E. Freud et al., USE OF VICRYL MESH TO SUPPORT THE ESOPHAGEAL WALL AFTER CIRCULAR MYOTOMY (LIVADITIS PROCEDURE) IN LONG-GAP ESOPHAGEAL ATRESIA - AN EXPERIMENTAL-STUDY, Pediatric surgery international, 11(8), 1996, pp. 539-543
Circular esophageal myotomy (GEM) is currently a well-accepted techniq
ue for elongation of the upper esophageal pouch in cases of long-gap e
sophageal atresia (EA). Esophageal pseudodiverticulum is a frequent an
d perhaps underreported sequela of this technique, characterized by ba
llooning or outpouching of the esophageal mucosa in the myotomized are
a. The present study was designed to seek a supplement for the CEM tec
hnique in order to avoid possible pseudodiverticulum formation in the
myotomized area, We created an animal model to simulate the anatomic c
onditions present after primary repair of EA facilitated by CEM. Three
groups of dogs underwent either cervical (1 group) or thoracic (2 gro
ups) esophageal myectomy. In the cervical and first thoracic groups, t
he denuded mucosa was left without any support. In the second thoracic
group, the denuded mucosal area was wrapped with polyglactin 910 (Vic
ryl) mesh. In all three groups the esophagus was narrowed by a Marlex
mesh ring 3 cm distal to the myectomized zone, simulating a condition
resulting from anastomotic narrowing. The dogs underwent barium swallo
ws under fluoroscopy at different postoperative periods and were kille
d 4 or 6 months after surgery. The esophagi were removed for gross and
radiologic investigation under maximal insufflation as well as for hi
stologic assessment. The proposed canine model proved to be useful for
study of the myectomized esophagus, mimicking the anatomy and conditi
ons after CEM in long-gap EA repair. Wrapping the denuded mucosa with
Vicryl mesh fortified the weakened esophageal wall, thus diminishing t
he likelihood of future pseudodiverticulum development, In light of th
e simplicity of the technique and the absence of any evident risk or c
omplications, we recommend that the use of Vicryl mesh wrap be conside
red during CEM to reinforce the esophageal wall.