Esophagojejunal Anastomosis by Circular Stapler in Pediatric Patients: Size Minima Defined by Experience and Geometry

Abstract

Background:

Esophagojejunostomy is facilitated by use of a circular stapler, particularly when performed laparoscopically. The minimum patient size that will allow use of circular staplers in the small intestine is unknown.

Materials and Methods:

Retrospective review of esophagogastric dissociations performed at a single tertiary care institution for 48 months. This was combined with a geometric derivation of a size-estimation formula.

Results:

From the 7 cases identified, patients weighing >16 kg easily accommodated the 21 mm stapler. There was a narrow fit in the patient weighing 13.6 kg, and the 6 kg patient was too small for the stapler.

Conclusions:

Through a combination of clinical observation and physical reasoning, circular stapler applicability in small intestine is predicted by patient weight or intestinal measurement. Patients weighing >16 kg will accept the stapler, whereas patients <13 kg are likely too small. Alternately, on the basis of a geometric derivation, if the width of the flat intestine is >1.6 × the device diameter, the device will fit. This calculation can be applied broadly (e.g., incision length for laparoscopic ports or single-port access devices).

Introduction

Esophagojejunostomy and the related gastrojejunostomy are anatomic rearrangements that are used frequently for the management of gastric malignancy and morbid obesity in adults. In pediatric patients, esophagojejunostomy is the core element of esophagogastric dissociation for patients with severe retching and/or aspiration combined with severe oral aversion.¹ The judicial use of esophagogastric dissociation in high-risk tube-fed patients has been shown to be a definitive intervention with significant improvement in patient and caregiver quality of life.^2,3

Laparoscopic esophagojejunostomy is a technically demanding operation, which is infrequently reported in children, but notably facilitated by use of a circular stapler with transoral anvil delivery.^4–7 (Fig. 1) In adults, selection of the device's diameter is guided by patient size and intended anastomotic caliber. In children, use of even the smallest circular stapler is limited by the ability to pass the stapler through the Roux limb of jejunum. The smallest circular staplers currently available have an active end with a 21 mm diameter, creating a lumen 12.4 mm in diameter.⁸ To our knowledge, no data exist on size criteria to suggest candidacy of pediatric patients for application of the circular stapler. We sought to determine size limitations for circular stapling techniques in pediatric patients.

FIG. 1.

Diagram of esophagogastric dissociation performed with a circular stapler. Division of the gastroesophageal junction prevents reflux and aspiration. A Roux-en-Y limb of jejunum is then anastomosed to the distal esophagus to allow drainage of secretions. Art by Annie Van Den Heuvel, 2012, reproduced with permission.

Materials and Methods

We reviewed our experience with esophagojejunostomy in esophagogastric dissociation from January 2009 through August 2012 at the Children's Hospital of Wisconsin. This was performed by analysis of data from a prospectively maintained clinical database and review of operative notes. The institutional review board of the Children's Hospital of Wisconsin approved this study.

Results

Seven patients underwent esophagogastric dissociation during the study period. All were performed by 1 of 4 pediatric surgeons. No patient suffered anastomotic leak or stricture, but 1 required reoperation for dehiscence of a prior gastrostomy site.

In 6 patients, esophagojejunostomy was performed with a stapling device; their characteristics are listed in Table 1. In all of these patients, the orally introduced anvil passed easily and jejunal Roux limbs accommodated the stapling end of the device. Patients ≥16 kg easily accommodated the stapler, but it narrowly fit through the intestine of the patient weighing 13.6 kg. The patient excluded from Table 1 weighed 6 kg, and her bowel was too small to allow insertion of the stapling device.

Table 1.

Characteristics of Patients Undergoing Esophagojejunostomy with Circular Stapled Anastomosis

Age (years)	Weight (kg)	Stapler	Technique
20	31.8	21 mm circular	Open
8	25	21 mm circular	Open
8	23.5	21 mm circular	Laparoscopic
5	19.4	21 mm circular	Open
6	16.0	21 mm circular	Laparoscopic-assisted
4	13.6	21 mm circular	Laparoscopic

Discussion

Esophagogastric dissociation is a major operation, but in the well-selected patient it can be the most definitive single operation to enhance quality of life for the patient and their care providers.² Ideal candidates are exclusively tube fed and suffer severe retching/vomiting, often with recurrent aspiration. We believe performing the operation laparoscopically reduces perioperative morbidity, particularly pulmonary complications in this population with chronic respiratory disease and developmental delay. However, laparoscopic esophagogastric dissociation is a technically demanding operation. Complexity is often magnified by nonergonomic patient positioning and port placement to work around patients’ contractures and implanted devices such as baclofen pumps. In the face of these challenges, a circular stapler facilitates the esophagojejunal anastomosis required for drainage of oral secretions.

By review of our clinical experience, we have identified the criterion of patient weight >16 kg to suggest likelihood of circular stapler accommodation, and <13 kg to indicate unlikely applicability. In apparently borderline cases, the intestinal size should be directly assessed to determine the likelihood of accommodating the stapling device.

Quantitative comparison between intestine and stapler head can be achieved by deriving a geometric relationship between the two. This relationship is based on the fact that when the intestine is configured as a tube, circumference can be used in lieu of cross-sectional area to determine whether the circular stapler will fit inside.

For the stapler head to fit within the intestine, the circumference (C) of intestine must match or exceed that of the stapler: \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} {C_{{ \rm{intestine}}}} \ge {C_{{ \rm{stapler}}}} \end{align*} \end{document}

Stapler circumference can be described in terms of its diameter (d): \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} {C_{{ \rm{stapler}}}} = {d_{{ \rm{stapler}}}} \cdot \pi \end{align*} \end{document}

Next, intestinal perimeter (P) is described according to its width (w) when flat. This configuration is chosen because in practice, it is this flat shape that surgeons measure when holding intestine or manipulating it with laparoscopic instruments (Fig. 2). The thickness of the intestinal wall is assumed to cause a negligible difference between internal and external dimensions. The intestinal perimeter (P) is thus:

FIG. 2.

Tubular and flat configurations of small intestine. When circular, the perimeter of the intestine is its circumference (C). When flat, the width (w) is what is actually measured. Art by Annie Van Den Heuvel, 2012, reproduced with permission.

\documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} {P_{{ \rm{intestine}}}} = 2 \cdot {w_{{ \rm{intestine}}}} \cdot \left( {1 + \varepsilon } \right) \end{align*} \end{document}

Here ɛ represents elasticity of the intestine: the fractional lengthening that results when tension is applied. Our characterization assumes an inelastic system so as not to introduce potentially deleterious effects of tension. An inelastic system allows no stretching (ɛ = 0), so the aforementioned expression simplifies to \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} {P_{{ \rm{intestine}}}} = 2 \cdot {w_{{ \rm{intestine}}}} \end{align*} \end{document}

The perimeter of the intestine is constant. When it is configured as a tube, the perimeter is a circumference: \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} {C_{{ \rm{intestine}}}}{ \bf{ = }}2 \cdot {w_{{ \rm{intestine}}}} \end{align*} \end{document}

Combination of the above expressions and rearrangement yields a practical and applicable formula: \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} {C_{{ \rm{intestine}}}} \ge {C_{{ \rm{stapler}}}} \end{align*} \end{document} \documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} 2 \cdot {w_{{ \rm{intestine}}}} \ge {d_{{ \rm{stapler}}}} \cdot \pi \end{align*} \end{document}

\documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} { w_ { { \rm { intestine } } } } \ge \frac { \pi } { 2 } \cdot { d_ { { \rm { stapler } } } } \end{align*} \end{document}

\documentclass{aastex}\usepackage{amsbsy}\usepackage{amsfonts}\usepackage{amssymb}\usepackage{bm}\usepackage{mathrsfs}\usepackage{pifont}\usepackage{stmaryrd}\usepackage{textcomp}\usepackage{portland, xspace}\usepackage{amsmath, amsxtra}\usepackage{upgreek}\pagestyle{empty}\DeclareMathSizes{10}{9}{7}{6}\begin{document} \begin{align*} {w_{\rm intestine}} \, \gtrsim \,1.6\cdot {d_{\rm stapler}} \end{align*} \end{document}

Therefore, to an approximation, if the width of the flat intestine is >1.6 × device diameter, the device will fit. This calculation can be applied more widely any time making a linear incision to accommodate a circular object (e.g., laparoscopic ports, single-port access devices).

An additional technical modification we have developed over time warrants mention. If the quality of the esophagus is questionable (i.e., thin tissue in a younger/smaller patient), gastrojejunostomy may be substituted for esophagojejunostomy. The stomach is transected just distal to the gastroesophageal junction, leaving a minimal gastric pouch just large enough to anastomose to the jejunum. This anastomosis to the gastric stump is inherently more robust than anastomosis directly to the esophagus due to collateral perfusion and the presence of serosa.

Limitations of our conclusions may stem from two elements: this is a relatively small series and we have assumed uniform correlation between intestinal diameter and patient weight. If this assumption is invalid, obese patients may have smaller intestinal caliber than predicted by our data. In this situation, though, the equation derived earlier ought to be applied so as to directly compare intestinal size with the stapler.

This brief report serves to guide pediatric surgeons with size criteria that suggest compatibility of a circular stapler with small intestine. Two types of size criteria have been determined: one by patient weight and the other by intestinal measurement. In a complementary application of medical experience and mathematical logic, the former arises from clinical experience, whereas the latter is based on a geometric derivation. These practical standards can be employed until device manufacturers develop smaller versions of staplers to broaden their utility in pediatric patients. The geometric derivation has broader application whenever making a linear incision for a circular object.

Footnotes

Disclosure Statement

No competing financial interests exist.

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