Those branchial cleft fistulas that originate from the 2nd branchial cleft are by far the most commonly found. They display themselves as small cutaneous opening along the anterior lower third border of the sternocleidomastoid muscle, communicates proximally with the tonsillar fossae, and can drain saliva or a mucoid secretion. Management consists of excision since inefficient drainage may lead to infection.

I have found that dissection along the tract (up to the tonsillar fossa!) can be safely and easily accomplished after probing the tract with a small guide wire (0.018 in.) in-place. This will prevent injury to nerves, vessels and accomplish a pleasantly smaller scar.

Technique: Make an elliptical incision around the pit area. Hold still the skin around the pit area with several silk 5-0 sutures. Gently introduce the straight part of the guide wire up until it stops. Ask the anesthesiologist to determine if the guide wire can be felt in the oral cavity (rare). Tie the guide wire to the silk sutures holding the removed skin so that it won't dislodged during dissection. Using a needle tip cautery and keeping traction on the tied skin-wire dissect the tract staying as near as possible to the fistulous tract until it can be safely removed. Occasionally a second stepladder incision in the neck will be required depending on the length of the tract.

Esophago-Myotomy for Achalasia

Achalasia in children is an uncommon esophageal motor disorder distinguished by clinical, radiological and manometric features. Clinical presentation is characterized by progressive dysphagia, regurgitation, weight loss, chest pain and nocturnal cough. Diagnosis is established by barium swallow and confirmed by manometry and motility studies. Primary therapy is surgical (Heller's modified esophagomyotomy), and results are similar after a transabdominal or thoracic approach.

I prefer to do the esophagomyotomy through the abdomen. Children above the age of four benefit from a midline upper incision. Below that age a transverse supra-umbilical incision gives better exposure, safer closure, and good cosmetic results.

Technique: After mobilizing circumferentially the distal esophago-gastric junction a purse string suture is placed in the proximal fundus of the stomach near the G-E junction. A 16-G foley catheter is threaded through the gastrostomy into the distal esophagus and once in the thoracic esophagus the balloon is inflated. The foley is slowly brought toward the stomach, the balloon will hold in the stenotic part of the distal esophagus. A longitudinal incision in the anterior esophageal wall is made avoiding the vagus nerve, dividing the muscle fibers (preserving the submucosa), and knowing that the procedure creates an adequate esophageal lumen while passing the inflated foley catheter concomitantly. This maneuver can be repeated as needed to be sure that the myotomy was completed. The gastrotomy is closed, crura approximated and the surgeon decides whether to construct an antireflux procedure or not depending on his preference.

CVC Placement in VLBW infants

Very low birth weight (VLBW) infants (less than 1500 gms) needs multiple venous access to meet all the fluid, antibiotic and nutritional requirements during periods of intensive supportive care. Central Venous Catheter (CVC) placement has improved care and survival of these sick infants. Percutaneous placement of subclavian catheters carries the risk of pneumo/hemothorax, easy dislodgement, and a significant failure rate of cannulation. An alternative is placement of a 4.2 Fr or 2.7 Fr Broviac catheter through the external jugular vein (EJV) or internal jugular vein (IJV).

Technique: The procedure can be done at the NICU or a nearby OR using either sedation or general anesthesia. The right side of the neck and retro auricular area is exposed, prep and draped. A small transverse incision is done over the EJV at the base of the neck. The Broviac catheter is tunneled to exit somewhere behind the earlobe. Proximal limb of the catheter is threaded through a venotomy into the superior vena cava/right atrial junction. Alternatively, if the EJV is non-useful, the incision can be extended medially and the IJV used instead.

Gastroesophageal reflux is common in small children and either is asymptomatic or can usually be controlled with conservative maneuvers. Nevertheless, in some special group of patients, like the neurologically impaired and acquired GER after an esophageal injury due to ingested caustic substances etc. will inevitably need antireflux surgery some time during their early childhood. The most popular antireflux surgical techniques used in children are Nissen, Thal and Boix-Ochoa procedures. These techniques have a significant recurrence rate even in the best hands. The reason for this is inherited in the techniques themselves. In all above mentioned antireflux procedures fundic or crural muscles are sutured to the distal esophagus to create an acute angle of His with various degrees of fundic wraps (180 - 360 degrees) around the esophagus. The fundus of the stomach or the crura have very heavy and strong muscles when compared with the poor esophageal musculature. In a small child this difference is much more obvious when compared with that of an adult. As a result strong diaphragmatic and/or fundic contractions can be enough to tear off a wrap shortly after the operation or may be, as the child gets older and taller, the wrap may slip from the distal esophagus ending up with an obtuse angle of His. The aim is to try to find a way of creating a relative relapse proof antireflux barrier for GER patients.

Technique: Reflux esophagitis is first controlled with use of adequate antacid therapy before operative interventions (Omeprazole 1-2 mg/kg/day). After instituting general anesthesia the patients were esophagoscoped, dilated as necessary and a 10-mm outer diameter PVC tube is placed trans-orally into the stomach. The patent in supine position is laparotomized via a mid line abdominal incision. The triangular ligament is divided and the liver retracted laterally. An opening is made in the gastroepiploic membrane 2 cm long to the left of the esophagus. The lower jaw of a TA 60-3.5 stapling instrument (Auto Suture; US Surgical Corp., Norwalk, CT) is placed through this opening along the posterior wall of the stomach. The intragastric PVC tube is positioned in the lesser curvature and the stapler is placed next to the tube vertically parallel to the lesser curvature. The instrument is closed and the titanium staples fired. The instrument and the PVC tube are removed. As a result, a 6 cm long gastric tube is created starting from the esophagogastric junction and traveling along the lesser curvature down the stomach. A nasogastric tube is placed and the incision closed.

Details: http://www.med.ege.edu.tr/~pedsurg/om-plasty.htm

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If you have developed a technique in Pediatric Surgery that would like to share with our surgical community, please don't hesitate to send it to Dr. Humberto Lugo-Vicente for inclusion in this section of Pediatric Surgery Update.