Ann Thorac Surg 2008;86:1969-1971. doi:10.1016/j.athoracsur.2008.05.056
© 2008 The Society of Thoracic Surgeons
Case Reports
Combination of Spit Fistula Advancement and External Traction for Primary Repair of Long-Gap Esophageal Atresia
Holger Till, MD, PhDa,*,
Udo Rolle, MD, PhDa,
Werner Siekmeyer, MDb,
Wolfgang Hirsch, MD, PhDc,
John Foker, MD, PhDd
a Department of Pediatric Surgery, University of Leipzig, Leipzig, Germany
b Department of Pediatrics, University of Leipzig, Leipzig, Germany
c Department of Pediatric Radiology, University of Leipzig, Leipzig, Germany
d Department of Thoracic Surgery, University of Minnesota, Minneapolis, Minnesota
Accepted for publication May 19, 2008.
* Address correspondence to Dr Till, Department of Pediatric Surgery, University of Leipzig, Liebigstreet 20a, Leipzig, 04317, Germany (Email: holger.till{at}medizin.uni-leipzig.de).
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Abstract
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Primary repair of long-gap esophageal atresia with almost complete absence of thoracic esophagus was usually believed to be impossible. Thus, esophageal replacement with colon or gastric interposition seemed inevitable. Esophageal lengthening techniques could be an alternative approach. Herewith we describe for the first time the successful combination of the stepwise subcutaneous advancement of the upper esophageal segment (Kimura's technique) with transthoracic traction on the lower esophageal segment (Foker's technique). This combined lengthening technique leads to the primary repair of a long-gap esophageal atresia.
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Introduction
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In children with esophageal atresia (EA), most experts agree that the child's own esophagus is the best and should be repaired whenever possible [1]. However, in cases of long-gap EA (distance greater than 5 cm) an esophageal replacement with colon or gastric transposition is still considered inevitable [2, 3]. This shift of paradigm may be avoided for long-gap EA by using lengthening techniques, such as Kimura's technique in the advancement of a spit fistula or the traction technique introduced by Foker [4, 5]. Kimura's technique consists of multiple extrathoracic esophageal elongations of the upper esophagus to enable subsequent primary anastomosis [4]. Foker and colleagues [5] described a technique using traction sutures to lengthen both of the esophageal pouches and make a primary repair possible [5].
The child suffered from a pure EA, without a fistula, and a short lower pouch (Fig 1). As a newborn, she was treated with a gastrostomy, right-sided spit fistula and tracheostomy elsewhere. The parents opted for esophageal lengthening rather than esophageal replacement and transferred the child to our institution.
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Fig 1. Preoperative contrast study. The upper pouch ends above the right clavicle as a spit fistula. The lower pouch is above the level of the diaphragm.
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At the age 5 months the spit fistula was mobilized from the neck and advanced to the level of the clavicle according to the technique of Kimura. At the same time, a right thoracotomy was performed and the lower segment was found after identification of the vagal nerves. After careful dissection, leaving the hiatus and stomach below the diaphragm, pledgeted horizontal mattress sutures (5-0 polypropylene) were placed on the lower segment to provide adequate tissue holding power. At this surgical step, the lumen needs to be carefully avoided. Clips on the tip of the lower esophageal segment and the thoracic wall facilitated radiological follow-up of the progress. The sutures were brought out externally through the skin above the incision and secured over a special button. Daily increases in tension resulted in adequate growing of the lower esophagus after 8 days (Fig 2). At this point in time the child underwent a second thoracotomy, followed by dissection of both esophageal pouches. Primary esophageal anastomosis was completed without difficulty because both pouches presented with adequate length. Competent esophageal anastomosis was proofed by contrast study (Fig 3).
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Fig 2. Schematic drawing of the method. (A) Subcutaneous advancement of upper esophageal pouch. (B) Traction sutures on lower esophageal pouch. (C) Extracorporeal button for traction sutures.
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Postoperatively the child demonstrated an anastomotic stricture, which responded well to several dilations. We could take off the tracheostomy. The significant gastroesophageal reflux was controlled by a Nissen's fundoplication.
Currently the child is trained to eat orally, but is still dependent on gastrostomy feeds.
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Comment
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Esophageal replacement by colon or gastric transposition seems inevitable for children with long-gap EA [6]. Esophageal replacement techniques have relatively good short-term results. However, these interpositions might have potentially severe long-term consequences. For the gastric pull-up, the problems of malnutrition and anemia may be followed by cervical esophagitis with metaplasia and gastric atrophy. Colon interpositions often have poor emptying with chronic aspiration and even the problem of severe halitosis. For both of these solutions, the long-term results are still lacking, but the outcome might be unfavorable.
Although the child's own esophagus should provide the best solution, there is not yet enough information about the efficacy of the lengthening procedure to treat ultra-long gaps [7].
The Kimura technique is well known. The basic principle is to transform the upper segment (with or without a tracheoesophageal fistula) into a spit fistula, which is sequentially advanced. Thus, the upper esophageal segment grows longer stepwise [4].
The lengthening technique introduced by Foker uses traction on the segments to induce growth [4]. The physiological hypothesis of this approach (ie, the "stretch produces growth") awaits further conformation. Nevertheless, the clinical effect is proven by this case, but this report is meant to contribute clinical experience to this discussion.
In the presented case, the treatment strategy was a combination of both principles. On the spit fistula of the upper pouch, the Foker technique was avoided because it would have required closure of the spit fistula to use transthoracic traction sutures. Instead, the spit fistula was advanced subcutaneously, according to Kimura. This approach revealed several benefits (ie, closure of the spit fistula and conversion into a pouch would require a few weeks of healing before traction sutures could be used). Furthermore, then the child would have been hospitalized with suction probe. During that time the upper pouch carries a substantial risk of rupture and infection. These possible problems could be avoided using the Kimura method. Nevertheless, the Kimura method requires two to four subsequent steps, and therefore it takes time [8].
On the lower pouch, the Foker principle was effective and lengthening occurred from a small segment above the diaphragm into a substantial pouch, allowing a tension-free anastomosis at the level of the carina.
The growth method has proven to be very flexible in dealing with EA lesions and this case provides confirmation that it will be effective at the extreme end of the spectrum [9].
Drawbacks to the lengthening strategy are the need for repeated surgeries, including thoracotomies, the high incidence of postoperative gastroesophageal reflux requiring fundoplicatio, and a high risk of stricture formation dedicating the patients to a prolonged series of repeated esophageal dilations.
The case presented here comprises a successful combination of the two techniques that resulted in a lesser number of surgical steps, avoidance of suction probe within the upper esophageal pouch, and the possibility of sham feeding by mouth.
Granted that more successful cases and at least several years of follow-up will be needed to quiet the debate between growth induction and the interposition of another organ to solve the problem of long-gap EA, cases such as this one will provide the answer.
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References
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- Hirschl RB, Yardeni D, Oldham K, et al. Gastric transposition for esophageal replacement in children: experience with 41 consecutive cases with special emphasis on esophageal atresia Ann Surg 2002;236:531-541.[Medline]
- Spitz L, Kiely E, Sparnon T. Gastric transposition for esophageal replacement in children Ann Surg 1987;206:69-73.[Medline]
- Stone MM, Fonkalsrud EW, Mahour GH, Weitzman JJ, Takiff H. Esophageal replacement with colon interposition in children Ann Surg 1986;203:346-351.[Medline]
- Kimura K, Soper RT. Multistaged extrathoracic esophageal elongation for long gap esophageal atresia J Pediatr Surg 1994;29:566-568.[Medline]
- Foker JE, Linden BC, Boyle Jr EM, Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia Ann Surg 1997;226:533-543.[Medline]
- Spitz L. Oesophageal atresia Orphanet J Rare Dis 2007;2:24.[Medline]
- Hagberg S, Rubenson A, Sillén U, Werkmäster K. Management of long-gap esophagus: experience with end-to-end anastomosis under maximal tension Prog Pediatr Surg 1986;19:88-92.[Medline]
- Takamizawa S, Nishijima E, Tsugawa C, et al. Multi-staged esophageal elongation technique for long gap esophageal atresia: experience with 7 cases at a single institution J Pediatr Surg 2005;40:781-784.[Medline]
- Foker JE, Kendall TC, Catton K, Khan KM. A flexible approach to achieve a true primary repair for all infants with esophageal atresia Semin Pediatr Surg 2005;14:8-15.[Medline]
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Abstract
Introduction
