactate, which is a product resections. For patients who cannot tolerate
of human anaerobic metabolism, but D-lactate enteral iron or who remain deficient despite
can be catabolized and cleared very slowly, and enteral supplementation, parenteral iron may be
toxic blood levels can build up when the small given. Iron deficiency can be also due to chronic
intestine is overgrown with anaerobic bacteria. gastrointestinal bleeding [41].
Signs and symptoms of D-lactic acidosis include Another concern of the long-term PN is the
confusion, somnolence, dementia, ataxia, or even potential exposure to toxic plasma aluminum
seizures. This condition is characterized by aci- concentrations. A recent Canadian survey found
dosis associated with an anion gap but a normal that in pediatric patients receiving long-term PN,
blood L-lactate level. Lactobacilli and other bac- aluminum intake is significantly greater than rec-
teria, including Clostridium perfringens and ommended by the US Food and Drug
Streptococcus bovis, when present, may ferment Administration to prevent aluminum toxicity
non-absorbed carbohydrate to D-lactic acid, [54]. In SBS patients on PN, aluminum is stored
which cannot be metabolized by L-lactate dehy- in the body because the protective gastrointesti-
drogenase [41]. These microorganisms may pro- nal barrier is bypassed and renal function may be
liferate in the acidic environment of the colon impaired. The long-term aluminum exposure can
that is the result of the metabolism of unabsorbed contribute to chronic bone disease (by inhibition
carbohydrate to SCFAs. D-lactic acidosis pres- of PTH) and to neurotoxicity of PN. In addition it
ents with encephalopathy (ataxia, blurred speech, is involved in IFALD (it accumulates in the liver)
decreased consciousness) and should be consid- and in the development of hypochromic, micro-
ered when there is a high anion gap metabolic cytic anemia (binding to transferrin).
acidosis with normal serum lactate and high Colonic oxalate absorption is increased in
gram + strains in the stools [41]. Preventive mea- patients with SBS, resulting in hyperoxaluria and
sures for D-lactic acidosis include the reduction in calcium oxalate nephrolithiasis. The risk of
of carbohydrate intake, followed by antibiotics stone formation is reduced if the colon is partially
(such as metronidazole or co-trimoxazole) when or fully removed. Renal function can also be
dietary changes fail [51]. compromised by some antibiotics or by uncor-
Vitamin B12 absorption may be impaired rected control of fluids and electrolytes in the first
among patients who have undergone distal phase of IF.
small bowel resections. Serum levels of B12 are Growth is usually impaired in SBS at neonatal
sometimes falsely elevated because of the pro- onset. These infants will be small and to push
duction of biologically inactive B12 analogues their weight gain to the 50th percentile or higher
124 A. Diamanti et al.

is not physiologic. It is more appropriate to exam- of the European Society of Paediatric

Gastroenterology, Hepatology and Nutrition
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Vascular Rings and Pulmonary
Gaetano Domenico Gargiulo, Francesco Petridis,
Gabriele Egidy Assenza, and Emanuela Angeli

7.1 Introduction The unifying characteristic of all these anom-

alies is the presence of a complete or incomplete
Vascular rings are a group of congenital anoma- vascular structure (in some cases with fibrous
lies, in which the aortic arch and its branches replacement) surrounding the tracheoesophageal
form a complete or partial ring around the tra- unit.
chea, the bronchi, and the esophagus, with poten- The clinical picture can range from asymp-
tial extrinsic compression leading to variable tomatic patients to patients presenting with
degrees of respiratory problems or feeding breathing disorders and/or swallowing difficul-
difficulties. ties due to the bronchial and tracheal and/or
They constitute 1 % of all the congenital vas- esophageal constriction [3]. Vascular rings and
cular abnormalities [1], and the term vascular pulmonary slings may be associated with genetic
rings was originally introduced for the first time defects, such as 22q11.2 deletion (DiGeorge syn-
in 1945 by Gross, when he performed the first drome), or they may be combined with cardiac
surgical division of a double aortic arch [2]. conotruncal anomalies, as tetralogy of Fallot
Pulmonary sling describes a congenital vascu- (ToF), double outlet right ventricle (DORV), pul-
lar anomaly involving the development of the monary atresia (PA), truncus arteriosus (TA), and
pulmonary arteries, more often the left one. interrupted aortic arch (IAA) [4].
Usually, the anomalous left pulmonary artery
arises from the posterior aspect of the right pul-
monary artery; it courses over the right bronchus 7.2 Embryology
and running from right to left, posterior to the
trachea or carina and anterior to the esophagus; it During fetal development, the brachial vascular
reaches the hilum of the left lung, forming a sling system, which will give rise to the aortic arch and
around the trachea. its branches, develops and completes within the
second and seventh gestational week.
The complex and dynamic embryological
development consists of six paired aortic arches
(although never present at the same time during
G.D. Gargiulo (*) F. Petridis G. Egidy Assenza fetal life) connecting the dorsal and the ventral
E. Angeli aorta, which will reorganize with differential
Department of Pediatric Cardiac Surgery and GUCH growth and reabsorption during the fetal period
Unit, Azienda Ospedaliero-Universitaria S. Orsola- by processes of apoptosis and remodeling
Malpighi, Via Massarenti, 9, Bologna 40138, Italy
e-mail: (Fig. 7.1).

Springer International Publishing Switzerland 2017 127

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_7
128 G.D. Gargiulo et al.

a b




a a

b b

Fig. 7.1 The Rathke diagram: schematic representation of the six paired brachial arches (IVI). (a) The brachial arches
connect paired ventral aorta (a) and dorsal aorta (b). (b) Reabsorption of the first, second, and fifth arches

The first and second arches largely resorb and

contribute to minor facial arteries; the fifth
arches obliterate after the growth of the sixth RSA LSA
ones; the third, along with the ventral aortic por-
tion, will contribute to the development of the
vessels arising from the mature aortic arch. The Desc.Ao LCA
fourth will form the ultimate aortic arch, while E
the sixth will contribute to create the pulmonary
arteries and the ductus arteriosus. On the right T
side, the segment of the dorsal aorta comprised
between the fourth and sixth brachial arches will
disappear; in the left side, it persists as the duc-
tus arteriosus.
An unusual progression of obliterations and
growth of this primitive vessel arrangement will
result into a broad range of anatomical variations
of vascular rings and slings [1]. Ao
A clear description of the possible anatomical
variety is offered by Edwards scheme (Fig. 7.2);
it condenses the conclusive phase of the brachial
branches embryogenesis, depicting the totipo-
tent double (symmetrical) aortic arch, whose Fig. 7.2 Edwards diagram: totipotent double aortic arch
system. Legend: Ao aorta; Desc.Ao descending aorta; E
total or partial reabsorption or persistence may esophagus, T trachea, RCA right carotid artery, RSA right
determine different anatomical variations. subclavian artery, LCA left carotid artery, LSA left subcla-
In case of persistence of both left and right vian artery
fourth brachial branches, a double aortic arch
will result; if an obliteration of the portion of the left aortic arch will take place; instead, if the
right aortic arch between the subclavian artery reabsorption involves the opposite fourth arch, a
and dorsal aorta occurs, a normal formation of a right-sided aortic arch with so-called mirror
7 Vascular Rings and Pulmonary Sling 129

image arrangement of arch vessel will result. The most common abnormalities in the com-
Obliterations affecting other segments will plete form group are double aortic arch, right-
induce, in addition to the left or right location of sided aortic arch with left aberrant subclavian
the arch, the presence of an aberrant subclavian artery and Kommerell diverticulum, and
artery (Fig. 7.3). right-sided aortic arch mirror image type with
ligamentum arteriosum on the left side.
Among the incomplete forms, the most fre-
7.3 Classication quent are left aortic arch with right aberrant sub-
clavian artery and pulmonary sling.
There are different classifications of vascular Regarding the position of the aortic arch and
rings, some of which take into account the mor- branching pattern of the great vessels, different
phology of the ring and some others considering anatomical types can be identified:
the position and anatomy of the arch.
In relation to the morphology, vascular rings 1. Left aortic arch
can be divided into two large groups [5]: (a) Normal branching
(b) Aberrant right subclavian artery
1. Complete: when fibrovascular elements cre- 2. Right aortic arch
ate a complete ring around the trachea and (a) Mirror image
esophagus (b) Aberrant left subclavian artery
2. Incomplete: if the trachea and esophagus are 3. Double aortic arch
not completely encircled by fibrovascular 4. Pulmonary artery sling
structures 5. Cervical aortic arch








Ao Ao Ao Ao Ao


Fig. 7.3 Edwards diagram: hypothetical double arch vian artery, LAA-ARSA left aortic arch- aberrant right sub-
system. Legend: Ao aorta, Desc.Ao descending aorta, E clavian artery, LAA left aortic arch, RAA right aortic arch,
esophagus, T trachea, RCA right carotid artery, RSA right RAA-ALSA right aortic arch-aberrant left subclavian
subclavian artery, LCA left carotid artery, LSA left subcla- artery, Double AA double aortic arch
130 G.D. Gargiulo et al.

Other anomalies exist, but they are either sig- tomography scan (CT scan), magnetic resonance
nificantly less frequent or are usually imaging (MRI), invasive angiography, and bron-
asymptomatic. choscopy. All of these diagnostic techniques
present advantages and disadvantages.

7.4 Clinical Presentation

and Diagnosis 7.5.1 Chest X-Ray (CXR)

Clinical presentation is heterogeneous (Table 7.1) Chest radiography, with or without barium
and can vary from asymptomatic patients with esophagography, can be considered the first-line
incidental diagnosis during adulthood to severe imaging modality used in diagnosing tracheal or
early symptoms of either tracheal or esophageal esophageal compression, particularly in chil-
compression, leading to early recognition of the dren. CXR double projection (straight and lean-
more severe forms. ing) can enlighten tracheal compression by
The breathing difficulty involves symptoms nearby structures or tracheal displacement
varying from wheezing, dry cough, and inspira- related to aortic arch location. In case of double
tory dyspnea, with worsening during stress or aortic arch, the CXR image describes the tra-
meals. The wheezing can be misled as an asth- chea in axis, with two lateral compressions. The
matic pathology. CXR with barium esophagography can display
Esophageal constriction is less frequent and a posterior incision on the esophagus due to the
characterized by increased risk of ab-ingestis presence of anomalous subclavian artery or
events, gastroesophageal reflux, and progressive Kommerell diverticulum, and in the presence of
dysphagia, firstly at ingestion of solid food and pulmonary sling, the cleft will be on the anterior
only after for ingestion of liquids. wall of the esophagus. Moreover, there could be
Eventually, recurrent infections of the respira- present signs of pulmonary atelectasis or lung
tory tract can occur, in particular during the first hyperinflation in case of bronchial compression.
year of patient life. Between 18 and 24 months, Unfortunately, this technique does not allow
the symptoms tend to decline due to the physio- direct images of vascular structures or vessels
logical growth of body structures. anatomy, preventing from an accurate surgical

7.5 Imaging
7.5.2 Bronchoscopy
Nowadays many possibilities exist to make a
diagnosis in case of suspicion of vascular ring or Bronchoscopy is nowadays an important tool to
pulmonary sling: chest X-Ray (CXR), barium make a diagnosis when symptoms of respiratory
esophagram, echocardiography, computerized distress are present. This procedure may demon-
strate the presence of pulsatile compression and
Table 7.1 Vascular ring and sling: clinical presentation also the degree and precise location of such com-
Asymptomatic pression. In cases of pulmonary sling, bronchos-
Respiratory Stridor, wheezing, chronic copy shows the length of hypoplastic tracheal
symptoms cough, recurrent respiratory segment, the diameter of this segment, and the
infections, seal bark cough, presence of complete tracheal rings.
tachypnea, intermittent cyanosis,
Bronchoscopy is mandatory after surgical treat-
Digestive symptoms Feeding difficulty, dysphagia, ment to evaluate the results of surgery and in the
recurrent emesis, gagging, postoperative period to follow the outcome of
choking, others correction.
7 Vascular Rings and Pulmonary Sling 131

7.5.3 Echocardiography structures or compression of the trachea [6].

Inspiratory and expiratory CTA studies allow the
The echocardiography can be considered the first dynamic evaluation of tracheal caliber for narrow-
tool to confirm the suspicion of vascular ring or ing or traction, which is particularly important in
sling. It is usually able to demonstrate the aortic patients with associated tracheomalacia. CTA
side; the anomalies of vessels of the aortic arch, scanning times are shorter than magnetic reso-
such as aberrant subclavian artery or aneurysm of nance imaging (MRI), and therefore sedation is
the brachiocephalic trunk; the double aortic arch; usually not necessary, which is a significant advan-
and the anatomy of the pulmonary artery. tage in a young or respiratory distressed patient.
However, echocardiography is a poor imaging The principal disadvantages of CTA are the need
tool to either establish or exclude the diagnosis of for intravenous contrast agents and the potential
a vascular ring in case of poor acoustic windows late consequences of radiation-dose exposure.
such as in adult patients. In addition, it does not
depict the ligamentous structures and hyperinfla-
tion of the lungs and the compression of the tra- 7.5.6 Magnetic Resonance Imaging
chea or esophagus. Echocardiography is (MRI)
absolutely necessary for investigating associated
cardiac defects. MRI is currently the gold standard diagnostic
modality, because of the anatomical definition of
the anomaly with functional and dynamic study
7.5.4 Angiography of the heart and vessels. Advantages of MRI over
CTA include the freedom from exposure to both
Angiography was the first procedure used to per- radiation and intravenous iodine contrast, as well
form diagnosis in these patients until the last as the ability to undertake functional studies in
decade, but currently this imaging modality is patients with intracardiac lesions. The limitations
rarely used, and it is useful only in selected cases. of MRI include longer scanning time than CTA
Angiography may be considered, if the anatomy and the need for sedation in pediatric patients.
of the patent vessels must be visualized, includ-
ing the size of the two arches, in case of a double
aortic arch, in order to make a proper selection of 7.6 Vascular Rings
the arch that has to be cut. However, angiography
is unreliable in demonstrating the tracheal or 7.6.1 Double Aortic Arch
esophageal compression, and moreover it is an
invasive procedure, requiring vascular access and The double aortic arch (Fig. 7.4) is the most fre-
the use of ionizing radiation and contrast agent. quent type of vascular ring and sums up about
40 % of the all anatomical varieties.
This vascular malformation consists of the
7.5.5 Computed Tomography Scan presence of a double aortic arch, one left and one
(CT Scan) right, both completely patent; generally one of the
two arches is larger than the other, and the
Computed tomography angiography (CTA) allows descending aorta is generally left sided although it
for an accurate description of vascular and respira- may be right sided or positioned in the midline.
tory tract anatomy. Patent vascular channels are In 75 % of the cases, the right arch is dominant,
evident on CTA as contrast-enhancing segments while in the remaining 25 %, the left is the domi-
and are well visualized on reconstructed 3D nant one or there is a balance between the two [7].
images. Conversely, atretic vascular segments and This malformation is often associated with
ligaments are not evident, but their presence can other cardiac defects, such as tetralogy of Fallot,
be inferred from traction on associated vascular truncus arteriosus, or pulmonary atresia.
132 G.D. Gargiulo et al.







Double Aortic Arch

Fig. 7.4 Double aortic arch: persistence of the right and right carotid artery, RSA right subclavian artery, LCA left
left aortic arch, both completely patent. Legend: Ao aorta, carotid artery, LSA left subclavian artery
Desc.Ao descending aorta, E esophagus, T trachea, RCA

About 20 % of the cases are associated with The embryological development is related to a
chromosomal anomalies such as 22q11.2 dele- break occurring between the left common carotid
tion syndrome (CATCH 22) [7]. artery and the left subclavian artery of the left-
The clinical presentation can include respiratory sided fourth brachial branch. The subsequent
and/or digestive symptoms, and the surgical correc- anatomy is a right aortic arch with aberrant left
tion includes the resection of the nondominant arch. subclavian artery (ALSA) (Fig. 7.5). The ALSA
In case of a balanced double aortic arch, it is pre- usually takes origin from the Kommerell diver-
ferred to maintain the right-sided arch. The surgical ticulum, representing the remnant of the right
approach through a thoracotomy is usually per- dorsal aorta and, in some cases, can create a pos-
formed on the opposite side of the dominant arch. terior compression of the esophagus.
Surgical correction usually allows resolution of This is the spot where the vestige of the liga-
the symptoms, despite in some cases clinical mentum arteriosum connects the aortic arch to
improvement is not immediate but delayed in time, the ipsilateral pulmonary artery forming a com-
due to the persistence of the constriction previously plete vascular ring.
established on the esophagus and trachea. The existence, at once, of a bulky Kommerell
diverticulum and the residual ligamentum arteri-
osum causes an important compression above the
7.6.2 Right Aortic Arch, Aberrant posterior esophageal wall, showing up with swal-
Left Subclavian Artery, and lowing difficulty.
Left Ligament (RAA-ALSA) With the body growing, Kommerell diverticu-
lum can evolve into an aneurysmatic formation,
The presence of a right aortic arch with left sub- causing dysphagia in adulthood and could be the
clavian artery arising from a Kommerell diver- source of life-threatening collateral events, such
ticulum is the second most common vascular ring as aortic dissection or wall rupture. The risks of
and represents about 30 % of cases, and in 510 % rupture and aortic dissection are strictly related to
of cases, it can be associated with other congeni- the dimension of the diverticulum [8, 9].
tal cardiac abnormalities such as tetralogy of The surgical repair is indicated in the presence
Fallot or ventricular septal defects (VSD). of clinical symptoms and consists of the resection
7 Vascular Rings and Pulmonary Sling 133




T Ligamentum



Fig. 7.5 Right aortic arch with aberrant left subclavian carotid artery, ALSA aberrant left subclavian artery;
artery. Legend: Ao aorta, PA pulmonary artery, RCA right *= Kommerell diverticulum
carotid artery, RSA right subclavian artery, LCA left

of the ligamentum arteriosum, resection of ized by a right aortic arch with the left brachioce-
Kommerell diverticulum, and reimplantation of the phalic artery (BCA, Fig. 7.6).
left aberrant subclavian artery to the left common Usually this anatomy is asymptomatic, and it
carotid artery. This surgery can be complex due to does not form a vascular ring. However in rare
the extreme fragility of the diverticulum wall. cases, the presence of ligamentum arteriosum can
In adult patients when complete resection of pull back the BCA realizing an anterior tracheal
the aneurysmatic segment of the thoracic aorta is compression. The RAA could be associated with
required, the surgery must be performed with the conotruncal cardiac anomalies such as tetralogy
aid of cardiopulmonary bypass with or without of Fallot or double outlet right ventricle (DORV)
hypothermic circulatory arrest. In these cases, and could be associated with genetic syndromes
the surgery is very challenging and includes a as CATCH 22.
significant risk of death (12 %) and paraplegia Surgery is indicated only in cases when a tra-
(4 %). cheal compression is evident. In case of tracheal
compression by the right ascending aorta or
anomalous innominate artery, it may be per-
7.6.3 Right Aortic Arch with Mirror formed as a simple aortopexy pulling the aorta
Image of the Arch Vessels toward the sternum, associated with the resection
and Retroesophageal of ligamentum arteriosum.
Ligamentum (RAA)

This type of vascular ring named right aortic arch 7.6.4 Left Aortic Arch with Aberrant
with mirror image anatomy results from the per- Right Subclavian Artery
sistence of the fourth right aortic arch and oblit- (LAA-ARSA)
eration of the left one. When reabsorption takes
place in the posterior portion of left dorsal arch, The presence of a left aberrant subclavian artery
behind the origin of the left subclavian artery, the is definitely the most common anomaly associ-
consequent vascular anatomy will be character- ated with the left aortic arch. This anomaly occurs
134 G.D. Gargiulo et al.



T arteriosum


RAA mirror image

Fig. 7.6 Right Aortic Arch (RAA) mirror image. Legend: Ao aorta, PA pulmonary artery, RCA right carotid artery,
RSA right subclavian artery, LCA left carotid artery, LSA left subclavian artery

when the portion of the right arch, included 7.6.5 Pulmonary Sling
between the origin of the right subclavian artery
and the right common carotid artery, undergoes This anomaly is characterized by an unusual drift
reabsorption; it usually is not associated with a of the left pulmonary artery, climbing over the
vascular ring (Fig. 7.7). right bronchus, passing behind the trachea and in
Sometimes the right aberrant subclavian front of the esophagus, heading to the left hilum
artery arises from a Kommerell diverticulum, (Fig. 7.8).
leading, in this case, to the formation of a vascu- The left pulmonary artery is often hypoplastic
lar ring. This variant is rarely symptomatic, and and smaller than the right artery, which can even-
symptoms usually depend on a voluminous tually be enlarged because of the volume over-
diverticulum causing swelling discomfort or load; the small size of the left pulmonary artery
difficulty. may help to explain the high incidence of anasto-
Occasionally, its presentation is associated motic problems that have been observed in the
with other cardiac defects, among which coarcta- past with attempts to reimplant it.
tion of aorta, hypoplastic left heart syndrome, Approximately 50 % of patients with a pul-
tetralogy of Fallot, or a ventricular septal defect. monary artery sling have complete tracheal
Surgical repair is rarely indicated and consists of rings, that is, the posterior membranous compo-
the resection of the ligamentum arteriosum and, nent of the trachea is absent, and the tracheal
if needed, resection of the Kommerell diverticu- cartilages, rather than being U shaped, are O
lum. In many cases, the surgical treatment was shaped.
found to be completely unsuccessful because the It usually presents as isolated malformation,
majority of these patients continued to have but it can be associated with other congenital
symptoms. heart diseases like tetralogy of Fallot.
7 Vascular Rings and Pulmonary Sling 135





Fig. 7.7 Left aortic arch with aberrant right subclavian artery. Legend: RCA right carotid artery, ARSA aberrant right
subclavian artery, LCA left carotid artery, LSA left subclavian artery

The clinical scenario is dominated by the E

compression of the distal part of the trachea asso-
ciated with severe tracheal and/or bronchial
hypoplasia and stenosis. Respiratory symptoms
predominate because of the direct tracheal com-
pression and are essentially the same respiratory
symptoms as those described for vascular rings.
In case of severe airway obstruction, it is
necessary to establish a preoperative ventilator LPA
support or occasionally an extracorporeal mem-
brane oxygenation (ECMO). Symptoms of RPA
esophageal compression are rarely present. LMB
Surgical repair should be performed in those
patients showing respiratory obstructive diffi- RMB
culty and consists of a relocation and reimplanta-
tion of the left pulmonary artery anterior to the
Additionally, surgery on the trachea can be
required, because of the narrowing provoked by
the compression around the portion surrounded PUlmonary sling
by the sling; tracheal surgical repair can compli- Fig. 7.8 Pulmonary artery sling. Legend: T trachea, E
cate the correction, increasing the risk of unsuc- esophagus, RPA right pulmonary artery, LPA left pulmo-
cessful outcome. For the pulmonary artery nary artery, RMB right main bronchus, LMB left main
relocation and tracheal repair, surgery is per- bronchus
136 G.D. Gargiulo et al.

formed by central sternotomy, and extracorpo- Asymptomatic patients do not require surgical
real circulation may be required in order to repair, unless surgical treatment of an associated
maintain an adequate oxygenation of the patient. congenital heart defect is necessary.
The crucial point of this correction is repre- The surgical approach depends on the type of
sented by tracheal surgery. The experience in the vascular rings or sling, and it may be performed
treatment of tracheal stenosis remains limited, by sternotomy, thoracotomy, or in specific cases
and the size criteria for tracheoplasty have not video-assisted thoracoscopic surgery (VATS).
been clearly established. Many techniques have Nowadays the surgical correction of vascular
been proposed with related advantages and rings can be carried out with low mortality and
disadvantages. morbidity, as described by Backer and coll [12].
Direct resection of the stenotic segment and In a cohort of 209 patients, who underwent sur-
direct anastomosis are ideal for locally limited gery between 1949 and 2003; there was no opera-
stenosis. Tracheal reconstruction using pericar- tive mortality since 1959, and morbidity was
dial patch is an option for more extended narrow- mainly related to airway issues: four patients
ing but currently is less used due to associated (2 %) required late aortopexy for recurrence of
problems like patch collapse or excessive phe- airway symptoms.
nomenon of granulation in the midterm follow- Recently Ruzmetov and coll. reviewed their
up. Nowadays the technique of choice is experience in the treatment of vascular rings
considered the slide tracheoplasty. This technique, from 1970 to 2008 in 183 patients [13]. There
firstly introduced by Tsang [10] and popularized was no intraoperative mortality, but three patients
by Grillo [11], is used currently both for localized died within 30 days of surgery; mean follow-up
and diffuse stenosis. The main advantage of this was 9 8.3 years, and overall survival was 96 %
technique is the possibility of avoiding the use of at 35 years [13]. Overall freedom from reopera-
graft material with immediate stability of the tra- tion was 100 % at 35 years, and 75 % were free
chea, reducing the ventilation time and conse- from compressive symptoms within 1 year of the
quently the excessive granulation process. operation; none of the patients showed any evi-
The trachea is divided transversely at the mid- dence of recurrent vascular ring anomalies at the
point of the narrow segment. Subsequently, a lon- last follow-up [13].
gitudinal incision of the proximal and distal
segment of the divided trachea is performed.
Such incision is carried across opposite (facing) 7.7.2 Pulmonary Sling
walls of the two segments, in order to complete a
sliding oblique anastomosis to restore a final In cases of diagnosis of pulmonary sling, the repair
large working diameter. is mandatory, in order to avoid the progressive
In some cases with associated tracheobroncho- damage of the trachea and lung and dangerous
malacia, it may be necessary, after repair, to stabi- asphyctic spells. The results of pulmonary sling
lize the trachea by placing endotracheal stents. surgery without tracheal repair are excellent with
low mortality and morbidity, and also the repair of
associated anomalies can be performed with no
7.7 Treatment and Results added mortality. Yong and colleagues reported no
mortality in nine patients who undergone pulmo-
7.7.1 Vascular Rings nary sling surgery alone and 25 % of mortality in
patients with associated airways surgery [14].
Surgery is recommended in all symptomatic The most important factor to achieve good
patients, especially those with severe respiratory results in surgery of pulmonary sling seems to
distress. In those patients, the surgery is manda- be the diameter of the trachea. Huang and col-
tory in order to avoid tracheobronchial damage or leagues reviewed a small number of patients
unexpected and graves events, like sudden death. who underwent treatment of pulmonary sling
7 Vascular Rings and Pulmonary Sling 137

showing no mortality in the cohort of patients rings, tracheal stenosis, pectus excavatum. Ann
Thorac Surg 69(4 Suppl):S308S318
with internal tracheal diameter larger than
6. Lowe GM, Donaldson JS, Backer CL (1991) Vascular
3 mm and in which it was not associated a tra- rings: 10-year review of imaging. Radiographics
cheal surgery [15]. 11(4):637646
Surgical treatment of tracheal stenosis has 7. Stojanovska J, Cascade PN, Chong S, Quint LE,
Sundaram B (2012) Embryology and imaging review
been reported having different results due to the
of aortic arch anomalies. J Thorac Imaging
complexity of the anatomy (length of the narrow- 27(2):7384
ing and diameter of stenotic segment), the pres- 8. Austin EH, Wolfe WG (1985) Aneurysm of aberrant
ence of tracheomalacia, and the type of surgical subclavian artery with a review of the literature.
J Vasc Surg 2(4):571577
9. Cin CS, Althani H, Pasenau J, Abouzahr L (2004)
Backer and colleagues, in their series of 28 Kommerells diverticulum and right-sided aortic arch:
patients treated with pericardial patch tracheo- a cohort study and review of the literature. J Vasc Surg
plasty, reported 6 % of early mortality and 18 % 39(1):131139
10. Tsang V, Murday A, Gillbe C, Goldstraw P (1989)
of late deaths [16].
Slide tracheoplasty for congenital funnel-shaped tra-
Similar results (11 % of mortality) are reported cheal stenosis. Ann Thorac Surg 48(5):632635
by Fanous and colleagues in their series of 26 11. Grillo HC (1994) Slide tracheoplasty for long-
patients who undergone patch tracheoplasty [17]. segment congenital tracheal stenosis. Ann Thorac
Surg 58:613619
Recently, several reports demonstrated that
12. Backer CL, Mavroudis C, Rigsby CK, Holinger LD
slide tracheoplasty is the technique of choice (2005) Trends in vascular ring surgery. J Thorac
because it is burdened by a lower mortality and Cardiovasc Surg 129(6):13391347
postoperative airway complications. Manning 13. Ruzmetov M, Vijay P, Rodefeld MD, Turrentine MW,
Brown JW (2009) Follow-up of surgical correction of
and colleagues reported an operative mortality of
aortic arch anomalies causing tracheoesophageal
2.5 % after slide tracheoplasty in 80 patients compression: a 38-year single institution experience.
operated between 2001 and 2009 [18]. J Pediatr Surg 44(7):13281332
14. Yong MS, dUdekem Y, Brizard CP, Robertson T,
Robertson CF, Weintraub R, Konstantinov IE (2013)
Surgical management of pulmonary artery sling in
References children. J Thorac Cardiovasc Surg
1. Ganie IS, Amod K, Reddy D (2015) Vascular rings: a 15. Huang SC, Wu ET, Wang CC, Chen SJ, Chen YS,
radiological review of anatomical variations. Chang CI, Chiu IS, Wang SS (2012) Surgical
Cardiovasc J Afr 26:17 management of pulmonary artery sling: trachea diam-
2. Gross RE (1945) Surgical relief for tracheal obstruc- eter and outcomes with or without tracheoplasty.
tion from a vascular ring. N Engl J Med 233: Pediatr Pulmonol 47(9):903908
586590 16. Backer CL, Mavroudis C, Gerber ME, Holinger LD
3. Woods RK, Sharp RJ, Holcomb GW 3rd, Snyder CL, (2001) Tracheal surgery in children: an 18-year
Lofland GK, Ashcraft KW, Holder TM (2001) review of four techniques. Eur J Cardiothorac Surg
Vascular anomalies and tracheoesophageal compres- 19(6):777784
sion: a single institutions 25-year experience. Ann 17. Fanous N, Husain SA, Ruzmetov M, Rodefeld MD,
Thorac Surg 72(2):434438; discussion 438439 Turrentine MW, Brown JW (2010) Anterior pericar-
4. McElhinney DB, Clark BJ 3rd, Weinberg PM, Kenton dial tracheoplasty for long-segment tracheal stenosis:
ML, McDonald-McGinn D, Driscoll DA, Zackai EH, long-term outcomes. J Thorac Cardiovasc Surg
Goldmuntz E (2001) Association of chromosome 139(1):1823
22q11 deletion with isolated anomalies of aortic arch 18. Manning PB, Rutter MJ, Lisec A, Gupta R, Marino
laterality and branching. J Am Coll Cardiol BS (2011) One slide fits all: the versatility of slide
37(8):21142119 tracheoplasty with cardiopulmonary bypass support
5. Backer CL, Mavroudis C (2000) Congenital Heart for airway reconstruction in children. J Thorac
Surgery Nomenclature and Database Project: vascular Cardiovasc Surg 141(1):155161
Congenital Esophageal Stenosis
Michela Maf and Mario Lima

8.1 Introduction 8.2.1 Tracheobronchial Remnant

Congenital esophageal stenosis (CES) is a rare The embryological origin of the cartilaginous
entity with an estimated incidence of 1:25,000 ring is to be found in the separation of the primi-
50,000 live births [1]. This anomaly was first tive esophagus and respiratory diverticulum,
reported in 1936 by Frey and Duschl who which is performed by the tracheoesophageal
described the case of a dead 19-year-old girl with septum, formed by the proliferation of cells start-
a suspected diagnosis of achalasia. The necropsy ing from the lateral crests of the primitive fore-
revealed cartilage in the cardia [2]. At the begin- gut. It may happen that, with the consequent
ning of the past century, all the esophageal steno- cranial lengthening of the esophagus and the
ses diagnosed in newborn were considered respiratory tree, mesenchymal cells belonging to
congenital so that Sir Arthur Keith in a report of the respiratory diverticulum can remain embed-
1910 did not differentiate between esophageal ded in the esophageal wall. These ectopic tissue
stenosis and atresia [3]. CES was also described remnants are typically represented by seromuci-
as a further type of esophageal atresia (EA) and nous respiratory glands, respiratory epithelium,
included in Gross classification as type F [4]. and cartilaginous tissue. Stenosis results from
extrinsic compression by the ectopic tissue, as
well as from inextensibility caused by the struc-
8.2 Classication ture of the cartilaginous tissue. Heterotopic tissue
of the tracheobronchial origin is most frequently
The most used classification of CES has been seen in the distal esophagus, particularly in the
proposed by Nihoul-Fkt et al. in 1987 [5]. lower third with a preference to the cardia level.
This classification delineates three forms of CES:

1. Tracheobronchial remnant 8.2.2 Segmental Fibromuscular

2. Segmental fibromuscular hypertrophy Hypertrophy
3. Membranous web
This form is characterized by subepithelial prolif-
eration of the smooth muscle and fibrosis. The
M. Maffi (*) M. Lima embryologic origin of the esophageal stricture has
Pediatric Surgery, S. Orsola-Malpighi Hospital, to be found in developmental defects incurred
Bologna University, Via Massarenti 11, 40138 within the first 10 weeks of gestation. The primi-
Bologna, Italy
e-mail:; tive gut separates from the trachea for the formation

Springer International Publishing Switzerland 2017 139

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_8
140 M. Maffi and M. Lima

of a tracheoesophageal septum to approximately ing, and regurgitation. The inability to place a

the 36th day of development. After 4 weeks, the nasogastric tube in the stomach confirms the
muscular and submucosal layers are well repre- diagnosis. However if the diaphragm is incom-
sented. Subsequently, between the seventh and the plete or broken, or in case of fibromuscular steno-
eighth week of gestational life, there is a process sis or cartilaginous ectopic tissue, the clinical
of rapid proliferation of epithelial cells that leads onset occurs later in life, usually when solid
to an almost complete closure of the primitive foods are introduced in the diet. In the literature,
esophagus lumen except for small vacuolated it is reported that the onset of symptoms can
areas that remain in the context of obliterated occur in a wide range of age, from 1 day old to 57
lumen. These areas, at the end of the 10th week of years of age, but it usually takes place during the
gestational age, give rise to a process of channel- first year of life, with dysphagia, vomiting during
ing which leads to the reformation of a tubular meals, regurgitation of undigested food, insuffi-
cavity. The primitive fetal esophageal epithelium cient growth, and relapsing pneumonia due to
is composed of ciliated cells that are being aspiration.
replaced, at about the 4th month, by stratified
squamous epithelium. The fibromuscular stenosis
is mainly located in the middle third and in the 8.5 Diagnosis
proximal part of the lower third of the esophagus.
The diagnosis of esophageal stenosis is not par-
ticularly difficult and is done with a barium
8.2.3 Mucosal Web esophagogram performed on the indication of the
clinical feature (Fig. 8.1). Less simple and cer-
The development of this web is similar to that of the tainly more important for a correct surgical ther-
diaphragm which can be located in any other intes- apy is the differential diagnosis that must be
tinal tract. These membranes are in fact strictly made between the various forms of esophageal
related to defects of recanalization of the previously stenosis; among these, achalasia and peptic stric-
obliterated lumen which occurred during the 10th tures may also be included.
week of gestation. Histologically these diaphragms The radiologic appearance is morphologi-
are composed only by mucosa and submucosa. cally similar in all cases of esophageal stenosis:
an important esophageal dilation followed by a
threadlike narrowing. The site of the stricture
8.3 Associated Anomalies can be useful to reach a first differential diagno-
sis. It has been seen how the three different forms
CES can be associated with other congenital of congenital cause have different favorite
anomalies in 1733 % of cases [6]. The most localizations.
reported association is with esophageal atresia The ectopic cartilaginous tissue is found in
and/or tracheobronchial fistula whose frequency more than 90 % of cases in the lower third of the
ranges from 3 to 14 % [1]. Other anomalies esophagus and especially near the cardia; fibro-
include chromosomal anomalies, cardiac anoma- muscular stenosis is more frequently found
lies, intestinal atresia, anorectal malformation, between the middle and the lower third with a
and trisomy 21 [1, 3]. predilection for the proximal part of the latter; in
achalasia instead, by definition, the stenotic por-
tion is always located in the cardia.
8.4 Symptoms A first rough differentiation between the three
types of CES can be made by examining the
The clinical feature of the complete esophageal patient. Symptoms caused by tracheobronchial
web appears at birth, and it is the same for esoph- remnants and fibromuscular stenosis are typical
ageal atresia, characterized by drooling, cough- in early infancy, while those caused by achalasia
8 Congenital Esophageal Stenosis 141

examination. Also the outcome of dilations can be

used as a diagnostic criterion: in case of achalasia,
improvement will only be transitional, while it
will be present and often progressive in case of
congenital stenosis sensitive to expansion.
Endoscopic ultrasonography (EUS) is a use-
ful tool in differential diagnosis between the
three types of congenital stenosis. In particular,
EUS is able to evidence the presence of cartilage
which is difficult to be seen with CT scan or
MRI. EUS is available for pediatric patients from
2001, and recently, a 3D miniprobe has been used
to obtain multiplanar and oblique views of the
stenosis [79].

Fig. 8.1 Congenital stenosis of the distal third of the

8.5.1 Therapy

usually occur later in school age; also peptic The first-line treatment of CES is dilation. It can be
stricture typically affects older children. When performed with hydrostatic balloon probe or with
radiographic examination is not able to identify Savary-Gilliard bougie. There is no strong evidence
the diagnosis, an endoscopic study can highlight on which is the better technique, and the choice
the main characteristics of the lesion. The direct depends on the expertise of each center. Jones et al.
vision of the section affected by a peptic stricture reported advantages of balloon dilation because of
will show an inflamed area also above the steno- radial and localized force applied by the baloon,
sis; the endoscopic images, associated with medi- rather than axial shearing force applied on stenosis
cal history and evaluation of symptoms, lead to by the bougie [10]. On the other hand, Romeo et al.
the correct diagnosis. Regarding other types of reported a higher risk of perforation with balloon
stenosis, correct diagnosis can be made in the dilation affirming that bouginage seems safer [9].
course of endoscopic examination, based on the An endoscopic check after dilation is mandatory,
ease or otherwise to overcome the restricted por- and in case of deep mucosal laceration, an esopha-
tion by the endoscope. gogram is recommended.
In case of achalasia, the cardia can be passed Whatever the technique chosen, the dilations
by the endoscope, forcing it kindly, and a mild are usually performed every 15 days until reach-
dilation can be obtained, albeit only temporarily. ing a stable esophageal caliber. The subsequent
In the presence of fibromuscular stenosis, the dilations are established on the basis of clinics,
endoscope cannot exceed the stenotic tract that age, and results obtained on each patient.
can be dilated with special probes. In ectopic car- Some authors reported success in endoscopic
tilaginous ring, the direct vision does not allow electrocauterization or partial resection of muco-
the differential diagnosis, but the attempt to dilate sal web added to dilations [11, 12].
the narrow tract is usually unsuccessful, and this Fibromuscular stenosis and mucosal web usu-
causes the operator to desist. In case of cardia ally respond successfully to dilations, while in
localization of fibromuscular stenosis, differential case of cartilaginous remnant or dilation failure,
diagnosis with achalasia becomes more difficult it is necessary to undergo surgery (Fig. 8.2).
and in some cases impossible even after endos- In these cases, the treatment of choice is the
copy. Even if most of the patients endoscopic resection of the stenotic tract followed by end-to-
examination can lead to diagnosis, further infor- end anastomosis (Fig. 8.3) and eventual fundopli-
mations can be obtained with a manometric cation if the stenosis is closed to gastroesophageal
142 M. Maffi and M. Lima

8.6 Complications and Outcome

The most serious complication is surely the

esophageal perforation whose reported incidence
varies widely (from 10 to 44 %) [9]. The treat-
ment in these cases is initially conservative with
fasting, nasogastric tube, and parenteral nutri-
tion. In severe cases, segmental replacement of
the esophagus may be necessary [13].
Despite various therapeutic options that could
obtain a resolution of the stricture from a morpho-
logical point of view, a substantial proportion of
patients (approximately 3060 %) continues to
complain of dysphagia [7]. This suggests that these
patients should be followed up for a long time.

Fig. 8.2 Barium esophagogram after six dilations. The

patient continued to complain of severe dysphagia References
1. McCann F, Michaud L, Aspirot A, Levesque D,
Gottrand F, Faure C (2015) Congenital esophageal
stenosis associated with esophageal atresia. Dis
Esophagus 28(3):211215
2. Rebelo PG, Ormonde JV, Ormonde Filho JB (2013)
Congenital esophageal stenosis owing to tracheobron-
chial remnants. Rev Paul Pediatr 31(3):406410
3. Appignani A (1993) Stenosi esofagee congenite. In:
Dmini R, Lima M (eds) Chirurgia delle malformazi-
oni digestive. Piccin, Bologna
4. van Poll D, van der Zee DC (2012) Thoracoscopic
treatment of congenital esophageal stenosis in combi-
nation with H-type tracheoesophageal fistula.
J Pediatr Surg 47(8):16111613
5. Nihoul-Fkt C, De Backer A, Lortat-Jacob S et al
(1987) Congenital esophageal stenosis: a review of 20
cases. Pediatr Surg Int 2:8692
Fig. 8.3 The previous case after resection of the stenotic 6. Vasudevan SA, Kerendi F, Lee H, Ricketts RR (2002)
tract and end-to-end anastomosis Management of congenital esophageal stenosis.
J Pediatr Surg 37(7):10241026
7. Michaud L, Coutenier F, Podevin G et al (2013)
Characteristics and management of congenital esoph-
junction [2, 13]. The stricture can be identified
ageal stenosis: findings from a multicenter study.
externally by palpation or with the use of a cath- Orphanet J Rare Dis 8:186
eter placed preoperatively. Maeda and Saito 8. Bocus P, Realdon S, Eloubeidi MA, Diamantis G,
reported two patients affected by tracheobron- Betalli P, Gamba P, Zanon GF, Battaglia G (2011)
High-frequency miniprobes and 3-dimensional EUS
chial remnant treated with circular extramucosal
for preoperative evaluation of the etiology of congeni-
myectomy at the stenotic level followed by suture tal esophageal stenosis in children (with video).
of the esophageal wall. This technique allows Gastrointest Endosc 74(1):204207
extirpation of the cartilage and muscular disar- 9. Romeo E, Foschia F, de Angelis P et al (2011)
Endoscopic management of congenital esophageal
rangement avoiding lumen opening [14, 15].
stenosis. J Pediatr Surg 46(5):838841
8 Congenital Esophageal Stenosis 143

10. Jones DW, Kunisaki SM, Teitelbaum DH, Spigland 13. Amae S, Nio M, Kamiyama T, Ishii T, Yoshida S,
NA, Coran AG (2010) Congenital esophageal steno- Hayashi Y, Ohi R (2003) Clinical characteristics and
sis: the differential diagnosis and management. management of congenital esophageal stenosis: a
Pediatr Surg Int 26(5):547551 report on 14 cases. J Pediatr Surg 38(4):565570
11. Chao HC, Chen SY, Kong MS (2008) Successful 14. Maeda K, Hisamatsu C, Hasegawa T, Tanaka H, Okita
treatment of congenital esophageal web by endo- Y (2004) Circular myectomy for the treatment of con-
scopic electrocauterization and balloon dilatation. genital esophageal stenosis owing to tracheobronchial
J Pediatr Surg 43(1):e13e15 remnant. J Pediatr Surg 39(12):17651768
12. Takamizawa S, Tsugawa C, Mouri N, Satoh S, 15. Saito T, Ise K, Kawahara Y, Yamashita M, Shimizu H,
Kanegawa K, Nishijima E, Muraji T (2002) Suzuki H, Gotoh M (2008) Congenital esophageal
Congenital esophageal stenosis: therapeutic strat- stenosis because of tracheobronchial remnant and
egy based on etiology. J Pediatr Surg 37(2): treated by circular myectomy: a case report. J Pediatr
197201 Surg 43(3):583585
Achalasia and Esophageal
Motility Disorders
Olivier Reinberg

9.1 Etiology and Pathogenesis in 0.11/100,000 annually between 7 and 13

years of age. However today, progresses make
Esophageal achalasia (EA) is a rare functional diagnosis earlier than before. Our youngest
motility disorder of the esophagus of unknown patient was 1.1 year old [39].
origin, characterized by abnormal motility of the The etiology is unknown. Achalasia is
body of the esophagus associated with delayed or believed to be an acquired functional esophageal
absent relaxation of the lower esophageal sphinc- motility disorder. However its physiopathology
ter (LES), inducing stasis in the esophagus with remains unclear, and possibly there are several
subsequent dilatation. forms of the disease with different etiologies
Sir Thomas Willis described the disease in including primary disorder of the esophagus and
1674 [1]. He did the first mechanical dilatation partial achalasia. This could explain that the
for achalasia, using an orally inserted cork- results of treatments are not as good as expected.
tipped whalebone. In 1881, Mikulicz described Several studies have suggested that the genetic
the disease as a cardiospasm, i.e., the symp- background may have a role in the pathogenesis
toms were due to a functional problem rather [10]. It could be an autoimmune disease, geneti-
than a mechanical one. Ernst Heller realized cally determined, then triggered by viral
the first myotomy to release the symptoms in (Herpes), bacterial, or parasitic (Chagas dis-
1914 [2]. The procedure done by Heller was an ease caused by Trypanosoma cruzi) infections
anterior and a posterior myotomy. However it resulting in a loss in inhibitory neurons of myen-
is still named after him, even if the procedure teric plexus [11, 12]. In some patients it could be
today differs. In 1929, Hurt and Rake realized malformative very similar to Hirschsprungs
that the disease was caused by a failure of LES disease. The genetic theory is supported by the
to relax and coined the term achalasia (i.e., high frequency of congenital anomalies or asso-
failure to relax). ciated syndromes such as the Down syndrome,
The highest incidence in adults is between the the Allgrove syndrome (AAA syndrome,
fourth and seventh decades. Children count for addisonianism-alacrima-achalasia), the congen-
5 % of all cases of achalasia; thus it is an uncom- ital central hypoventilation syndrome, the
mon condition in pediatric population, appearing Rozycki syndrome (deafness, vitiligo, esopha-
geal achalasia), and the Hirschsprung disease
[10, 1316]. Achalasia is frequent in siblings or
O. Reinberg
can be familial with an autosomal recessive
Pediatric Surgery,
Rochettaz 24, CH 1009 Pully, Switzerland mode [10, 17, 18]. It is frequently associated
e-mail: with an eosinophilic esophagitis.

Springer International Publishing Switzerland 2017 145

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_9
146 O. Reinberg

However, this explains only partially the is highly probable [19, 21]. What is known today
pathogenesis. Histology, electron microscopy, is that patients with achalasia have a loss of
and immunohistochemistry provide answers. The myenteric plexus and enteric neurons; a loss in
Italian Camillo Golgi (18431926) invented the number and modifications of the ultrastructure of
fixation and tissue stainings with methylene blue the ICC, being replaced by fibrosis or inflamma-
and silver impregnation. Thanks to this, the tion (plexitis); and no immunoreactivity for
Spanish Santiago Ramon y Cajal (18521934) VIP [19, 26, 27].
described the neuron and the organization of the Because of the relatively low incidence of the
central nervous system. They got together the disease in children, our knowledge is based on
Nobel Prize of Medicine for that in 1906. In small series or extrapolated from adult studies.
1911, Cajal, searching for a neural network to We ignore if achalasia in children differs from
study, simpler than the brain, used the rabbit that in adults. For instance, esophageal manome-
small intestine to find interstitial cells he believed try has allowed better description of esophageal
to be the end cells of the sympathetic nervous primary disorders in children such as partial
system. His drawings of what we call after him achalasia with various clinical conditions [28].
the Interstitial Cells of Cajal (ICC) are still accu- Unfortunately, no clinical or manometric features
rate. ICC can be studied due to electron micros- can differentiate the patients who present a favor-
copy and immunohistochemical staining for able outcome under medication from those
c-Kit [19]. requiring surgery.
The ICC are related to intestinal pacemaker In addition, the environment could play a role
activity [20]. However the esophagus has very that is not known yet. So achalasia appears to be
few ICC associated with the myenteric plexus but a multifactorial and multimodal disease that
has abundant intramuscular ICC (ICC-IM) dis- remains partially understood.
persed throughout the circular and longitudinal
muscle layers. ICC-IM are thought to be involved
in pacemaking and slow-wave propagation in the 9.2 Diagnosis and Pretreatment
stomach [20]. Three types of ICC have been Work-Up
described: the ICC-MY, ICC-IM, and ICC-SEP
[2023]. They are located, respectively, in the 9.2.1 Symptoms
myenteric plexus between the circular and longi-
tudinal muscle layers, within the muscle layers Achalasia can be difficult to recognize because
and within the septa between the circular muscle there may be nonspecific symptoms that may
bundles. ICC are most frequent in the esophageal include feeding aversion, failure to thrive, non-
part of the LES but rare in the gastric part. The specific regurgitation suggestive of gastroesopha-
absence or reduction in the number of ICC causes geal reflux (GER), and respiratory symptoms.
abnormal electrical slow waves with a decreased The diagnosis is often delayed.
contractility of smooth muscle cells, resulting in The most common complain is dysphagia.
a diminished intestinal transit. Impaired produc- Children progressively refuse food intake, and
tion of nitric oxide (NO) and vasoactive intestinal then have special vomitings whose content is
peptide (VIP) affects both ICC and muscles thus related to undigested previous meals. Dysphagia
inhibiting relaxation of the LES as it has already begins with solids but can reach the point where
been suggested in intestinal pseudo-obstruction liquids cannot be absorbed (paroxysmal dyspha-
and Hirschsprungs disease [19, 24]. Anomalies gia). They complain retrosternal pains and pyro-
of the ICC have been evocated in diseases such as sis. Their relatives notice fetor. Secondary signs
idiopathic gastric perforation, hypertrophic are dehydration, failure to thrive, and weight loss.
pyloric stenosis, intestinal pseudo-obstruction, Due to aspirations, respiratory symptoms (cough
meconium ileus, and Hirschsprungs disease [21, and repeated pneumonia) are often present [5,
25]. Thus debated, ICC involvement in achalasia 79, 29].
9 Achalasia and Esophageal Motility Disorders 147

9.2.2 Upper Gastrointestinal 9.2.3 Esophageal Manometry

Contrast Study
Esophageal manometry should be performed fol-
The most common investigations performed in lowing the recommendations of the North
children are upper gastrointestinal contrast American Society for Pediatric Gastroenterology,
study (UGI) and manometry. The use of barium Hepatology, and Nutrition (NASPGHAN) [31],
should be avoided in case of aspiration, and the American Gastroenterological Association
hydrosoluble contrasts should be preferred for [32], and other experts [29, 33, 34]. However, the
the UGI. X-ray studies classically demonstrate adult recommendation to use a continuously per-
a dilated esophagus that ends with birds fused low-compliance system should not be fol-
beak like tapering of the distal esophagus. The lowed in infants as it may provide an unacceptable
presence or the absence of esophageal contrac- amount of water in the esophagus. Thus minia-
tions on serial views should be mentioned ture strain-gauge pressure transducers mounted
(Fig. 9.1). within thin pediatric catheters should be pre-
Even if the esophagogram study alone with ferred. Manometries should not be done under
all the classical signs can be pathognomonic, as sedation, but we place the catheter using inhaled
the disease is not clearly understood and as equimolecular mixture of oxygen and nitrous
many variations may occur, it is wise to confirm oxide (EMONO, equivalent of MEOPA) [35, 36].
the achalasia with an esophageal manometry Elevated resting LES pressure
[30]. (>22 10 mmHg), absent or low-amplitude peri-

Fig. 9.1 Upper gastrointestinal contrast study showing a dilated esophagus that ends with birds beak and the
absence of esophageal contractions on serial views
148 O. Reinberg

stalsis, or non-relaxing LES upon swallowing technology with a greatly increased number of
(relaxation rate <90 %) are diagnostic findings on pressure sensors. In conventional manometry,
esophageal manometry in children [4, 6, 17, 37]. the pressure sensors are spaced at 35 cm inter-
However, the absence of some of these findings vals. In HRM, 36 sensors are spaced at 1 cm and
does not rule out the diagnosis of achalasia as distributed longitudinally and radially along the
LES function in children is heterogeneous. Partial probe. This allows simultaneous pressure
relaxations are common, and normal LES relax- recording in the esophagus. During swallow, the
ations after wet swallows may also be present on movements and pressure are recorded giving a
manometries [29]. Only 4.2 % patients had all topographic and cinematic view of the pressures
four common manometric features (elevated LES in the esophagus from UES to LES. Pressure
pressure, abnormal LES relaxation, aperistalsis, magnitude is encoded in color, conventionally in
increased intraesophageal pressure) for achalasia red for high pressures and blue for low [41].
in Agrawals study (children and adults). Most of This technique discriminates between differ-
the 72 patients of his series had elevated increased ent types of achalasia according to the LES but
intraesophageal pressure, elevated LES relaxation also to the intraesophageal pressure and move-
pressure, normal LES pressure, and low baseline ments. Thereby, achalasia has been classified
impedance. The resting LES pressure can be nor- into three types based on esophageal motility
mal in up to 4070 % of achalasia patients [30]. but helps to describe many other esophageal
motility disorders as well (The Chicago
Classification [42]). It provides an algorithmic
9.2.4 Intraluminal Impedancemetry scheme for diagnosis of esophageal motility
disorders. Type I is characterized by the failed
Intraluminal impedancemetry (IIM) allows intralu- relaxation of the LES and 100 % failed peristal-
minal measurements of electric impedance between sis; Type II involves failed relaxation of the
several closely arranged electrodes during bolus LES with no normal peristalsis and panesopha-
passage. Impedance is inversely proportional to geal pressurization with 20 % of swallows;
conductivity. When a highly conductive material is Type III, or spastic achalasia, associates failed
present inside the esophagus, the impedance relaxation of the LES, with preserved fragments
decreases, i.e., with reflux, and increases with air. of distal peristalsis or premature (spastic) con-
Combined multichannel IIM and esophageal tractions with 20 % of swallows. Many other
manometry offers the ability to evaluate the rela- esophageal motility disorders are described
tionship between esophageal contraction and bolus such as distal esophageal spasm, hypercontrac-
transit during the same swallow [30, 38]. Impaired tile esophagus, and absent peristalsis and statis-
bolus flow for liquid and viscous is found in most tically defined peristaltic abnormalities (weak
patients with achalasia as a translation of the aperi- peristalsis, frequent failed peristalsis, rapid
stalsis of the esophagus. Thus, those combined contractions with normal latency, and hyperten-
investigations are useful to ensure achalasia and to sive peristalsis). This Chicago classification has
understand the behavior of the esophagus. occasionally been used in children [39].
This technique contributes to better under-
stand the variations of the outcomes after differ-
9.2.5 High-Resolution Manometry ent treatments, as it appears that achalasia is not a
(HRM) unique pathology but that this term covers differ-
ent diseases.
The recently introduced high-resolution manom-
etry (HRM) enlarges diagnostic investigations in
esophageal dysmotility and may replace conven- 9.2.6 Endoscopy
tional manometry. However, the experience with
using HRM in children is limited [39, 40]. HRM Some authors use endoscopy only in case of
combines improvements in pressure-sensing unclear diagnosis. However, as others, we believe
9 Achalasia and Esophageal Motility Disorders 149

performing systematically an upper endoscopy is given. Nifedipine, a calcium channel blocker,

reasonable to rule out esophagitis, Trypanosoma inhibits the transmembrane calcium influx in car-
cruzi, and other secondary causes of achalasia, diac and smooth muscle and has been primarily
eventually with biopsies [43]. In some cases we used to release the LES in adults, with efficiency
found food impactions filling the esophagus (like between 13 and 19 % [46, 47]. It should be given
a fecaloma in the esophagus) that was not easy to 1030 mg sublingually 3045 min before meals
empty. Once done, there was such an important in adults [44].
underlying esophagitis that we postponed the sur- Other substances have been used in adults:
gery to give time to the inflammation to decrease long-acting nitrates (isosorbide dinitrate) and
and avoid perforation when doing the myotomy. phosphodiesterase-5 inhibitors (sildenafil).
The Society of American Gastrointestinal and There are few reports of short series on the use of
Endoscopic Surgeons (SAGES) provides guide- nifedipine in children but with good results [48].
lines on esophageal achalasia. The recommenda- However the benefits are temporary, and the
tions are that patients with suspected achalasia treatment cannot be used for long-lasting ther-
should undergo an UGI, an upper endoscopy, and apy due to secondary effects (orthostatic hypo-
an esophageal manometry to confirm the diagno- tension, headaches) occurring in 30 % of patients.
sis, with strong evidences (level 3+) according to However, it can be used as a bridge to relieve
the GRADE system [44]. symptoms until another treatment is undertaken.
The SAGES recommendations are that medi-
cations play a very limited role in the treatment
9.3 Treatments of Achalasia of achalasia and should be used in very early
stages of the disease, temporarily before more
As the pathogenesis of the disease remains definitive treatments, or for patients who fail or
unknown, no etiological therapy is available. are not candidates for other treatment modalities
Treatments focus on relief of symptoms by with strong evidences (level 4+) according to the
reducing the functional obstruction caused by a GRADE system [44].
non-relaxing LES, in the hope that can restore
esophageal emptying and peristalsis. They
include medications, chemical paralysis of the 9.3.2 Botulinum Toxin
LES, mechanical or pneumatic dilatations, and
endoscopic or surgical esophagomyotomies Botulinum toxin is a potent neurotoxin that
with or without fundoplications. Because of the inhibits the release of acetylcholine at presynap-
low incidence of the disease in children, treat- tic terminals of motor neurons. It is endoscopi-
ments are based on small case series or extrap- cally injected into the LES in the four quadrants
olated from adult studies. To date, there is no [49]. Botulinum toxin has been used as diagnos-
prospective randomized trial in the pediatric tic and therapeutic purposes. In children, the dose
literature on achalasia, and a meta-analysis on and the timing of injection frequency have not
seven retrospective reports is not conclusive been well defined. Its effect is temporary, and the
due to the heterogeneity of the study designs mean duration of symptom relief is 4 months in
and the various methods of treatment used both children, thus requiring repeated treatments [50].
within and between studies [45]. Unfortunately In the 2014 Cochrane database, 80 % of patients
adequate comparative data are lacking to deter- experienced an immediate relief of their symp-
mine the ideal treatment of pediatric achalasia. toms, but the recurrence rate was 60 % within a
year [47, 51]. In the SAGES statements, 85 % of
patients were initially improved, but the effect
9.3.1 Medications diminished over time (50 % at 6 months and 30 %
at 1 year), and universal symptomatic relapse
Medications should be used sublingually because occurred at 2 years [44]. In case of failure, these
of the unpredictability of absorption if orally patients need surgical treatments. They are the
150 O. Reinberg

most difficult cases for the surgeons as the years [55, 56]. These results are worse than those
inflammation induced by the toxin evolves after surgery (see below). No long-term follow-
toward a fibrosis between the mucosa and the up studies after dilatations are available for chil-
muscular layers with a subsequent increased risk dren. The advantages of dilatations are a shorter
of perforation [43, 44]. length of stay and decreased costs [53].
Many adult studies compare the effects of
dilatation with laparoscopic Heller myotomy
9.3.3 Dilatations (LHM), with an advantage for the surgery on
short- and long-term follow-up [57, 58]. The
The aim of dilatations is to mechanically enlarge same results have been reported in pediatric
the LES. This can be done either using pneumatic series [6]. Some authors advocate for dilatations
dilatations or with bougies as the Savary-Gilliard in older children suffering achalasia as safe and
bougies (M. Savary was our Chief of ENT in effective initial treatments thus avoiding sur-
Lausanne, Switzerland) under general anesthesia gery [53, 54, 59]. However, surgery after dilata-
in children. Both are endoscopically placed over tions has an increased risk of perforation due to
a guidewire under fluoroscopic guidance. In both scarring adhesions between the mucosa and the
techniques, even under view control, passing the muscle layers, not as high as after botulinum
LES with the guidewire can be difficult in those toxin but higher than if done as a first
cases where it is firmly tight. When using balloon procedure.
dilatators, a radial pressure is performed on the The SAGES recommends dilatations as the
LES that some authors thought to be better than a most effective nonoperative treatment. However,
longitudinal direction of dilatations as done with it is associated with the highest risk of complica-
the other method. When using balloon dilata- tions. It should be considered in selected patients
tions, it can be difficult to control the strength of who refuse surgery or are poor operative candi-
expansion when the balloon inflates suddenly. dates with strong evidences (level 4+) according
For this reason, Savarys technique is softer and to the GRADE system [44].
more progressive. Our belief is that all different
techniques should be available and adapted to
each case and dilatation. Multiple dilatations are 9.3.4 Peroral Endoscopic Myotomy
often required [52]. The choice of dilator size is (POEM)
based on the size of the child. The sizes range
from 12 to 35 mm [6, 45, 53, 54] The greater POEM is a new endoscopic technique for acha-
number of sessions per child varies from two to lasia introduced by Inoue in 2008 [60]. It is one
five [45]. of the applications of the natural orifice translu-
Dilatations bear an immediate risk of perfora- minal endoscopic surgery (NOTES) concept.
tion estimated at 2.4 % (0.55.6 %) [53, 55, 56], Under endoscopic vision, a mucosal incision is
and 50 % or more of these patients with perfora- performed 1520 cm above the LES. Then a
tions required emergency surgery [57]. In addi- submucosal tunnel is done downward to allow
tion, the release of the LES may induce a an endoscopic section of the muscular layers. At
gastroesophageal reflux disease (GERD). the end of the procedure, endoscopic clips are
In the Cochrane database (children and placed on the mucosal wound. To date, more
adults), the initial release of symptoms was 70 %, than 3000 patients have been operated, and the
and 4050 % of patients remained asymptomatic number of publications is increasing. Some
after a year and several dilatations [47]. Hamza small pediatric and adolescent series have been
has reported a 90 % success rate in children reported, all but one including less than ten cases
treated with multiple pneumatic dilatations [54]. [6164], the latest with 27 cases [65]. The
After dilatations, 61 % of patients were asymp- youngest operated child was 3, suffering severe
tomatic at 5 years of follow-up and 47 % at 10 growth retardation, achalasia, and Downs syn-
9 Achalasia and Esophageal Motility Disorders 151

drome [66]. Li gives a detailed description of the The HLM in children is performed under gen-
pediatric procedure with references for the eral anesthesia. We set the child supine at the foot
equipments [63]. The selected cases had no pre- end of the table, the legs being wrapped in the
vious treatment, and the reported problems are frog position for infants or extended on stir-
related to firm adhesions between the mucosa rups, with the knees slightly flexed by 2030 in
and the muscle. Caldaro has published a com- children and adolescents. The table is tilted to a
parative study in children receiving nine LHM 30 reverse Trendelenburg position. The surgeon
vs nine POEM with no conclusive results, but stands at the foot of the table, facing the hiatus. A
the series is very small [62]. transumbilical port is inserted according to the
In adults, there are 16 % reported minor com- Hasson technique for a 5 mm 30 angulated
plications and 3 % severe but nonfatal, as to men- telescope. We work with three ports (3 or 5 mm
tion: emphysema, pneumothorax (0.2 %), according to the age), the right upper one for an
pneumoperitoneum (8.3 %), bleedings (1 %), atraumatic liver retractor and the two remaining
leaks 0.2 %, and prolonged hospital stay >5 days ones for the working instruments. The cardio-
(1 %) [67]. phrenic membrane is opened anteriorly. The
The results seem good with 82100 % imme- anterior face of the esophagus is freed by 58 cm
diate relief of symptoms, but the longest follow- according to the patients size. The anterior vagus
up published is 1624 months [6769]. The mean nerve is identified and mobilized so that the
GERD rate is 35 % (limits 1546 %). In the pedi- myotomy can be done high up on the esophagus
atric series by Chen, during the follow-up period beneath the nerve. We do not dissect the esopha-
of 24 months, 19.2 % patients develop a GERD gus posteriorly, so we do not surround the esoph-
[65]. A randomized study with a 6 months fol- agus with a traction loop. Traction is applied on
low-up reports no difference between LHM and the stomach below the esophagogastric junction
POEM [67]. However LHM has been shown to using a Babcock clamp, to expose the anterior
provide more durable symptom relief [70] and part of the distal esophagus. The myotomy is
additionally could result in less post-intervention started on the esophagus just above the gastro-
GER [71]. esophageal junction with an incision in the ante-
rior muscular wall down to the mucosa. Usually
the mucosa separates easily from the muscular
9.3.5 Surgeries layers, if there have been no previous treatment
with botulinum toxin or dilatations. The muscu- Heller Myotomy lar section is done according to the surgeons
The Heller myotomy is performed today doing preference with scissors, with a monopolar hook,
an anterior incision of the muscular layers of the with a sealing-cutting device (LigaSure LS
esophagus, approximately 5 cm above the esoph- 1500 Dolphin Tip or Maryland laparoscopic
agogastric junction and carried onto the gastric instrument by Covidien), or with a harmonic dis-
wall by 23 cm. Laparoscopic Heller myotomy sector (Ultracision by Ethicon). A great care
(LHM) is the treatment of choice in adults and in should be taken to lift up the muscle from the
children giving advantages of less pain, better mucosa when using a monopolar hook or a har-
cosmesis, shorter hospital stay, and faster return monic dissector as those instruments heat and
to normal activity [37, 43, 59, 7274]. A survey can perforate. The muscular incision must be
concerning 64 pediatric centers worldwide done undertaken down on the anterior face of the stom-
by Myers in 1994 could only conclude that car- ach by 22.5 cm. The transition from esophageal
diomyotomy performed by the abdomen gives to gastric muscle fibers can be seen as they
best results [75]. The highly debated point is change from a horizontal circular orientation to
whether it is necessary or not to add a fundoplica- an oblique one and are more adhered to the
tion to reduce the occurrence of iatrogenic mucosa. This ensures having been enough down-
GERD. ward. It is mandatory to check the integrity of the
152 O. Reinberg

mucosa after the myotomy. This can be done Anti-reux Procedures
using instilled water, air, or methylene blue in the A fundoplication can be added to prevent GERD
esophagus at the level of the myotomy or better, following Heller myotomy. Whether it should be
as we do, performing a peroperative endoscopy done, and with which wrap, is one of the most
for both perforation and adequacy of the myot- debated points among surgeons. Several authors
omy. In case of a tear in the mucosa, an attempt dont believe it necessary, including in children
of suture can be done, and we leave a suction [72, 79]. If done, several anti-reflux procedures
probe at the level of the leak for a few days. Then can be used: a total fundoplication (loose 360
according to the surgeons preferences, an anti- Nissen) [77, 80], a partial posterior 270 wrap
reflux wrap can be built. (Toupet) [57, 81], or an anterior 180 wrap (Dor
Antibiotics are not given routinely. Without or Thal) [6, 37, 43, 74].
perforation, the child is orally fed in the operative Several adult studies have compared the LHM
day or the next one. Some authors perform sys- with and without anti-GER procedure with an
tematically an UGI to check the integrity of the advantage for the combined procedure summa-
esophagus before discharging the child [9, 37]. rized by Tsuboi [57]. The 2012 guidelines of the
We do not. SAGES also strongly recommended a combina-
The Cochrane review and other studies report tion of laparoscopic myotomy with anti-reflux
good initial results after LHM, with 8897 % surgery [44]. They did not precise which type of
relief of symptoms [44, 47, 51, 76]. This improve- procedure is the best, as long as it is a partial one.
ment appears to be long lasting. However, 79 % The circular fundoplication (i.e., the Nissen)
of patients remain asymptomatic after 5 years of should be avoided because of the risk of persis-
follow-up and 76 % at 10 years [44, 55, 56]. tence and/or recurrence of the disease.
Complications of surgery are related to perfo- The most efficient anti-GER is the Nissen.
rations and GERD. Perforation rates occur from However, even a loose Nissen applies a pres-
0 to 15 % in large series [72, 77, 78]. Most of sure on an LES that we wanted to release [9,
them heal spontaneously if recognized. In their 72]. When doing a Toupet, the two rows of
comparative adult series, Weber and Chen have stitches of the 270 wrap are tied to the edges of
evidenced a higher risk of perforation with LHM the myotomy. Those who advocate for a Toupet
(4.8 %) than with dilatations (2.4 %). However it believe that it helps to keep the myotomy open.
should be noticed that the rate of reoperations On the other hand, a Toupet leaves the anterior
was far smaller in the LHM group (0.6 %) than in mucosa exposed without coverage. Finally,
the dilatation (2.4 %) as most of the perforations both the Nissen and the Toupet require poste-
due to dilatations have been ignored whereas the rior dissections of the hiatus, which is not the
one done under LHM are immediately identified case with an anterior wrap that preserves the
and treated [55, 56]. periesophageal ligaments. In addition the ante-
The rate of perforation rises significantly dur- rior wrap protects the uncovered esophageal
ing a redo procedure ranging from 4.7 to 30 % mucosa.
[58]. Several studies have suggested an increased In a randomized controlled study on 144
risk of perforations during LHM up to 28 %, after adult patients followed up during 125 months,
previous endoscopic treatment (botulinum toxin Rebecchi determined that laparoscopic Dor fun-
or balloon dilatations). Reversely, other studies doplication after a LHM was superior to Nissen
found no association between preoperative endo- fundoplication because the recurrence rate of
scopic treatment and perforations. The warning dysphagia was significantly higher in patients
from the SAGES is that previous endoscopic who received a Nissen fundoplication (15 %)
treatment for achalasia may be associated with than a Dor (2.8 %) [80]. However, as Franklin
higher myotomy morbidity, but the literature is we wonder if recurrence of the dysphagia is a
inconclusive. Then a careful approach by an failure of the surgical treatment or is related to
experienced team is advisable [44]. the nature of disease [37]. A pediatric multi-
9 Achalasia and Esophageal Motility Disorders 153

center prospective study, published by Rawlins 9.4 Long-Term Follow-Up

and involving 85 children followed up for 36 and Cancer
months, compared LHM and Dor or Toupet
showing no difference of the De Meester scores Chronic irritation of the esophageal mucosa
at pH-metries performed 6 and 12 months post- increases the risk of squamous cell carcinoma
operatively. The conclusion was that LHM pro- and/or adenocarcinoma. Long-lasting achalasia
vides significant improvement in dysphagia and increases 16 times the risk of developing a can-
regurgitation symptoms in achalasia patients cer. Due to residual GERD and poor peristalsis,
regardless of the type of partial fundoplication the risk persists even after (surgical) treatment
[82]. [88]. The risk of both squamous cell carcinoma
Laparoscopic surgery for esophageal achala- and adenocarcinoma of the esophagus is believed
sia provides symptomatic improvement, but to be significantly increased in patients with
some patients have a poor outcome. It can be achalasia; however the absolute excess risk is
related to the surgery (insufficient myotomy, too small [89]. Leeuwenburgh has statistically evalu-
tight wrap, too lose wrap with subsequent ated the risk of cancer in non-treated achalasia vs
esophagitis) thus requiring redo procedure. treated by dilatations. The conclusion was that
Esposito suggested that the experience contrib- Barretts esophagus is incidentally diagnosed in
utes to decrease the rate of complications since untreated achalasia patients despite high LES
their incidence of postoperative dysphagia pressures but is more common after successful
dropped from 50 to 16 % with further experience treatment, especially in the presence of hiatal her-
[74]. Patients with severe preoperative dyspha- nia. Patients treated for achalasia should be con-
gia, aperistalsis, or esophageal dilatation have sidered for GERD treatment and surveillance of
greater risks of a poor outcome [81]. Favorable development of Barretts esophagus, in particu-
factors in adults are the short duration of the lar, when they have low LES pressures and a hia-
symptoms without previous use of botulinum tal hernia [90]. Thus, some authors recommend to
toxin [83]. An initial LES pressure >35 mmHg perform repeated endoscopies since the second
had more than 21 times the likelihood to achieve decade [76]. However, given limited data and
excellent dysphagia relief after myotomy as com- conflicting opinions, it is unknown whether con-
pared with those with an LES pressure sensus regarding screening practices in achala-
35 mmHg [84]. sia among experts exists. Ravi created a
High-resolution manometry (HRM) has evi- worldwide survey distributed to 28 experts to
denced that there might be several types of acha- assess screening practices in achalasia. While
lasia and esophageal dysmotility including in 82 % of experts endorsed long-term follow-up of
children who may have primary dysmotility and patients, no consensus was found regarding its
partial achalasia [28, 32, 47]. To date, no inves- timing [91].
tigation has a predictive value. However, several
studies have evaluated the treatment outcome by Conclusions
type on HRM. The analysis found that Type II The pathogenesis of esophageal achalasia is
had the greatest therapeutic response (95.3 %), not elucidated, and the pathogenic mechanism
followed by Type I (85.4 %), and then Type III is not understood. Many questions remain
(69.4 %) [32, 8587]. Thus, possibly Type III is unanswered. We dont know why we have a
another misunderstood form of the disease for depletion of ICC and could this possibly be
which a new treatment should be developed. Very responsible for the lack of LES relaxation,
recently Sodikoff has reported a correlation because of missing inhibitory neurotransmis-
between HMR types of achalasia and the immu- sion. Does achalasia in children differ from
nohistological findings on surgical biopsies of adults? Are biopsies with c-Kit staining of
the muscularis propria obtained from 46 patients predictive value? The answers to these ques-
during LHM [27]. tions will help to promote optimal treatment in
154 O. Reinberg

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analysis of 13 cases. World J Pediatr 5(1):5659
18. Chen CP, Lin SP, Lee CC et al (2006) Partial trisomy
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Laryngotracheal Clefts
LlusNisa andKishoreSandu

10.1 Introduction occurs in a context of polymalformative disor-

ders, endoscopic diagnosis may not be the prior-
Laryngotracheal clefts (LTC) constitute a rare ity in many cases [4, 5].
cause of congenital upper airway malforma- From an embryologic perspective, the larynx
tion. First described in a doctoral dissertation develops from endodermic tissues (which in turn
on unavoidable causes of neonatal death in the derive from the primitive gut) as well as mesen-
eighteenth century by Richter, LTC incidence is chymal tissues derived from the IVVI branchial
estimated to be around 1in 10,00020,000 live arches. Toward the fourth week of development
births, accounting for 0.21.5% of all congeni- begins the midline fusion which is meant to lead
tal laryngeal anomalies [1, 2]. to the separation of the digestive (esophageal)
The presenting signs and symptoms as well as and respiratory (tracheal) axes. This fusion pro-
the age of diagnosis largely depend on the type of cess takes place in the caudal to cranial direction
cleft (Table10.1) as well as the eventual presence [3]. The esophagus elongates and reaches its final
of associated malformations. Moreover, it has relative length toward the seventh week. LTCs
been previously pointed out that the actual inci- are pathological clefts thought to be the result of
dence of LTC may be highly underestimated [3]. a closure failure between the tracheal and esoph-
Potential reasons for this include asymptomatic ageal axes during embryogenesis, but despite the
or pauci-symptomatic disease especially in type I explanatory power of this theory, it is important
clefts, difficulties in endoscopic diagnosis mostly to point out that it has been challenged as it does
related to physicians unawareness, and immedi- not allow explaining the origin of other patho-
ate mortality in high-grade clefts without post- logical entities such as isolated tracheoesopha-
mortem diagnosis. Furthermore, since LTC often geal fistulae.

10.2 Diagnostic Aspects

L. Nisa
Department of Clinical Research, University of Bern, 10.2.1 Grading
3010 Bern, Switzerland
Several grading classifications for LTCs have
K. Sandu (*) been proposed, primarily based on the craniocau-
Department of Otorhinolaryngology Head and
dal extent of the cleft. Such classifications are
Neck Surgery, Lausanne University Hospital,
Lausanne, Switzerland mainly descriptive, help in therapeutic choices,
e-mail: and have to some degree prognostic value. The

Springer International Publishing Switzerland 2017 157

M. Lima (ed.), Pediatric Digestive Surgery, DOI10.1007/978-3-319-40525-4_10
158 L. Nisa and K. Sandu

Table 10.1 Classification of laryngotracheal clefts Monniers classification pays particular attention
Benjamin and Inglis to two specific features in these severe forms of
(1989) Sandu and Monnier (2006) disease: (1) whether the cricoid plate is partially
Type Description Type Description or completely involved by the LTC in type III
I Supraglottic cleft 0 Submucosal cleft clefts and (2) whether the cleft is supra- or infra-
I Interarytenoid cleft carinal in type IV LTCs (Fig.10.1).
with the absence of
the interarytenoid
II Cleft with partial II Posterior cleft 10.2.2 Clinical Presentation
cricoid extending partially
involvement through the cricoid
The classical diagnostic triad of LTC consists of
husky cry, aspiration pneumonia, and swallow-
III Cleft beyond the IIIa Posterior cleft
cricoid cartilage extending down to ing disorders in a newborn child with associated
with involvement the inferior border of congenital anomalies [7]. While such scenario
of the cervical the cricoid plate should immediately prompt active search for
trachea IIIb Posterior cleft LTC, disease spectrum can often complicate
extending into the
cervical trachea, but
anddelay LTC diagnosis. Indeed, LTCs are con-
not beyond the genital laryngotracheal disorders which can
sternal notch present as submucosal closure defect in the
IV Involvement of IVa Laryngotracheal cleft mildest cases versus complete laryngotracheo-
thoracic trachea extending into the esophageal clefts (LTEC) in some other severe
intrathoracic trachea
to the carina cases. Breathing difficulties are typically due to
IVb Intrathoracic prolapsing of retroarytenoid mucosa caused by
extension of the cleft the absence of the aerodigestive party wall and
involving one main obstruction of the posterior respiratory glottis
(Fig. 10.2). Therefore, presenting signs and
symptoms related to LTC may vary depending
most widely used classification is the one pro- on disease severity [7, 8].
posed by Benjamin and Inglis in 1989 [3]. LTCs without involvement of the posterior
Benjamins classification was modified and cricoid plate (type 0 and I) may be asymptomatic
updated by Sandu and Monnier [2] in 2006, in or in the case of type I clefts present with mild
order to introduce parameters with therapeutic occasional episodes of aspiration, hoarse cry,
and prognostic implications previously over- aspiration, cough, or in some cases dyspnea or
looked (Table10.1). cyanosis during feeding [810]. Due to their rar-
Unlike previous classifications, Sandu and ity, diagnosis of type 0 and I clefts requires a
Monnier introduce type 0 clefts (occult or more high-suspicion index.
accurately submucosal), which appear as a con- Regarding clefts with cricoid (with or without
sequence of a posteriorly defective cricoid carti- tracheal involvement), the outstanding issue is
lage accompanied by the absence of transverse severe aspiration and subsequent lower pulmo-
interarytenoid muscles [6]. Type I clefts are man- nary tract infection, as well as respiratory prob-
ifest interarytenoid clefts with the absence of lems in some cases [9, 11]. Finally, type IV LTCs
interarytenoid muscles which do not involve at have a dim prognosis due to respiratory distress,
all the cricoid cartilage. Type II clefts extend par- poor airway tone, and difficulties to maintain a
tially through the cricoid cartilage. By definition, patent airway even when using invasive proce-
type III and type IV clefts extend above and dures [1113]. Table10.2 summarizes the clini-
below the thoracic inlet, respectively. Sandu and cal presentation of LTCs [14].
10 Laryngotracheal Clefts 159

a b c d e f


Fig. 10.1 LTC classification according to Sandu and Monnier

Table 10.2 Clinical presentation of LTCs

Feature Incidence (%)
Aspiration 5380
Chronic cough 2735
Stridor 1060
Weak voice/cry 16
Salivary stasis in the pharynx 1023
Aspiration pneumonia 1654
Neonatal asphyxiation 33

pointed out that aspiration in an otherwise healthy

child most often correlates with an underlying
anatomic abnormality [16].
It is important to keep in mind that children
Fig. 10.2 Airway obstruction secondary to arytenoid with an undiagnosed LTC presenting with swal-
prolapse and mucosal invagination into the trachea lowing disorders may have undergone several
MBSs in the past, and the cumulative radiation
dose can be substantial.
10.2.3 Radiologic Studies

While the mainstay of LTC diagnosis is endoscopic 10.2.4 Functional Endoscopic

(discussed below), some imaging exams may be Evaluation ofSwallowing
contributive. Plain chest X-ray is often performed (FEES)
in children with persistent respiratory symptoms,
whether or not such symptoms are secondary to an FEES provides an extremely accurate dynamic
underlying LTC.Patients with LTC may present assessment of the laryngeal function during swal-
aspiration pneumonia or peribronchial cuffing, but lowing. FEES is usually possible in children older
chest X-ray is normal in up to 25% of type I and than 1 year but is otherwise difficult to perform in
around 10% of type II LTCs [15]. younger children. During FEES, several food
Modified barium swallow (MBS) performed consistencies should be tested. Hypopharyngeal
under the supervision of a speech and swallowing stasis and/or laryngeal penetration may be visual-
pathologist, testing diverse food consistencies, ized in cases of early-stage LTCs [17].
may help identifying patients with discoordinated Like MBS, FEES can be normal in children
swallow or aspiration. It has been previously with grade I cleft with only intermittent aspiration.
160 L. Nisa and K. Sandu

10.2.5 Endoscopic Diagnosis

Definitive LTC diagnosis relies on endoscopic

examination. Due to the high incidence of associ-
ated malformations, complete endoscopy of the
upper aerodigestive tract is mandatory, and
should include:

Transnasal fiberoptic laryngoscopy, performed

with the patient under spontaneous breathing.
The entire airway is examined dynamically
from the nostrils to the bronchi. The glottis
ought to be sprayed with local anesthesia in
order to examine the lower airway. In case the
child bears a tracheotomy, the canula is
removed intermittently during ventilation to
facilitate comprehensive dynamic airway
Fig. 10.3 The use of a blunt-angled probe to diagnose an
examination. Typically, LTC is associated with LTC
varying degrees of tracheobronchomalacia due
to the absence of the trachealis muscle.
Direct laryngoscopy and esophagoscopy: Paramedian position of the vocal folds
Laryngoscopy must be performed using an Interarytenoid erythema
anesthesia Macintosh spatula as well as 0, Mucosal cobblestoning (secondary to gastro-
30, and 70 telescopes, prior to airway esophageal reflux)
Suspension laryngoscopy in order to evaluate
the morphology of the glottis and assess the 10.3 Management
posterior commissure using a Lindholm vocal
fold retractor allows the diagnosis of a sub- The therapeutic approach to the child with LTC
mucosal or small type I cleft. Palpation of the largely depends on the extent of the cleft, severity
interarytenoid region using a blunt probe is of clinical manifestations, and associated or
the hallmark to the diagnosis of an LTC underlying disorders. All decisions should be
(Fig.10.3). The probe dips down into the pos- taken in consultation with the parents and in the
terior commissure in the presence of a cleft. context of a multidisciplinary team, especially in
The lower limit of the probe and simultane- children with severe comorbidities (such as car-
ous visualization by a telescope gives an idea diac, respiratory, etc.). In symptomatic patients,
regarding the cleft depth and thus its type. within the period between diagnosis and eventual
The esophagus and stomach are equally surgical management, two issues stand out: respi-
examined, paying particular attention to ratory and swallowing disorders.
the presence of an eventual tracheoesopha- Type 0 and I LTCs without respiratory symp-
geal fistula [4, 18], GER, and microgastria toms may benefit of regular follow-up and even-
(may be associated in type IV clefts). tually prophylactic-intermittent antibiotherapy in
order to prevent pulmonary complications of
Associated airway findings in LTC include: recurrent pneumonia. Most of these patients are
likely to require surgery at some point in their
Narrowed interarytenoid distance with pro- lives for chronic intractable aspiration. Type II
lapsing retroarytenoid mucosa that blocks the clefts present with feeding difficulties and quasi-
posterior respiratory glottis systematically require surgical management.
10 Laryngotracheal Clefts 161

Type III and type IV LTCs may quickly degrade Sandu and Monnier reported a small series of
from a respiratory point of view, imposing patients with types IIIa and IIIb LTCs managed
oxygen therapy and pharyngeal aspiration tubes. endoscopically [2]. In their reported experience
The degree of invasiveness of oxygenotherapy carbon dioxide laser is used in ultrapulse mode to
may vary from nasal administration of oxygen to incise the cleft from caudal to cranial direction
invasive ventilation (i.e., endotracheal tubes and cleft apex up to the cuneiform cartilages. The
even tracheostomy). CO2 laser is a precise cutting tool giving a blood-
With respect to swallowing disorders, less field and causes no mucosal charring. Two
measures to avoid tracheobronchial aspiration
layers of mucosae are created: laryngotracheal
and GERD must be considered a priority. and pharyngoesophageal. Starting caudally, a set
Tracheobronchial aspiration in advanced-type of inverted Vicryl 5.0 sutures are placed on the
LTCs represents a serious and immediate threat tracheal aspect of the cleft and the knots tied fac-
to the vital prognosis and consequently requires ing the pharyngoesophageal side. The second
aggressive management approaches. More spe- mucosal layer is sutured in similar fashion in dis-
cifically, LTCs of type I and II require medical tal to proximal direction with knots facing the
anti-GERD treatment and thickened food. More esophagus while gradually withdrawing the sus-
severe cases may impose suspension of oral feed- pension laryngoscope (Fig.10.4). The procedure
ing and enteral administration through a nasal or is performed under spontaneous respiration and
a gastrostomy tube, or even parenteral nutrition without endotracheal intubation. At the end of the
in case of longer clefts. procedure, it is important to maintain an adequate
In summary, even though the management of posterior commissure and avoid posterior glottic
LTCs is far from being consensual, there is some stenosis (Fig.10.5). Special endoscopic suturing
agreement that children with type I clefts instruments are a must and their role needs
maybenefit from a trial of medical management emphasis. The details of such instruments are
and regular follow-up, while longer clefts (with described in related articles [2].
cricoid involvement) require early surgical The advantages of the endoscopic repair are:
approaches to avoid the pulmonary complica-
tions of aspiration [7, 15, 17, 19]. Furthermore, a The surgeon is axial to the larynx and gets
minimally invasive endoscopic approach has the best view of the cleft. This is important
become standard for the management of types I, so as to achieve a meticulous closure of the
II, and IIIa (and even selected IIIb) LTCs, while cleft and avoid excessive crowding of
major types IIIb and IV clefts most often require mucosa into the airway lumen and thus its
open approaches [2, 15, 2022]. Open approaches obstruction.
are equally indicated as salvage for failed Maintains stability of the laryngotracheal
attempts of endoscopic repair. framework.

10.3.1 Endoscopic Repair 10.3.2 Open Surgical Approaches

Since the late 1970s, various endoscopic Several open surgical techniques for the repair of
approaches have been successfully used primar- LTCs exist, depending on their extent. All
ily for types I and II clefts [25]. Injection laryn- approaches require a layer-by-layer closure of
goplasty using different products (Gelfoam, the cleft (esophageal and tracheal). The use of
bioplastic) has been reported [26, 27]. Endoscopic interposition material to reinforce the closure has
repair has progressively become the standard of been suggested by some authors (tibial perios-
care for types I and II clefts that remain symp- teum, auricular cartilage, sternocleidomastoid
tomatic despite adequate medical treatment after muscle flap, fascia temporalis, or costal cartilage)
an observation period of 46 months [14, 16, 17]. [20, 2224].
162 L. Nisa and K. Sandu

a b c d

Fig. 10.4 Endoscopic closure of LTC: (a) Type IIIb LTC (c) Caudo-cranial suturing of the pharyngoesophageal
and the use of CO2 laser to create two mucosal layers, layer. (d) End of the two-layer LTC closure. Note that in
laryngotracheal and pharyngoesophageal. (b) Vicryl 5.0 is the end, we should have an adequate posterior commis-
used to suture the inner laryngotracheal layer from caudal sure and avoid a posterior glottic stenosis
to cranial, with the knots tied toward the esophageal side.

a b c

Fig. 10.5 Endoscopic closure of LTC post-LTC repair ing. (c) Simultaneous endoscopic visualization of the lar-
endoscopy: (a) Placement of naso-esophageal suction ynx and trachea shows complete healing of the LTC and
catheter and injection of dilute methylene blue. (b) Avoid no residual fistula
excessive spillage of the colored solution and airway soil-
10 Laryngotracheal Clefts 163

Cervical approaches differ in cases of extra- cartilage graft that can be sutured to the splayed
and intrathoracic LTCs and can be summarized posterior cricoid plate similar to a posterior car-
as follows: tilage expansion graft (Fig.10.6d). To calibrate
the endolaryngeal reconstruction, Monniers
1. Extrathoracic LTEC LT mold stent can be used temporarily.
The surgery begins with a nasotracheal intu- 2 . Intrathoracic LTEC
bation using a soft Portex blue line ET tube. The repair is done under cardiopulmonary
Surgery begins with a horizontal neck incision bypass or extracorporeal membrane oxygen-
and separating the pre-laryngeal strap muscles ation (ECMO) [7]. The long cleft is
in the midline. The thyroid isthmus is divided approached by a longitudinal incision along
and retracted. An extended laryngotracheofis- the right tracheoesophageal groove from the
sure is performed dividing the anterior com- origin of the right main bronchus up to the
missure exactly in the midline (Fig.10.6a, b). level of the cricoid cartilage. A long laryngo-
The posteriorly placed laryngeal cleft is identi- tracheofissure causes severe airway frame-
fied. The edges of the cleft are incised to create work instability and is hence avoided. The
two layers: pharyngoesophageal and laryngo- right lateral esophageal wall is dissected in
tracheal depending on the cleft extension the groove, and the common tracheoesopha-
(Fig. 10.6c). These layers are then sutured geal space is entered. The objective of dis-
independently in between tissue interpositions, secting and mobilizing the right esophageal
using perichondrium, tibial periosteum, or rib wall is to use this mucosa to reconstruct the

a b

c d

Fig. 10.6 Open repair of LTC. (a) Anterior extended posterior costal cartilage graft is sutured into the cricoid
laryngofissure. (b) Dissection in the right tracheoesopha- defect. In addition, a small Monniers LT mold is inserted
geal groove and (c) esophageal mucosa flipped over to the for temporary airway calibration
left that is used to reconstruct the posterior trachea. (d) A
164 L. Nisa and K. Sandu

posterior tracheal wall after identifying and not identified. The trachea is then peeled off from
incising the left tracheoesophageal cleft the esophagus up to the lower end of the cleft. A
mucosa. The rest of the esophageal mucosa is complete laryngofissure is performed, and the
rotated and sutured on to the left side. The splayed cricoid is reconstructed using a rib carti-
trachea and esophagus are sutured longitudi- lage. Proximal pharyngoesophageal and laryngo-
nally up to the cricoid. The laryngeal part of tracheal mucosae are flipped across each other to
the cleft is then approached by laryngofis- close above the posterior cricoid and reaching the
sure. The posterior laryngeal cleft is identi- interarytenoid region. The front of the esophagus
fied and sutured as described above along is sutured in the caudal to cranial direction. The
with tissue interposition. A small LT mold excess of esophageal mucosa is used to recon-
(avoiding excess contact pressure on the struct the posterior tracheal wall. The back of the
suture line) is inserted to calibrate the airway trachea is then sutured in a similar fashion up to
and the laryngofissure closed. The LT mold is the cricoid cartilage. At this stage, the trachea is
removed endoscopically at a later date. reconnected to the cricoid. The authors note the
Ideally and if possible, a tracheostomy is to following advantages with this technique
be avoided in LTC management as it destabi- improved visibility, access, airway stability, and
lizes the tracheal framework, erodes the poste- coverage of the anastomosis with interpositional
rior suture line of repair, and can potentially sternal periosteum permitting a three-layer
lead to severe tracheomalacia albeit to say, it closure.
has to be done as per the patient requirements
and for oxygenotherapy [19, 22]. In long LTC
repairs, a well-fixed nasotracheal tube is pre- 10.4 Associated Disorders
ferred during the immediate postoperative
period. As previously mentioned, LTCs are often a mani-
festation of a larger spectrum of developmental
disease and therefore are often embedded in a
10.3.3 Transcervical Approach Using context of associated congenital malformations
Cricotracheal Separation (Table 10.3). The most common comorbidities
are esophageal atresia, considered to occur in
Propst and Rutter [29] described a technique to 2037% of cases of LTCs, while various midline
repair a type IV LTC.The long cleft is approached malformations including craniofacial and heart
transcervically, without sternum split and with- malformations would occur in around 10% and
out deploying ECMO or a cardiopulmonary 1633% of the cases, respectively [3, 19]. The
bypass (Fig.10.7). The surgery is performed co-occurrence of LTC and tracheoesophageal fis-
under spontaneous total intravenous anesthesia. tula is estimated to be between 10 and 15% [28].
An angioplasty balloon catheter is passed into the As mentioned above, complete digestive and
stomach and inflated, so as to avoid gastric insuf- respiratory examination is essential given the
flation by anesthesia gases and oxygen during the number of cases with associated malformations.
entire intervention. The surgery begins as LTCs can equally occur in a number of syn-
described earlier up to exposing the laryngotra- dromic contexts, especially Opitz-Frias syn-
cheal framework. The cricoid cartilage and the drome, Pallister-Hall syndrome, DiGeorge
trachea are transected at the first tracheal ring. syndrome, CHARGE syndrome, and VACTERL
The dissection is continued posteriorly to iden- association (Table10.4).
tify the long LTC.Recurrent laryngeal nerves are Genetic counseling is a must in such cases.
10 Laryngotracheal Clefts 165

a b c d e

Fig. 10.7 Open repair (transcervical approach with cri- positional costal cartilage graft is used to reconstruct the
cotracheal separation): (a) Trachea transected from the splayed cricoid defect. (d) Repair of the back of the tra-
cricoid at the first tracheal ring. (b) Trachea peeled off chea and front of the esophagus. (e) Trachea is recon-
from the esophagus. (c) Complete laryngofissure and clo- nected with the cricoid
sure of the pharyngeal and laryngeal mucosae. An inter-

Table 10.3 Most common associated malformations

10.5 Prognosis
System Malformations
Head and face Cleft lip and palate,
micrognathia, glossoptosis, The outcome of LTCs depends on several factors,
microtia, hypertelorism, and mainly cleft extent and associated comorbidities
choanal atresia [22]. Early diagnosis and active prevention of
Respiratory Tracheoesophageal fistula, lower airway infection and GER equally have an
tracheomalacia, hyaline
impact on disease progression. Longer clefts are
membrane disease, irregularities
in size and shape of lower associated with syndromic anomalies and comor-
airways bidities and carry a poor prognosis. The mortality
Gastrointestinal Esophageal atresia, duodenal rate of LTCs was around 50% in the 1980s (43%
atresia, imperforated anus, for types I and II, 42% for type III, and 93% for
intestinal malrotation
type IV) but more recent series report rates of
Cardiac Aortic coarctation, great vessel
transposition, double outlet right 625% [19].
ventricle, patent ductus
arteriosus, and septal defects
Genitourinary Renal malformations,
hypospadias, and inguinal

Table 10.4 Associated syndromes

Disease OMIM ID Chromosomal region Inheritance mode Incidence Phenotypical manifestations
Opitz-Frias syndrome 145410 22q11.23 AD 1:40001:10,000 Hypertelorism, telecanthus, cleft lip, palate, and uvula,
X linked hypospadias (male) and splayed labia majora (females),
mental retardation, developmental delay, and congenital
heart diseases
Pallister-Hall 146510 7p14.1 AD Unknown Extremity anomalies (polydactyly, syndactyly),
syndrome hypothalamic hamartoma, bifid epiglottis, imperforated
anus, and hydronephrosis/hydroureter
DiGeorge syndrome 188400 22q11.21 AD 1:20001:7000 Variable developmental delay, obesity, ear anomalies,
eye anomalies, cleft palate/uvula, tetralogy of Fallot or
multiple other heart malformations, endocrine and
metabolic disorders
Mnemonic: CATCH22 Cardiac abnormality, Abnormal
facies, Thymic aplasia, Cleft palate or VPI,
Hypocalcemia/hypoparathyroidism, 22q11.2
CHARGE syndromea 214800 7q21.11 AD 1:850012,000 Variable phenotype
8q12.2 Mnemonic: CHARGE Coloboma, Heart defect,
Atresia choanae, Retarded growth and development,
Extremity abnormalities
VACTERL association 192350 1.6 cases/10,000 live Variable phenotype
births Mnemonic: VACTERL Vertebral anomalies, Anal
atresia, Cardiovascular anomalies, Tracheoesophageal
fistula, Esophageal atresia, Renal anomalies, preaxial
Limb anomalies
Source: Online Mendelian Inheritance in Man (
Abbreviations: AD autosomal dominant
Two different genetic lesions have been identified, and CHARGE syndrome overlaps with Kallmann syndrome
L. Nisa and K. Sandu
10 Laryngotracheal Clefts 167

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Esophageal Atresia
and Tracheoesophageal Fistula
Arnold G. Coran, Steven W. Bruch, and
Shaun M. Kunisaki

Esophageal atresia (EA) with or without tracheo- associated scores, and Table 11.2 shows the mortal-
esophageal fistula (TEF), a defect occurring in about ity stratified by risk factor scores [5].
1 in 3000 live births, remains a challenging problem
for pediatric surgeons [1]. Since Cameron Haight
performed the first successful primary anastomosis 11.1 Anatomy
in 1941 [2], survival rates have improved due to
refinements in surgical technique and advances in An understanding of the anatomy involved with
neonatal care. In 1994, Spitz predicted survival each case of EA and TEF is important when
based on birth weight (greater or less than 1500 g) devising a treatment strategy. There have been
and associated complex anomalies usually cardiac in several classification systems, but a description
nature [3]. Spitz reexamined this in 2006 and found of each type is the easiest and most practical way
that survival for babies without cardiac anomalies to classify the five different types of EA and TEF
and weighing more than 1500 g was 98.5 %, similar as shown in Fig. 11.1. The most common config-
to that in 1994. However, survival rates improved uration is EA with a distal TEF. This configura-
from 59 to 82 % in babies born less than 1500 g or tion occurs in 86 % of cases [6]. The proximal
had a major cardiac anomaly over this time. And esophagus ends blindly in the upper mediasti-
during this same period, survival rates improved num. The distal esophagus is connected to the
from 22 to 50 % in babies who were born less than tracheobronchial tree usually just above or at the
1500 g and had a major cardiac anomaly [4]. Using carina. The second most common type is the iso-
the Kids Inpatient Database (KID) in 2014, Brindle lated EA without a TEF. This configuration occurs
calculated the odds ratio for significant predictors of in 8 % of cases [6]. The proximal esophagus ends
inhospital mortality in babies born with EA and blindly in the upper mediastinum, and the distal
TEF. Table 11.1 describes the risk factors with their esophagus is also blind ending and protrudes a
varying distance above the diaphragm. The dis-
tance between the two ends is often too far to
A.G. Coran (*) bring together shortly after birth. The third most
C.S. Mott Childrens Hospital, University of common configuration, occurring in 4 % of cases
Michigan Hospital and Health Systems, [6], is a TEF without EA. The esophagus extends
Ann Arbor, MI, USA
e-mail: in continuity to the stomach, but there is a fistula
between the esophagus and the trachea. The fis-
S.W. Bruch, MD S.M. Kunisaki, MD
C.S. Mott Childrens Hospital, University of tula is usually located in the upper mediastinum
Michigan, Ann Arbor, MI, USA running from a proximal orifice in the trachea to

Springer International Publishing Switzerland 2017 169

M. Lima (ed.), Pediatric Digestive Surgery, DOI 10.1007/978-3-319-40525-4_11
170 A.G. Coran et al.

Table 11.1 Odds ratio for significant predictions for Table 11.2 Mortality stratified by risk factor scores
% of EA TEF
Risk factor Odds ratio Risk points Risk score population % mortality
Birth weight <1500 g 9.05 9 Low risk (06) 86.3 4.4
Chromosomal abnormality 5.80 6 Intermediate risk 12.0 33.8
Major cardiac anomalya 2.68 3 (714)
Renal anomaly 1.89 2 High risk (1520) 1.7 67.5
CNS and GI abnormalities did not contribute to mortality
Major cardiac anomaly defined as all other than PDA or ASD

a 86 % b 8% c 1%
Most common Atresia alone, Proximal and
abnormality no fistula distal fistulae
Small stomach,
gasless abdomen
Usually long gap

d 1% e 4%
Proximal tracheo- No esophageal
esophageal fistula atresia
No distal fistula Congenital tracheo-
Small stomach, esophageal fistula
gasless abdomen
Often long gap

Fig. 11.1 Types of esophageal atresia and tracheoesoph- and distal tracheoesophageal fistulas. (d) Esophageal atre-
ageal fistula with rates of occurrence. (a) Esophageal atre- sia with proximal tracheoesophageal fistula. (e) H-type
sia with distal tracheoesophageal fistula. (b) Isolated tracheoesophageal fistula
esophageal atresia. (c) Esophageal atresia with proximal
11 Esophageal Atresia and Tracheoesophageal Fistula 171

a more distal orifice in the esophagus. This is also three or more of these abnormalities and occurs
known as an H-type or N-type TEF. Two in up to 33 % of babies with EA and TEF [9].
more forms of EA and TEF exist, both of which Chromosomal abnormalities occur in 5 % and
occur about 1 % of cases [6]. These are EA with include trisomies 13, 18, and 21 [12]. Other syn-
both proximal and distal TEF and EA with a dromes associated with EA and TEF include the
proximal TEF. These two forms correspond to the Feingold syndrome, CHARGE syndrome,
first two forms described with the addition of a anophthalmia-esophageal-genital (AEG) syn-
proximal fistula between the upper pouch and the drome, Pallister-Hall syndrome, Opitz syndrome,
trachea. A proximal fistula is often difficult to and Fanconis anemia [13]. Infants with EA and
diagnose preoperatively even when bronchos- TEF also have a higher incidence of pyloric ste-
copy is performed, resulting in the real incidence nosis compared to the normal population [14].
being higher than previously reported [7]. Again
the EA with proximal TEF, similar to its counter-
part without the proximal fistula, will have a long 11.3 Clinical Presentation
gap between the two ends of the esophagus, mak- and Diagnosis
ing it difficult to repair shortly after birth.
Prenatal diagnosis of EA remains difficult with
only 1632 % of babies born with EA and TEF
11.2 Associated Anomalies having the diagnosis before delivery [15, 16].
The use of fetal ultrasound to screen for polyhy-
As noted earlier, prematurity and associated car- dramnios and a small or absent stomach followed
diac and chromosomal anomalies often deter- by MRI looking for a dilated upper esophageal
mine the outcome of a baby with EA and pouch for confirmation can lead to a correct diag-
TEF. Babies with EA and TEF are often born pre- nosis of EA and TEF in 66.7 % of those suspected
maturely due in part to the polyhydramnios [17]. The majority of babies diagnosed prior to
resulting from fetal esophageal obstruction [8]. delivery will have pure EA as it is more difficult
Recent series revealed a mean gestation age of to diagnose EA with a distal TEF [16, 18]. The
36.5 weeks with 3.5 % being born between 24 vast majority of cases of EA and TEF are initially
and 29 weeks estimated gestation age (EGA), and diagnosed shortly after birth with inability to
38.3 % between 30 and 36 weeks EGA [9], and a handle saliva and episodes of coughing, choking,
birth weight of 2500 g [10]. Up to two thirds of and cyanosis, especially with the first attempt to
EA and TEF babies have one or more associated feed. This usually leads to the placement of a
anomalies that are usually chromosomal or tube in the esophagus, which meets resistance.
related to the VACTERL association [9, 11]. The Plain films of the chest and abdomen will show
VACTERL association includes abnormalities in the tube coiled in the upper mediastinum. This
the following areas: vertebral, anorectal, cardiac, confirms the presence of esophageal atresia. If
tracheal, esophageal, renal, and limb. A break- there is gas in the distal bowel, a distal TEF is
down of the individual incidences of the anoma- present, while a pure EA will present with a
lies in babies with EA and TEF is presented in gasless abdomen. The remainder of the preopera-
Table 11.3 [9]. The VACTERL syndrome requires tive evaluation targets the associated anomalies
and looks to determine the presence of a proxi-
Table 11.3 Incidence of associated anomalies with EA mal fistula between the trachea and the esopha-
and TEF gus. The VACTERL anomalies can be identified
Associated anomalies Occurrence (%) using physical exam (limb and anorectal), plain
Vertebral 25.4 films (tracheal, esophageal, vertebral, and limb),
Atresia, anorectal, and duodenal 16.3 abdominal ultrasound (renal and a tethered spinal
Cardiac 59.1 cord), and an echocardiogram (cardiac). The
Renal 21.8 position of the aortic arch needs to be identified
Skeletal 6.4 during the echocardiogram. If a right-sided arch
172 A.G. Coran et al.

is present, which occurs in 26 % of series [19], standpoint, is brought to the operating room and
evaluation with a CT scan or an MR angiogram placed under a general anesthetic. Rigid bronchos-
will find a complete vascular ring 37 % of the copy may be performed to locate the distal fistula,
time [20]. A chromosome analysis should also be usually at or near the carina, look for a proximal
considered. A proximal pouch fistula can be fistula or cleft, and assess for tracheomalacia. The
interrogated in two ways. A pouchogram, or con- baby is then placed in the left lateral decubitus
trast evaluation of the proximal esophageal position in preparation for a right posterolateral
pouch, will often reveal a proximal fistula if pres- thoracotomy. If the preoperative echocardiogram
ent. An experienced radiologist should perform reveals a right-sided aortic arch, which occurs in
this exam with 1 or 2 ml of contrast material to 26 % of cases, the repair should be approached
decrease the risk of aspiration. Rigid bronchos- from the left chest [19, 21]. Attempting to bring
copy looking for a proximal fistula just prior to the ends of the esophagus together over a right-
surgical repair is often used in conjunction with sided aortic arch results in a high anastomotic leak
the pouchogram. During the dissection of the rate in the range of 40 % due to increased tension
proximal pouch, the surgeon should always look [22]. The preoperative echocardiogram identifies
carefully for a proximal fistula. If the proximal a right-sided aortic arch correctly in 2062 % of
pouch is not thick walled and dilated, there may the cases [20, 22]. A right-sided arch discovered
be a proximal fistula that has relieved the usual intraoperatively should prompt an attempt at
distending pressure in the proximal pouch. A repair of the esophagus through the right chest. If
TEF without EA (H-type fistula) may not present this cannot be completed due to tension, divide the
in the initial neonatal period and is more difficult fistula, close the right chest, and complete the
to diagnose. The tube will go into the stomach anastomosis through a left-sided thoracotomy.
when originally passed, but persistent coughing In the typical case, a right-sided posterolat-
and choking with feeds by mouth should prompt eral thoracotomy using a muscle-sparing, retro-
a search for an isolated fistula. A prone pullback pleural approach gives access to the mediastinal
esophagram and bronchoscopy with esophagos- structures. An extrapleural axillary approach
copy are used to identify the isolated fistula. provides another option to gain exposure. The
azygos vein is divided, revealing the tracheo-
esophageal connection. The distal esophagus is
11.4 Treatment divided, and the tracheal connection is closed
with 5-0 monofilament suture. Manipulation of
After the diagnosis is confirmed, plans for opera- the distal esophagus is minimized to protect the
tive repair should be made. In healthy newborns, segmental blood supply to this portion of the
the operation can take place within the first 24 h of esophagus. The proximal esophagus has a rich
life to minimize the risk of aspiration and resulting blood supply coming from the thyrocervical
pneumonitis. Before the operation, the baby should trunk and may be extensively dissected as
be kept supine with the head elevated 3045. A depicted in Fig. 11.2. The dissection of the upper
tube should be in the proximal pouch to constantly esophageal pouch proceeds on the thickened
suction saliva and prevent aspiration. Intravenous wall of the esophagus to prevent tracheal injury.
access should be established and fluids instilled Dissection is carried as high as possible to gain
along with perioperative antibiotics and vitamin K. length for a tension-free anastomosis and to look
The goal of operative therapy for EA and TEF for a proximal fistula, which occurs rarely. A
is to establish continuity of the native esophagus single-layered end-to-end anastomosis is per-
and repair the fistula in one setting. Most of the formed as depicted in Fig. 11.3. A tube placed
time, primary repair can be achieved. There are through the anastomosis into the stomach allows
special situations where this may not be possible decompression of the stomach and eventual
or advisable. These situations will be described enteral feeding. A chest tube placed in the retro-
later. In the usual scenario, the baby, who is stable pleural space next to the anastomosis controls
both hemodynamically and from a pulmonary any subsequent leak. Some surgeons prefer not
11 Esophageal Atresia and Tracheoesophageal Fistula 173

to use a chest tube if the pleura remains intact. A leak into the retropleural space will result in a
The advantage of a retropleural approach is that controlled esophagocutaneous fistula that will
if the anastomosis leaks, the baby will not soil almost always close spontaneously.
the entire hemithorax and develop an empyema. Since the first thoracoscopic repair of EA by
Lobe in 1999, this approach has become increas-
Branches ingly popular [23]. Visualization of the posterior
of inferior mediastinum depends on patient position and cre-
thyroid artery ation of a pneumothorax. The baby is placed in a
semi-prone position elevating the right chest
about 30. The camera trocar avoids competing
with the working ports by being placed just poste-
rior to the scapula tip in the fifth intercostal space.
The two working ports are then placed two inter-
spaces above the midaxillary line and one to two
Bronchial interspaces below and slightly posterior to the
branches camera port. This allows the instruments to meet
at a 90 angle at the site of the anastomosis [24].
Aortic Insufflation of CO2 gas at a flow of 1 L/min and a
pressure of 4 mmHg provides an adequate work-
ing space. The improved visualization allows for
a precise division of the fistula at the membranous
portion of the trachea and an extensive mobiliza-
of inferior tion of the proximal fistula up into the neck while
phrenic preserving the recurrent laryngeal nerves. Suture
artery Ascending
branch of
placement proves to be the biggest challenge
left gastric especially when the ends of the esophagus are
artery brought together under tension. Advantages of
the thoracoscopic approach include better cos-
metic results, improved musculoskeletal function
of the thorax, and improved visualization.
Fig. 11.2 The vascular supply of the esophagus in esoph- Disadvantages include a steep learning curve
ageal atresia and tracheoesophageal fistula even for those with excellent thoracoscopic skills,

b c

Fig. 11.3 Single-layer end-to-end esophageal anastomo- anastomosis into the stomach. (c) Anterior row sutures
sis. (a) Corner sutures are placed. (b) Posterior row complete the anastomosis
sutures are placed. A tube is then passed through the
174 A.G. Coran et al.

difficulty in small (<2,000 g) infants or in neo- path for air provided by the ventilator. The stiff
nates with significant cardiac or pulmonary dis- lungs have a higher resistance than the fistulous
ease, and the potential impact of elevated pCO2, tract, allowing a significant portion of each inspi-
acidosis, and cerebral hypoperfusion from pro- ratory volume to go into the distal esophagus and
longed carbon dioxide pneumothorax [25]. A then the stomach, resulting in abdominal disten-
meta-analysis comparing thoracoscopic and open tion and elevation of the hemidiaphragms, further
repair of EA with or without TEF found no differ- impeding ventilation. Various strategies have
ence in leakage rate or anastomotic strictures been developed to deal with this situation. A
[26]. change to high-frequency ventilation decreases
Postoperatively, the baby is returned to the the portion of tidal volume lost to the fistula [28].
intensive care unit and continued on intravenous A number of techniques designed to prevent ven-
nutrition and antibiotics. Special care should be tilation through the fistula have been proposed:
directed toward preventing aspiration with fre- advancing the endotracheal tube past the fistula
quent oropharyngeal suctioning and elevation of opening [29], bronchoscopically placing and
the head of the bed 3045. Feedings may be inflating Fogarty catheters for temporary occlu-
started through the transanastomotic tube into the sion [30], and temporarily occluding the esopha-
stomach 23 days after the operation. Acid- gus at the gastroesophageal junction [31]. If a
suppressive therapy should be instituted to pre- gastrostomy tube is present, the tube can be
vent acid irritation of the anastomosis and placed to underwater seal to increase the resis-
subsequent stricture. On postoperative day 57, tance of the tract and reduce airflow through the
an esophagram is obtained to check the integrity fistula [6]. However, to prevent further respiratory
of the anastomosis. Feeds are initiated orally, and decompensation, and to ameliorate the risk of
if there is no leak clinically or radiographically, gastric perforation, these babies often require an
the chest tube is removed. If a leak is present, it is urgent thoracotomy and control of the TEF. If the
treated conservatively with intravenous antibiot- baby stabilizes, the remainder of the repair can
ics, nutrition, and chest tube drainage. Another proceed at that time, which is the usual case [32].
esophagram is ordered in a week. These leaks However, if the baby remains unstable, the esoph-
will invariably close without further operative agus is secured to the prevertebral fascia, the
intervention [27]. Only a complete disruption of chest is closed, a gastrostomy tube is placed, and
the anastomosis requires further operative proce- the definitive repair is completed when the baby is
dures. In that case the proximal esophagus should stabilized. In very low birth weight infants, less
be brought out of the left neck as a cervical than 1500 g, a staged repair should be considered.
esophagostomy, the distal esophagus should be Compared to a primary repair in these very low
tied off, and the mediastinum and chest should be birth weight infants, staged repair resulted in
adequately drained. fewer anastomotic leaks and strictures [33].
The second special situation occurs when
there is a long gap between the two ends of the
11.5 Special Situations esophagus. This often occurs with pure EA or EA
with a proximal TEF. On occasion, a baby with
Three unique situations require different tactics: EA and distal TEF may fit into this special group.
babies with EA and TEF with concomitant respi- If the baby presents with a gasless abdomen, a
ratory insufficiency where the fistula contributes long gap should be suspected. The baby is
to the ventilator compromise, long-gap EA, and brought to the operating room for a gastrostomy
H-type TEFs. Babies with respiratory insuffi- tube placement to allow enteral feedings while
ciency and a TEF are usually premature neonates waiting for the two ends of the esophagus to grow
with lung immaturity requiring significant venti- spontaneously, so a primary anastomosis can be
latory support. The connection between the tra- attempted. The stomach is quite small in these
chea and the distal esophagus may be the preferred babies because it was unused during fetal life and
11 Esophageal Atresia and Tracheoesophageal Fistula 175

has not yet stretched to its full capacity. Care weeks, and, if the two ends are within two to
must be taken to avoid injury to the small stomach three vertebral bodies, a thoracotomy and attempt
and its blood supply while placing the gastros- at anastomosis are performed. Waiting longer
tomy tube. Careful placement will not compro- than 4 months rarely provides extra growth of the
mise the use of the stomach for an esophageal esophageal ends. The gap will close to within two
replacement if necessary. During gastrostomy to three vertebral bodies in close to 70 % of these
tube placement, an estimate of the distance babies [36]. Intraoperatively, several techniques
between the two ends of the esophagus is made help gain length on the esophageal ends if needed.
using a neonatal endoscope in the distal esopha- These include complete dissection of the upper
gus and fluoroscopy. If the two ends of the esoph- pouch to the thoracic inlet. A circular myotomy
agus are more than three vertebral bodies apart, of livaditis performed on the upper pouch pro-
they will not be easily connected. The baby is duces about 1 cm of length for each myotomy as
then nursed with a tube in the proximal pouch to depicted in Fig. 11.4 [37]. A tubularized graft of
remove the saliva and is fed via the gastrostomy the upper pouch can be created and connected to
tube. During the first several months of life, the the distal esophagus [38]. If these techniques do
gap between the two ends of the esophagus short- not allow an adequate anastomosis, the distal
ens because of differential growth of the atretic esophagus is mobilized, despite its segmental
esophagus [34]. The upper pouch may undergo blood supply, to gain length [6]. If these maneu-
serial dilation attempting to stretch the pouch vers do not allow an adequate anastomosis, then
[35]. The gap distance is measured every 24 one of three options must be chosen. The first

a b

Fig. 11.4 Repair of esophageal atresia and distal tra- of primary anastomosis between the two esophageal seg-
cheoesophageal fistula using a circular myotomy to pro- ments is assessed. (c) A proximal esophagomyotomy pro-
vide adequate length. (a) The tracheoesophageal fistula is vides extra length to allow for a primary anastomosis
closed with 5-0 monofilament suture. (b) The feasibility
176 A.G. Coran et al.

option is a two-stage procedure in which a cervi-

cal esophagostomy is initially created in the left
neck followed by an esophageal substitution at a
later time. The esophagostomy will allow the
baby to take sham feeds to prevent oral aversion
without the risk of aspiration while awaiting
esophageal replacement. The replacement opera-
tion usually takes place between 9 and 12 months
of age. The second option is a one-stage
esophageal-substitution procedure using a gastric
transposition, a gastric tube, or a colon interposi-
tion to replace the native esophagus. Currently, a
gastric transposition is our preferred approach
and has been shown to be a reliable and reproduc-
ible procedure at other centers worldwide [39]. A
third option for esophageal reconstruction in
long-gap esophageal atresia involves the place-
ment of traction sutures on both ends of the
esophagus and either attaching them under ten-
sion to the prevertebral fascia if the gap is moder-
ate length or bringing them out through the back
and increase the tension on them sequentially
over the ensuing 2 weeks (Foker technique). A
delayed primary anastomosis is carried out after
the two ends of the esophagus are in close prox-
imity [40]. Although the Foker technique allows
for a primary repair, it requires multiple thora-
cotomy incisions, is associated with a very high
stricture rate, and invariably requires a gastric
fundoplication procedure to control gastroesoph-
ageal reflux [41]. Thoracoscopic techniques have Fig. 11.5 An H-type tracheoesophageal fistula is demon-
been introduced for both the gastric transposition strated as contrast is injected through a nasoesophageal
[42] and the Foker technique [43]. tube. Contrast is noted passing from the esophagus,
through the fistula, and filling the upper trachea and
The third special situation is the H-type tra-
cheoesophageal fistula without esophageal atre-
sia. An H-type fistula will often escape the
discovery in the neonatal period but will be found incision just above the clavicle. The fistula is
later during evaluation of coughing and choking identified and divided. If possible, the muscle or
episodes with feeds. Often the fistula is identified other available vascularized tissue is placed
by contrast studies, usually a prone pullback between the two suture lines to help prevent a
esophagram as shown in Fig. 11.5. However, it is recurrence.
not unusual to also require bronchoscopy and
esophagoscopy to make the diagnosis. To repair
this fistula, rigid bronchoscopy and esophagos- 11.6 Postoperative Complications
copy are used to find the fistula, place a glidewire
through it, and bring the two ends out of the Complications following repair of EA and TEF
mouth to aid in its identification during the explo- relate to the anastomosis and to the underlying
ration. The right neck is then explored through an disease. The anastomotic problems include anas-
11 Esophageal Atresia and Tracheoesophageal Fistula 177

tomotic leaks, anastomotic strictures, and recur- repeat right thoracotomy with closure of the fis-
rent TEFs. The issues related to the underlying tula is a difficult operation. Identification of the
disease include gastroesophageal reflux and fistula tract is improved with placement of a
tracheomalacia. glidewire or ureteral catheter through the fistula
The number of anastomotic problems that at bronchoscopy just before opening the chest.
occur after repair is directly dependent on the After the fistula is identified and divided, a viable
amount of tension that is used to create the anas- piece of tissue, usually a vascularized muscle flap
tomosis. The incidence of leak at the anastomosis or a portion of pleura or pericardium, should be
varies from 5 to 20 % [44] and has remained sta- placed between the suture lines to prevent recur-
ble over the years [45, 46]. The majority of these rence of the fistula, which occurs in up to 20 % of
leaks seal within 12 weeks with conservative these repairs [51]. Endoscopic techniques may be
management. Complete disruption of the anasto- attempted prior to surgical closure of a small
mosis, a rare complication occurring in less than recurrent TEF. It appears that the combination of
2 % of cases, presents with a pneumothorax and de-epithelialization of the fistula tract with an
significant salivary drainage from the chest tube. energy source (diathermy or laser) combined
This scenario may require early thoracotomy and with tissue adhesives (Histoacryl or fibrin glue)
revision of the anastomosis or a cervical esopha- works better than either techniques alone to close
gostomy and gastrostomy for feeding with subse- the fistula tract with a reported short-term suc-
quent esophageal replacement. cess rate of 75 % [50].
Anastomotic strictures occur in one third to Gastroesophageal reflux is commonly associ-
one half of repairs, a rate that has remained stable ated with EA and TEF. This stems from a number
over the past 25 years [47]. All repairs will show of issues including the abnormal clearance of the
some degree of narrowing at the anastomosis, but distal esophagus due to poor motility and the
dilations are not instituted unless the stricture is altered angle of His that occurs as a result of ten-
symptomatic, causing dysphagia, associated sion on the distal esophagus and proximal stom-
respiratory difficulties, or foreign body obstruc- ach to allow for an adequate anastomosis. Using
tion. Most strictures respond to repeated dila- videomanometry with topographic analysis,
tions. These are carried out every 36 weeks over Kawahara et al. found two subgroups of patients
a 36-month period. Strictures that are recalci- with repaired EA and TEF. Neither group had
trant to dilations are often related to gastroesoph- esophageal contractions at the anastomosis. One
ageal reflux disease and will not resolve until the group had distal esophageal contractions and did
reflux is controlled. The perforation rates for not develop reflux, whereas the other group
uncomplicated esophageal strictures for balloon lacked distal contractions, and 15 of 17 devel-
dilation and bougienage are 02 % and 89 %, oped symptomatic reflux [52]. In multiple series
respectively [48]. Esophageal stenting may be over the past 30 years, the incidence of signifi-
useful to temporize an esophageal stricture but cant gastroesophageal reflux following EA and
has not yet been successful as a definitive treat- TEF repair has remained stable with an average
ment [49]. incidence of 43 % [53]. The reflux is treated med-
The incidence of recurrent TEF formation ically with acid-reducing medication. Close to
ranges from 5 to 10 % in recent series [50]. These half of those who develop reflux will require a
children present with coughing, choking, and fundoplication, especially if an anastomotic stric-
occasional cyanotic episodes with feeding and ture develops that remains resistant to dilation, or
with recurrent pulmonary infections. Recurrent repeated pulmonary aspiration secondary to
fistulas are often associated with anastomotic reflux complicates the postoperative course [53].
leaks, but the possibility of a missed proximal fis- Careful consideration should be given to a partial
tula must also be entertained. A prone, pullback fundoplication in these children, but a loose
esophagram and bronchoscopy with esophagos- Nissen fundoplication remains the preferred
copy are useful to diagnose recurrent fistulas. A method following EA and TEF repair [54, 55]. A
178 A.G. Coran et al.

fishmouth on expiration, as depicted in

Fig. 11.6. Recently, the use of dynamic airway
multidetector CT scanning in the diagnosis of
tracheomalacia has been described [58].
Tracheomalacia is often self-limiting but may
require intervention in children with severe life-
threatening symptoms. If treatment with continu-
ous positive airway pressure is not effective, then
aortopexy [59] or tracheal stenting may be
required [60]. Intervention for tracheomalacia is
required in up to 5 % of children with EA [61].

11.7 Outcome

The outcome for babies with EA and TEF has

improved over time to the point where now,
Fig. 11.6 Tracheomalacia after repair of esophageal atre- unless major cardiac anomalies, significant chro-
sia and tracheoesophageal fistula. Bronchoscopic view of mosomal abnormalities, severe pulmonary com-
the tracheal lumen during spontaneous respirations shows
almost complete collapse or the trachea during expiration
plications, or birth weight less than 1500 g exist,
(please rotate figure counterclockwise 90 for final view) almost all will survive. The long-term problems
in children after repair of their EA and TEF
include pulmonary issues, especially reactive air-
comparison of fundoplications done in babies way disease, bronchitis, and pneumonias and
with and without EA and TEF revealed that those upper gastrointestinal complaints of dysphagia
with EA had more intra- and postoperative com- and gastroesophageal reflux. Pulmonary symp-
plications and more problems with recurrent toms severe enough to require hospitalization
reflux, dysphagia, and dumping after the fundo- occur in close to half of children after repair of
plication [56]. EA and TEF [62] Both obstructive defects with
Symptomatic tracheomalacia occurs in airway hyperresponsiveness resulting in asthma-
1020 % children after repair of EA and TEF [44, like symptoms and restrictive defects often
57]. Tracheomalacia refers to collapse of the tra- related to thoracotomy-induced rib fusions and
chea on expiration leading to expiratory stridor gastroesophageal reflux disease occur [63, 64]. A
and episodes of desaturations, apnea, cyanosis, recent meta-analysis of outcomes at least 10
and bradycardia that are often associated with years after EA and TEF repair revealed a pooled
feeds. This is thought to originate from weaken- prevalence of recurrent respiratory tract infec-
ing of the tracheal cartilage due to pressure tions of 24 %, persistent cough of 15 %, doctor-
exerted during fetal life from the fluid-filled diagnosed asthma of 22 %, and persistent
dilated upper esophageal pouch. The tracheoma- wheezing of 35 % [65]. Although the pulmonary
lacia may be severe enough to prevent extubation symptoms tend to persist into adulthood [66],
after the original repair. Determining the etiology they tend to be mild and not affect activities of
of this symptom complex can sometimes be dif- daily living [12].
ficult because tracheomalacia and gastroesopha- The dysphagia and gastroesophageal reflux
geal reflux both occur frequently in this commonly seen in these children stem from the
population and produce similar symptoms. altered innervation of the distal portion of the
Tracheomalacia is diagnosed with rigid bron- esophagus be it intrinsic or secondary to opera-
choscopy in the spontaneously breathing patient. tive dissection of the esophageal pouches. This
The trachea will flatten anteroposteriorly, or dysmotility persists into adulthood. In manomet-
11 Esophageal Atresia and Tracheoesophageal Fistula 179

ric studies of adolescents and adults with dren appears to be due to ongoing morbidity and
repaired EA, the main long-term motility deficits associated anomalies resulting in lower physical
are uncoordinated peristaltic activity and low- functioning and general health perception.
amplitude contraction of the distal esophagus. Following EA repair, adults have a comparable
Interestingly, the swallow-induced relaxation of QOL to the general population in most domains
the lower esophageal sphincter occurs normally [72]. A Dutch study of QOL in adults following
[67]. This abnormal esophageal motility sets the repair of EA compared to healthy subjects found
stage for dysphagia and gastroesophageal reflux. no difference in overall physical and mental
Using 24-h pH probe and esophageal biopsy health between the two groups. However, former
data, the incidence of gastroesophageal reflux EA patients reported worse general health and
has been documented in infants (41 %), in chil- less vitality than the healthy subjects because
dren up to the age of 10 (4550 %), and in adults of continued gastrointestinal difficulties reported
(40 %) after EA repair. No new cases of histo- in up to a quarter of the EA group. Marital and
logic esophagitis or abnormal pH probes family status did not differ from that of the gen-
occurred in children after age 5. The gastro- eral Dutch population [73]. The QOL of adults
esophageal reflux appears to develop early and after a colonic interposition as an infant is not as
persist in patients after EA repair [68]. good as it is for adults who had a primary repair
Esophageal strictures are uncommon as a late [74]. A recent review of QOL following repair of
complication. If a stricture occurs late in the EA at birth concluded that the overall health-
course, it is usually associated with gastroesoph- related QOL was reduced compared to healthy
ageal reflux. Symptoms do not appear to predict controls but that the associated effect of EA repair
abnormal endoscopic findings in patients with on overall QOL seems less than expected [75].
EA suggesting that routine endoscopy may be
useful [69]. Chronic reflux may lead to Barretts
esophagus, a precursor to adenocarcinoma of the
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Hiatal Hernia
andGastroesophageal Reflux
PhilippeMontupet and RevaMatta

12.1 Introduction endoscopy allows a simple and fast evaluation of

the possible repercussions of reflux on the esoph-
A hiatal hernia is a partial gastric pull-up across the ageal mucosa and may show a cardial gaping
hiatal orifice. Gastroesophageal reflux (GER) is fre- openness or a hiatal malposition. The manometry
quently associated. On the contrary, a GER disease goes further since it is also a mean to investigate
can exist without anatomical hiatal hernia. In many possible motor troubles and abnormalities of the
instances, a small hiatal hernia and slight or tran- lower esophageal sphincter (LES) pressure.
sient GER are asymptomatic or well tolerated. Newly the impedancemetry [13] combines 24-h
There is a broad spectrum of symptoms related records of pH, motility, and pressures an alka-
to hiatal hernia and GER.Postprandial regurgita- line GER may be detected as well.
tions and failure are suggestive, although upper Many children who suffer from a GER disease
respiratory or pulmonary symptoms can prevail. remain under-investigated. When a GER induces
In addition, ENT and allergic manifestations, or a severe complications or escapes a prolonged
failure to thrive, can be the main consequences in medical treatment, surgical indications have to be
terms of symptomatology. Diagnostic techniques considered. That is always the case for a large
are required to confirm GER and associated hia- hiatal hernia. Surgery could also be more fre-
tal hernia and also to assess its repercussions. quently indicated since advanced laparoscopic
Although the X-ray barium meal suffers from techniques and skill have improved dramatically
numerous limitations, it remains a useful tool. surgical results [4].
The pHmetry has gained popularity, performed All the techniques performed prior to the era
over a 24-h period in ambulatory conditions. The of minimally invasive surgery (MIS) are repro-
ducible under laparoscopy. However, the sur-
geons skill is related to a solid training, and as a
P. Montupet (*)
Hpitaux Universitaires Paris-Sud, Bictre Hospital, matter of fact any surgeon is faithful to a favored
Universit Paris XI, 78 avenue du Gnral Leclerc, technique. Thus, this chapter describes various
94275, Le Kremlin-Bictre Cedex, France approaches and also current trends.
R. Matta
Assistant Professor of Clinical Surgery,
University of Balamand, El-Koura, Lebanon
12.2 Pathophysiology
Division of Pediatric Surgery, Department of Surgery,
The esophagogastric junction is an anatomical
Saint George Hospital University Medical Center,
Beirut, Lebanon functional system anchored by anatomical ele-
e-mail: ments which create an antireflux barrier. The fac-

Springer International Publishing Switzerland 2017 183

M. Lima (ed.), Pediatric Digestive Surgery, DOI10.1007/978-3-319-40525-4_12
184 P.Montupet and R.Matta

tors of anchorage are intrinsic (sphincter and His least two of them must clearly establish abnormal
angle) and extrinsic (crura, membrane of Laimer, results. Eventually, a form of gentlemen agree-
gastrophrenic ligament). ment should impose a postoperative checking
The LES extends for about 12cm above the [14] and a long-term follow-up after the surgery.
diaphragm to reach the cardia. Its function partly As for associated pathologies, they can induce
depends on the vagus nerve. The LES pressure more surgical indications, despite the suitable
ranges in children from 10 to 20 mmHg, influenced choice of investigation and time for decision
by sympathetic and parasympathetic innervation. doesnt make a consensus. If huge hiatal hernias
The anatomical or physiological incompetence are operated sooner, on the contrary, in case of
of the crural sphincter may be responsible for beforehand operated esophageal atresia or dia-
reflux during LES relaxation. Inadequate responses phragmatic hernia, the time for surgical indication
of the LES to an increase of intragastric pressure is unclear. The correction of the GER represents a
due to a physiologic event or to a delayed gastric second operation, and the success is more difficult
emptying are also causes of GER. to warrant due to the age and fragility of the
Esophageal clearance and peristalsis consist patients. The question is somewhat similar regard-
in expelling material coming from the stomach. ing neurologically impaired patients (NIP).
Their failure induces alteration of the esophageal Finally, various arguments make the surgeon
mucosa. Ultimately, the columnar metaplasia of trends to increase or on the contrary to reduce his
Barretts esophagus may appear. own indications: centers ability to investigate
These anatomo-physiologic features have to GER, devotion to associated abnormalities, and
be reminded to emphasize some details of the own skill are the main factors.
surgical repair, such as vagus nerve preservation,
careful knotting on crural muscles, and right
positioning of the LES. 12.4 Initial Treatments
12.3 Surgical Indications
Initial therapy has to be prolonged to a minimum
Best results with drugs are achieved by an effec- of 68 months prior to discussing the surgery.
tive initial therapy. However, the effects of long- This period of time is under the control of the
term treatment are little known. Moreover, a pediatrician, who usually several drugs are pre-
long-lasting medical treatment implies regular scribed; among them are a prokinetic and a pro-
controls [5]. ton-pump inhibitor. The choice of therapy for a
As such, it might be not cost-effective because GER disease depends on the severity of signs and
the duration of this treatment is unpredictable; oth- the degree of esophagitis. After a break off, if
erwise, when it is not totally successful, the chronic there is a clear relapse of symptoms, investiga-
evolution of the disease consists in a great chal- tions are required again at least a barium meal
lenge for both parents and children. In addition, and a manometry [5] which will be used also as
numerous families are concerned by several GER preoperative workup.
among their members, and this should be corre- The preoperative workup has several goals:
lated with a genetic factor; some of those children
need an operation, and some others do not. To confirm the surgical indication
In terms of surgical indications regarding a To precise the anatomical condition, i.e., hia-
GER, especially because the parents expectation tal hernia
and their anxiety about complications or failure To make a checkup regarding associated
are great, surgeons are strongly required to be pathologies or anesthetic risk
cautious and advised. Since there are four
categories of possible investigations endos-
A thorough history of troubles and physical
copy, pHmetry, manometry, and barium meal at exam are the essential initial stage of any workup
12 Hiatal Hernia andGastroesophageal Reflux 185

for gastroesophageal disease, including compli- 12.5.1 Positioning andSetup

ance with treatments, familial status, and growth
landmarks. Complementary investigations appear In case of laparoscopic approach, the patient
to be objective arguments. Nevertheless, all are is supine in the reverse Trendelenburg posi-
neither available in a single center nor suitable in tion. If the child is under 68 years of age, the
a single patient. In fact, it seems correct to dis- legs are folded at the bottom of the table in a
cuss a surgical indication only if two of them frog position. If he is older, they are placed in
show a continuous and severe GER. the lithotomy position, and the surgeon sits
When a child and his parents are referred to between the legs. The video equipment is
the surgeons consultation, most of them spent placed at the right side of the patients head.
a long time of treatment, underwent several All the cables are fixed at the level of the right
more or less invasive investigations, and are leg. The assistants and the instruments table
anxious to obtain a better result. Their pediatri- are on the right hand of the surgeon, facing
cian briefly informed them about surgical pro- the video screen.
cedures and possible side effects, while they As for open approach, the incision can be on
could also get information from internet. The the medial supraumbilical line or more often
surgeon has to take these informations into transversal on the right side. A rigid retractor lifts
account, in order to provide detailed and pre- up the parietal wall. The left liver lobe is carried
cise surgical ones. A draft of the planned proce- up and to the right by a smooth retractor held by
dure helps the understanding, also the reasons an assistant. There is no special instrumentation
of its choice, the right description of the post- devoted to the open approach.
operative period, and eventually the long-term Laparoscopic instrumentation depends more
follow-up. Information should be given con- on the patient size than on the chosen technique.
cerning the risk of recurrences and the way to For infants and children less than 10kg, 3-mm
treat them. Anesthetic consultation has to be instruments of 1820cm are suitable. A
planned separately, to allow parents asking new 30-angled endoscope is preferentially used. The
questions as well. choice of energy source is related to the instru-
ments used, scissors or hook, sealing devices
which continuously are improved. Limitations
12.5 Surgical Procedures are also their relative cost.

The aim of the surgery is to create an efficient

sphincter process at the bottom of the esophagus 12.5.2 Laparoscopic Antireflux
[5]: principles are repositioning of the abdominal Surgery
part of the esophagus, calibration of the hiatal
orifice, and creation of an antireflux mechanism. Laparoscopic antireflux surgery (LARS) has
Children fast for an average of 6 h before sur- more and more replaced the open approach
gery (4 under 12 ms). A general anesthesia is worldwide [4], thanks to an excellent clinical
required, while vecuronium is given for muscle outcome and success rates. It was first reported in
relaxation only if necessary. Monitoring is stan- children in 1993 [6]. This evolution in terms of
dardized. A nasogastric tube is inserted. MIS is especially to be considered for children
As for laparoscopic surgery, a locoregional with neurological impairments who represent a
anesthesia is added by injection of marcaine lat- large part of the surgical indications.
erally to the umbilicus along the right muscles. At the beginning of LARS, it was advocated to
The gas insufflation is controlled at an 812 reply the same procedures as made by an open
mmHg level but varies during the different steps approach. Then, the tendency has been to com-
of the procedure in order to preserve a suitable pare the results of the three main used procedures
ventilation and to prevent hypercarbia. [4], and reports regarding the others became
186 P.Montupet and R.Matta

scarce. In spite of their progressive abandon, we stomach; the inclusion of the esophagus in each
will briefly describe them as well. suture should prevent a slipped Nissen. The top
Nissen, Toupet, and Thal techniques are stitch may also include the anterior diaphrag-
equally important to know, because even if a matic rim with the same goal. Additional stitches
pediatric surgeon is more trained with one, the may be placed between the wrap and the right
two others can be useful and applied to peculiar crus to help secure the wrap in the abdomen
cases, for instance, the redo cases. They are total [611].
fundoplication and partial posterior or ante-
rior fundoplication. In addition to differences Laparoscopic Nissen Rossetti
concerning the type of the wrap which is created Rossetti worked close to Nissen and finally
around the esophagus, these techniques can differ described his own modification of the technique.
by some techniques of dissection; the latter will His principle is to use the anterior wall of the
be emphasized within the discussion. stomach as a short and floppy wrap around the
esophagus. Moreover, the anterior wall of the Laparoscopic Nissen esophagus is not concerned by the wrap sutures.
First described in 1959, it has been one of the Dissection does not differ from a Nissen.
standards for antireflux surgery (ARS) for the last Short gastric vessels are divided as far as it is
50 years, because a 360 wrap was considered as considered useful to free the wrap. However,
the most effective antireflux valve. there is a minimal hiatal dissection; the posterior
Laparoscopy is started with a 30 endoscope vagal nerve is always identified first but never
placed through the umbilical site. The left lobe of dissected and always left close to the esophagus.
the liver is retracted. The procedure is started by The esophagus is pushed downward, but there is
dividing the gastro-hepatic ligament; it is advised a minimal hiatal dissection. Division of short
to respect an aberrant left hepatic artery, present gastric vessels is not always necessary.
in about 25% of cases. Both diaphragm crura are The sutures include only the stomach and no
cleared to allow adequate mobilization of the other structures (Fig.12.1).
intra-abdominal esophagus. Then the stomach is The risk of tension and stricture after Nissen
retracted medially, and the upper short gastric Rossetti or Nissen is the same, depending on the
vessels are divided in order to free a large part of surgeons training.
the gastric fundus. As such, a large retroesopha-
geal window is safely made (and the wrap will be Laparoscopic Toupet
tension-free). The retroesophageal window is Toupet described a partial wrap some years after
enlarged, taking care not to injure the posterior the complete one described by Nissen. A partial
vagus nerve. Mobilization of a good length of wrap seemed to him to be more physiological
intra-abdominal esophagus is critical to ensure than a complete one.
the formation of an adequate wrap. Once this has Dissection approaches the hiatal area on its
been completed, time is to reparation. right side, thanks to a liver retractor. A small
Even if the hiatus looks to be of normal size, nasogastric tube is on place. The lesser omentum
one or several crural stitches are placed using a is widely opened, and the right crus is easily
strong nonabsorbable suture; this routine closure identified. Then the posterior vagal nerve should
will help to prevent the development of a hiatal be the main landmark to find the relief of the left
hernia, one of the most common complications crus. When the fascia of the left crus has been
following a Nissen. A 360 wrap is formed with found, a large window toward the splenic area is
the fundus brought around behind the esophagus opened. In fact, because the short gastrosplenic
with a stent inside. The wrap is made 23cm in vessels will never been divided in this technique,
length and consists in three to four sutures going this step is only focused on the enlargement of a
from the stomach to the anterior wall of the retrocardial window, which will allow the wrap
esophagus and to the wrapped portion of the to be not twisted or stretched.
12 Hiatal Hernia andGastroesophageal Reflux 187

a b

c d

Fig. 12.1 Laparoscopic Nissen Rossetti fundoplication. behind the esophagus to create a wrap (c), suture of the
Creation of the retroesophageal window (a), suture of the wrap including only the stomach (d)
diaphragmatic crura (b), the fundus is brought around

The main feature of the wrap is to be only a position. The hiatus is calibrated by one or two
translation of the gastric fundus behind and sutures, while a stent is temporarily introduced
around the esophagus. Then this wrap is fixed into the esophagus.
onto the right crus by three stitches. Two other The fundoplication consists in two rows of
rows of three stitches make the wrap encircling three stitches between the anterior wall of the
the esophagus only on three-fourth of its girth. fundus and the anterior wall of the esophagus,
The final aspect shows an anterior esophagus in two layers. The last one fixes the wrap to
wall kept free [1214] (Fig.12.2). the anterior rim of the hiatus and to the right
crus. Laparoscopic Thal
This partial fundoplication according to Thal was Other Techniques ofLARS
described in the 1970s by an open approach. Many procedures have been described. All are
Then, laparoscopic series were provided, espe- feasible under laparoscopy; all were invented to
cially by the team of Utrecht. Hiatal dissection obviate some pitfalls or imperfect results of the
allows a mobilization of the distal esophagus until main techniques. Here are summarized some of
a sufficient part has reached an intra-abdominal them which knew popularity.
188 P.Montupet and R.Matta

a b

Fig. 12.2 Laparoscopic Toupet fundoplication. Creation of retroesophageal window (a), suture of the wrap to the
esophagus (b)

Jaubert de Beaujeu procedures combines a 12.6 H

 ow toChoose anAntireflux
reconstruction of the His angle according to the Procedure
Lortat-Jacob principle, an anterior fundoplication
as described by Thal and Dor, pulling the esopha- Any pediatric surgeon today received a training
gus down as far as possible and also anchoring it for LARS, with a favorite technique which is
to the crus and diaphragm. There is no need to depending on his/her team of learning. However,
divide short gastric vessels. Intra-abdominal fixa- trends and scientific studies moved, so that we
tion of the esophagus around the hiatus is the must be interested to learn different possible pro-
main step of the procedure. Both edges of the cedures. Nissen and Toupet are first; Thal is also
pulled down esophagus are sutured to the adja- mandatory, for instance, in case to end a Heller
cent crus and the anterior part of the esophagus to intervention.
the diaphragm. Then, when recreating the Hiss Having said that, our most frequent practice
angle, sutures include also the fascia of the left guaranties our best results. Another consideration
crus. Anterior fundoplication ends the is a professional trend to be adapted to a new sci-
procedure. entific evidence, such as repeated conclusions
Boix-Ochoa procedure gained popularity in from large series and among them RCT (random-
the 1980s. Again, the fundamental aim of this ized controlled trials).Nowadays, these studies
procedure was to restore and maintain the length are available [1419] to prove that postoperative
of the infradiaphragmatic segment of the esopha- dysphagia is reduced after a partial wrap without
gus. After dissection, several stitches are put impair of efficacy regarding the ARS.
between the esophagus and the hiatal orifice. The Then, the result of LARS in children is sup-
latter is calibrated by one or several stitches. posed to be maintained life lasting, while a redo
Then the greater curvature of the stomach is [20, 21] is acceptable in case of failure and has
mobilized and fixed to the undersurface of the also to be explained properly before any parents
diaphragm, and an anterior fundoplication is decision is made. Thanks to MIS, this possibility
performed. is acceptable and rates of failures as well.
Other techniques were developed by gastroen- There are some advices in order to propose suit-
terologists for adult patients; however, either they able details in case of specific indications which are
need sized devices which are not adapted to chil- not depending on the selected procedure.
dren like endoluminal plication or Stretta proce- Huge hiatal hernia makes more cautious and
dure or their follow-up is too short in order to complicated the step of dissection. In addition,
apply them to young patients, like injectable more stitches are needed to close the orifice prior
fluids. to the ARS.
12 Hiatal Hernia andGastroesophageal Reflux 189

Because a large amount of cases concern NIP, dissection is missed. We have to keep in mind
who often have to undergo heavy cares and pos- that the posterior vagus nerve is the main land-
sibly other surgeries, LARS has to be success- mark to identify in order to follow a good direc-
fully performed before pulmonary reflux tion close to the left crus.
complications make it at risk. First, the hiatus Perforation can also concern the pleura, and it
must be reinforced by several stitches. Second, a is immediately recognized by the anesthesiolo-
very large wrap, without possibility of tension or gist. More often it is a small tear, and the solution
twist, anchored to the right crus, taking in account is to leave this area for a while, without attempt to
the gastrostomy implantation, is recommended. close it.
The same advice can be applied to children with Any injury of the posterior vagus nerve will
a previous diaphragmatic hernia. have consequences, mainly a prolonged diarrhea
Many patients are not investigated regarding and then a dumping syndrome. We observed four
the esophageal motility because manometric stud- cases, but symptoms disappeared spontaneously
ies are not available everywhere. Even if a Nissen in 48 months.
floppy wrap is performed, dysphagia is more Because LARS is a repairing surgery, its suc-
often a complication, as proved by multicentric cess depends on a lot of details and careful atten-
RCTs. This is especially the case for patients tion. Some of them merit a special mention.
cured from an esophageal atresia, and moreover Knotting has to be minutely controlled, thanks to
the stomach size makes a difficult total wrap. A the video magnification, so that cutting knots, dis-
posterior partial wrap obviates this problem. ruption of knots, and transmural stitches can be
Statistically, a beating vasculonervous pedicle avoided. The size of the wrap is a main factor of
going to the left liver is visible in 15% of cases. its efficacy. Dividing or not dividing the short gas-
Even if it makes the procedure more demanding, tric vessels is frequently advocated. In fact, if the
it must be respected. anterior wall of the fundus is used, there will be
no tension and no twist; in addition, the transla-
tion can be enlarged on request, even if there is a
12.7 C
 omplications ofAntireflux small stomach. The calibration of the hiatus is
Surgery mandatory in two cases: NIP who have spastic
crisis and for them several stitches, never too
At the beginning of experience, a bleeding, a per- tight, are used and large hiatal hernia, for obvious
foration, and an abnormal duration of the proce- reasons. In our practice, one-third of normal-sized
dure can induce a conversion to an open approach orifice requires a stitch calibration. But when we
in order to control it. Although later, these are calibrate the hiatal orifice, be very careful.
possible complications to better manage The goal of LARS is to create a wrap, partial or
laparoscopically. total, to reinforce the pressure around the LES
Bleeding can occur during the dissection for pulled down in right position. Main causes of fail-
different reasons. Younger is the child, more frag- ures are disruption, migration, or being a too loose
ile is the liver. A suitable choice of the liver or too tight wrap. According to these requests, a
retractor, a regular checking of its position must partial wrap cannot be too tight because the ante-
avoid a tear of the liver. Other causes of bleeding rior esophagus wall is maintained free.
are injuries of retrocardial vessels or splenic
parenchyma when creating the retrocardial win-
dow. The last one is an injury of the inferior dia- 12.8 Redo Surgery
phragmatic vessels, more often the left one when
we release the superior part of the fundus. According to literature review, it appears that
Perforations may mainly concern the esoph- redo surgery in GERD was challenging in the
agus or the stomach, when the proper plan of times of open approaches. This has completely
190 P.Montupet and R.Matta

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