Gastric Pull-Up / Gastric Interposition

Adults with oesophaguses replaced by gastric pull-up have significantly worse levels of GI, respiratory and nutrition morbidity than found in short-gap OA closed by primary repair. Multiple factors are suggested for this, some related to the change in the position of the stomach by the surgery, such as displacement of the gastroesophageal junction. Others include delayed gastric emptying and negative intrathoracic pressure and positive intraluminal pressure in the transposed stomach. The presence of the stomach in the chest also reduces functional lung capacity.

GI symptoms

These are much increased in this population compared to primary repair patients.

• Vomiting – 16% report vomiting daily (compared with 3% primary repair (PR)), 30% weekly (10% PR) and 60% rarely (40% PR).
• Reflux – 25% report daily reflux (17% PR), 60% monthly (40% PR) and 70% monthly (65% PR).
• GI ulceration and/or bleeding found in 9%.
• Dumping syndrome – 12–34% had a formal diagnosis of dumping syndrome and 25% further had symptoms consistent with the diagnosis. (31,173)
• Delayed gastric emptying on endoscopy. (174)
• Anti-reflux medication in one study was prescribed to 71% and prokinetics to 14%.
• Anastomotic strictures can occur and need treatment in late childhood and adulthood. (48,50,175)
• Barratt’s oesophagus can occur in the oesophageal stump, as discussed above.(31,50)

Respiratory symptoms

Studies also show higher levels of respiratory symptoms than for those with jejunal interpositions and primary repair.

• Wheezing is reported in 57%.
• Dyspnoea on exertion is reported in 57%, and in infection in 14%.
• Noisy breathing is reported in 71% during infections.
• Recurrent pneumonia was reported in 14% and episodic in 14%; recurrent respiratory tract infection was reported in 14%.
• Lung function tests are also markedly abnormal in this group. Abnormal FEV1/FEV was found in 67%, FEV1 100%, PEF 100% and TLC is abnormal in 67%. (176)

Nutrition

Hannon et al. (31) reported that:

• BMI was significantly lower in gastric pull-up patients than PR.
• 19% required supplemental jejunal feeding.
• Anaemia was present in 47% and is attributed to poor iron absorption.