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We are very grateful to Karabulut et al for their interest in our paper reporting the method of partial gastric pull-up (PGP) in the treatment of long-gap esophageal atresia (LGEA).
We agree to the view that the central problem in treatment of esophageal atresia is at present lack of generally accepted defi nitions, for instance, the defi nition of LGEA as mentioned in their letter. In our study, we used a practical approach to define this entity by incapability of conventional primary anastomosis due to insufficient length of esophageal segments.[1] The measurement of the distances in vertebral bodies has a pure descriptive character. Karabulut et al acknowledged this type of defi nition.
Further, they demonstrated that all other techniques for treatment of LGEA are also associated with a significant number of complications like anastomotic leakage and esophageal stenosis/stricture. For postoperative stenosis, we used a generous definition that is essentially based on radiological, endoscopic but not on clinical findings.[1] Another more practical and frequently used defi nition is given by clinical symptoms revealing anastomotic stenosis, like swallowing difficulties, recurrent respiratory problems or foreign body obstruction.[2] Our definition does not exclude the possibility that patients without severe clinical problems are treated for anastomotic stricture. Thus, the comparability of our results regarding this type of complication remains elusive.
In our study, we were not able to show convincingly better treatment results after PGP compared with other already established methods like jejunal interposition, colon interposition and gastric pull-up. Thus, we have been very reluctant with the conclusions drawn. However, our results do not exclude the possibility of comparable results regarding the outcome after PGP. There is a clear lack of comparative studies.
The published Gazi method for the treatment of LGEA can be seen as a modification of the method of PGP by further reducing the tension on the esophageal segments using forceps.[3] It is well conceivable that this modification represents an effective extension of our approach, leading to a reduction of the complication rate. On the other hand, the tension within the partial pullup presented by us has been considerably low in all the reported cases. A study comparing the Gazi method with pure limited dissection in the method presented by us could appropriately answer this question.
Marc Reismann Department of Pediatric Surgery, Astrid Lindgren Children's Hospital, Karolinska Hospital, Stockholm, Sweden Email: marc.reismann@charite.de
References
1 Reismann M, Granholm T, Ehr¨¦n H. Partial gastric pull-up in the treatment of patients with long-gap esophageal atresia. World J Pediatr 2015;11:267-271.
2 Lydia Serhal, Fr¨¦ d¨¦ ric Gottrand, Rony Sfeir, Dominique Guimber, Patrick Devos, Michel Bonnevalle, et al. Anastomotic stricture after surgical repair of esophageal atresia: frequency, risk factors, and efficacy of esophageal bougie dilatations. J Ped Surg 2010;45:1459-1462.
3 Karabulut R, Turkyilmaz Z, Sonmez K, Ozbayoglu A, Basaklar AC. An approximation technique for primary anastomosis (Gazi Method) in selected cases of long gap esophageal atresia. Prensa Med Argent 2014;100:1. doi: 10.1007/s12519-016-0011-4
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