In general, when several different operations, each with its own vocal proponents and detractors, are described for a single clinical problem, one can be fairly certain that not one of them is the ideal solution for every patient. Nevertheless, it is clearly important for the pediatric surgeon to have confidence and experience with at least one of the operations and its various permutations and have some familiarity with the other options that are available so that patient care can be individualized and optimized.
Historically in the United States, the colonic interposition has been the most popular. It is perhaps the easiest to perform and patients generally do quite well for several years. The problem is that over time, the colon continues to grow in length and diameter, so that eventually it becomes huge, tortuous and poorly functioning. This has led to fairly widespread dissatisfaction with the technique and a recent intensification in the search for a better alternative. The gastric transposition (“gastric pull up”) is now increasingly being used for this reason. It is safe, technically straightforward and though the initial postoperative phase can be trying, the long-term results appear to be quite acceptable. Most surgeons prefer to perform a pyloroplasty, although a pyloromyotomy is also reasonable. It is also preferable, though not mandatory, to place the graft in the posterior mediastinum and if possible to avoid a thoracotomy. Regardless of the approach, it is essential to preserve the blood supply of the stomach and to create a tension-free anastomosis. Leaks are relatively common but usually easily managed, especially when the anastomosis is in the neck.
The jejunal conduit is the most appealing option in that the diameter of the graft approximates that of the esophagus, transit should be better since peristalsis is preserved, and the long-term issues seen with the other types of graft should be eliminated. However, the operation is technically challenging and the blood supply to the cephalad portion of the graft is often tenuous.