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Gastric transposition

The oesophagus is usually the best tube to convey food from the mouth to the stomach. When the oesophagus is absent or badly diseased, oesophageal replacement may be required.

Gastric transposition (also called gastric pull-up or stomach pull-up) involves moving the whole stomach upwards into the chest to join onto the top end of the oesophagus in the neck. This is probably the most commonly used technique for oesophageal replacement in children in the UK at present.

About the procedure

The question most parents ask when a gastric transposition is proposed is: “How can a child manage without a stomach in the abdomen?

The answer is that they manage just fine. 

When the stomach is in the chest, it doesn’t really function as a  reservoir to store food – it works more as a tube, or conduit, to convey liquids and solids to the small bowel.

The normal function of the stomach is to store food and liquid and release it, a little at a time, into the small bowel where it is digested and absorbed.

You don’t need a full stomach to feel full.

The feeling of fullness, or hunger, arises within the brain and is mainly due to the effects of gut hormones (substances released from the gut into the bloodstream) which act on the brain. This feedback system works normally whether the stomach is in the abdomen or the chest. The stomach is a robust organ with a very good blood supply. It sits in the top left hand side of the abdomen and connects with the duodenum (the first part of the small bowel).

This means that the stomach can be mobilised relatively easily, pulled up through the back of the chest and joined to the upper oesophagus in the neck.

Advantages of this technique are:

  • the excellent blood supply to the stomach.

  • it involves only one anastomosis; joining the oesophagus onto the stomach.

Timing of surgery

Gastric transposition operations have been performed in the neonatal period. Most surgeons however recommend waiting until sometime later in the first year. The decision depends on many factors including:

  • waiting to see if a delayed primary anastomosis is possible.

  • other problems (e.g. cardiac) that need treatment.

  • whether a cervical oesophagostomy is created so that the baby can spend time at home before surgery (this is our preference).
gastric transposition surgery
The stomach is pulled into place and anastomosed to the upper oesophagus in the neck.

Gastric transposition surgery

The operation of gastric transposition involves moving (transposing) the whole stomach from the abdomen into the chest and joining the top of the stomach onto the oesophagus in the neck.

There are two consequences of moving the stomach into the chest:

  • the pylorus, at the outflow point from the stomach and which normally controls the way food leaves the stomach, has to be widened. This procedure is called a pyloroplasty and is a routine part of a gastric transposition operation.

  • any gastrostomy has to be closed, because obviously after surgery its opening would be in the middle of the chest.

  • A new feeding tube has to be inserted into the small bowel. This is called a jejunostomy.

Post operative management

The operation takes between 4-8 hours. At the end of the operation the patient is transferred to the intensive care unit (ICU)asleep and ventilated.

It is usually necessary to ventilate a baby for several days after surgery which involves heavy sedation and muscle relaxant drugs. The surgical and ICU team monitor the baby closely during this period and look at many different factors to decide when they are ready to come off the ventilator. These factors include oxygen requirements, ventilation pressures and fluid balance.

Milk feeds can usually be started through the jejunostomy after 48-72 hours.

Would you like more information?

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With contributions from medical experts, the TOF Book contains chapters on every aspect of OA/TOF and VACTERL condition, from infancy to adulthood all presented in an easy-to-understand format.