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Journal of Indian Association of Pediatric Surgeons
     Journal of Indian Association of Pediatric Surgeons
Official journal of the Indian Association of Pediatric Surgeons         
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Table of Contents   
CASE REPORT
Year : 2019  |  Volume : 24  |  Issue : 2  |  Page : 132-134
 

A new operative approach for long-gap esophageal atresia


1 Department of Pediatric Surgery, Monastir Medical School, Fattouma Bourguiba Teaching Hospital, Research Laboratory, Monastir, Tunisia
2 Department of Pediatric Surgery, Mainz Medical School, Mainz, Germany

Date of Web Publication1-Mar-2019

Correspondence Address:
Dr. Amine Ksia
Department of Pediatric Surgery, Monastir Medical School, Fattouma Bourguiba Teaching Hospital, Research Laboratory, LR12SP13, Monastir 5000
Tunisia
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jiaps.JIAPS_172_17

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   Abstract 


Surgical management of long-gap esophageal atresia (LGEA) remains challenging. Yet, there is a consensus among pediatric surgeons to preserve native esophagus. We used a new surgical technique to successfully manage three children diagnosed with LGEA. This technique consists of a combined thoracic and cervical approach to the EA repair using the patient's native esophagus. All patients initially had had gastrostomy and continuous upper pouch suction while awaiting surgery. This new technique has the potential to become the choice method in LGEA management.


Keywords: Cervicotomy, long gap esophageal atresia, thoracotomy


How to cite this article:
Nouri A, Ksia A, Bouzaffara B, Munsterer O, Hidouri S, Chahed J, Sahnoun L, Mekki M. A new operative approach for long-gap esophageal atresia. J Indian Assoc Pediatr Surg 2019;24:132-4

How to cite this URL:
Nouri A, Ksia A, Bouzaffara B, Munsterer O, Hidouri S, Chahed J, Sahnoun L, Mekki M. A new operative approach for long-gap esophageal atresia. J Indian Assoc Pediatr Surg [serial online] 2019 [cited 2019 Jul 24];24:132-4. Available from: http://www.jiaps.com/text.asp?2019/24/2/132/253333





   Introduction Top


Surgical management of neonates with long-gap esophageal atresia (LGEA) remains challenging and controversial. Various methods have been developed to overcome the technical difficulties including delayed primary anastomosis, lengthening procedures, and esophageal substitution.[1] In this study, we describe three patients with LGEA managed successfully with a new operative technique using the native esophagus. This technique consists of a combined thoracic and cervical approach.


   Case Reports Top


Baby 1

A female baby was diagnosed as Type A LGEA. Three days after birth, a feeding gastrostomy tube was inserted. The nursing care included continuous upper pouch suction. The initially estimated gap distance was five vertebral bodies. This gap was measured by injecting radiopaque contrast into the stomach and by inserting a radiopaque catheter in the proximal esophagus [Figure 1]. At the age of 4 months, this radiological examiantion showed that the gap was the same. At this age, the baby underwent a right extrapleural thoracotomy. The anastomosis could not be achieved even after an extensive dissection of both pouches. We turned the patient supine and performed a right cervicotomy that allowed us to dissect and lengthen the upper part of the esophagus [Figure 2]. An end-to-end anastomosis was then performed [Figure 3]. On the 5th postoperative day, an anastomotic leak was observed and was treated by keeping the chest drainage for 9 days. After an 8-month follow-up, the baby was doing well. No dilatation was needed.
Figure 1: Gap measured by injecting sufficient radiopaque contrast into the stomach and by inserting a radiopaque catheter in the proximal esophagus

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Figure 2: An intraoperative view of the upper esophageal pouch after extensive cervical dissection through a cervical approach. The vascularization of the upper pouch is very well conserved

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Figure 3: (a) Initial Gap. (b) End-to-end anastomosis possible after the upper pouch dissection by the cervical incision

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Baby 2

A boy baby was born having a Type A LGEA. At 2 days of age, the baby underwent insertion of a feeding gastrostomy. The initial gap at this time measured more than five vertebral bodies making the primary anastomosis unachievable. The baby was operated at the age of 8 months. The distance was estimated to be 5.5 cm. The dissection of both pouches via thoracotomy allowed the gain of 2.5 cm, but an end-to-end anastomosis could not be achieved. We chose to attempt a cervical approach with a right cervical incision. The cervical dissection of the esophagus enabled us to perform an end-to-end anastomosis. Opacification done 5 days after showed no leakage or stenosis.

At the age of 2 years, the patient was doing well. No dilatation was needed.

Baby 3

A female infant diagnosed with LGEA. At the age of 2 days, the baby underwent insertion of feeding gastrostomy. The gap between the two ends of the esophagus was initially measured at the age of 2 weeks and was estimated to seven vertebral bodies. A Type B EA was suspected after recurrent pneumonia and confirmed later by bronchoscopy at the age of 7 months. The patient underwent surgery beginning by a division of the proximal esophageal-tracheal fistula by a right cervical incision. The dissection of the upper esophagus allowed the lengthening and stretching of the upper esophagus to allow an end-to-end anastomosis done by a thoracotomy. Opacification done 5 days after showed no leakage or stenosis [Figure 4].
Figure 4: Opacification done 5 days after surgery showing no leakage no stenosis

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At the age of 15 months, the patient had confirmed gastroesophageal reflux that seems responding to medical treatment.


   Discussion Top


Several techniques using the patient's native esophagus have been found to be effective in the management of LGEA. Suture approximation without anastomosis, along with magnetic compression anastomosis as nonsurgical treatment for EA, was shown to be feasible in patients with a gap no wider than 3 cm.[2],[3],[4] The “growth induction” by traction described by Foker remains a controversial primary approach for LGEA.[5],[6]

In the present report, all of the babies described had a gap of more than 5 cm. Our data show that the upper pouch dissection via cervical approach can give an extra 2–4 cm length by releasing the cervical esophagus from its adhesions and by straightening its curves. Moreover, it seems that a gentle yet extensive dissection of the upper pouch does not compromise its vascularity. However, one should avoid damage to the recurrent laryngeal nerves by dissecting just in contact with the esophagus.

Our technique can be used in LGEA repair, as well as in nondilatable esophageal strictures as long as 5 cm, independent of their cause. Its main goal was to preserve the native esophagus. The strength of this technique lies in the ability to bridge long gaps without the need to perform lengthening procedures before surgery. It also avoids the resort to operative maneuvers that would damage the esophagus, such as transverse myotomy or esophageal flap. Our next goal is to perform the esophageal anastomosis in neonates within the 1st week of life using this technique.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient's parent has given his consent for his images and other clinical information to be reported in the journal. The patient's parent understands that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
   References Top

1.
Séguier-Lipszyc E, Bonnard A, Aizenfisz S, Enezian G, Maintenant J, Aigrain Y, et al. The management of long gap esophageal atresia. J Pediatr Surg 2005;40:1542-6.  Back to cited text no. 1
    
2.
Zaritzky M, Ben R, Zylberg GI, Yampolsky B. Magnetic compression anastomosis as a nonsurgical treatment for esophageal atresia. Pediatr Radiol 2009;39:945-9.  Back to cited text no. 2
    
3.
Lovvorn HN, Baron CM, Danko ME. Staged repair of esophageal atresia: Pouch approximation and catheter-based magnetic anastomosis. J Pediatr Surg Case Rep 2014;2:170-5.  Back to cited text no. 3
    
4.
Stringel G, Lawrence C, McBride W. Repair of long gap esophageal atresia without anastomosis. J Pediatr Surg 2010;45:872-5.  Back to cited text no. 4
    
5.
Bobanga ID, Barksdale EM. Foker technique for the management of pure esophageal atresia: Long-term outcomes at a single institution. Eur J Pediatr Surg 2016;26:215-8.  Back to cited text no. 5
    
6.
von Allmen D, Wijnen RM. Bridging the gap in the repair of long-gap esophageal atresia: Still questions on diagnostics and treatment. Eur J Pediatr Surg 2015;25:312-7.  Back to cited text no. 6
    


    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4]



 

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