We read with great interest the article by Reismann et al about "Partial gastric pull-up (PGP) in the treatment of patients with longgap esophageal atresia (LGEA)." This article states that "The incidence of stenosis and gastro-esophageal refl ux (GER) after PGP is considerably high, even compared with alternative surgical techniques for the treatment of LGEA and with their high complication rates. PGP cannot yet be generally recommended for the treatment of LGEA."[1]

 

One of the challenges in evaluating the literature for the surgical treatment of long-gap esophageal atresia (LGEA) is the lack of a uniformly accepted defi nition for the entity. Some used a cutoff of a 2 cm gap to defi ne a long gap,[1] while others used 3 cm or more.[2] Practically, LGEA is one in which the ends of the esophagus cannot be brought together for a primary anastomosis without employing alternative techniques. Staged elongation of the esophagus in cases of LGEA has been effective in achieving esophageal length and preserving the native esophagus.[3] Internal (Foker) and external (Kimura) techniques have been described along with many modifi cations of each.[2,4] In a Kimura series, esophageal gaps of 2 to 7 vertebral bodies were treated with 1 to 5 revisions of esophagostomy for anastomosis. All patients developed strictures requiring multiple dilations and 11 of 12 patients required fundoplication for gastroesophageal reflux. Seven of the 12 patients have been able to eat normally.[5] In a Foker series, successful esophageal anastomosis required 2-15 thoracotomies in 52 patients.[6] A review article reported a mean complication rate of 11%-60%, an anastomotic leakage rate of 80%-83%, and an esophageal stricture rate of 83%-100% .[3] Reismann et al[1] reported a series of 9 cases of LGEA (including 7 cases of pure atresia). These patients but 2 underwent initially gastrostomy and delayed PGP for LGEA. The median distance between the upper and lower esophageal segment under tension was 3 vertebral bodies (range: 1-6). Leakage as early complication occurred in 3 patients, stenosis in 7, and GER as a late complication in 5.[1]

 

In our article "An approximation technique for primary anastomosis (Gazi Method) in selected cases of long gap esophageal atresia", we added fi ve patients with LGEA.[7] The fi ve patients were in type C and the gap length at the beginning of elongation varied from 3 to 5 cm. Dissection and anastomosis were carried out following an extrapleural right thoracotomy. The upper esophageal pouch was dissected up to the cervical inlet. The lower esophageal pouch was dissected as far down as the diaphragm. An eight French feeding tube was placed from the mouth and passed through the two pouches to the stomach. After this, both pouches were grabbed approximately 1 cm away from the cut ends, holding whole of the esophageal walls with tissue forceps and were approximated to each other under tension so that they contacted each other. The esophageal parts were held in this position until completion of the anastomosis using interrupted, 5-0 vicryl sutures (Gazi method). After all of the sutures were tied, the forceps were released so that the tension distributed evenly to all of the sutures and tissue holding the anastomosis. To minimize disruptive anastomotic forces, all infants with esophageal atresia were postoperatively kept paralyzed, sedated and mechanically ventilated for 2 to 5 days. In our series, 60% of our patients developed minor anastomotic leak and only 2 patients were given medication for GER. One patient required dilatation for anastomotic stricture. One patient with VACTERL syndrome died from cardiac failure at the 6th month. Its theoretical basis is that excellent intramural blood circulation in both upper and lower ends permits an excessive dissection, that esophageal lengthening could be achieved by intraoperative traction, and that an esophageal anastomosis could be constructed under considerable tension with associated minor complications if the tension is distributed evenly on the sutures. It is very important that the forceps holding and approximating the two esophageal ends to be released only after placing and tying the sutures. Advantages of our lengthening and approximation technique include no requirement of repeated thoracotomy, use of native esophagus, and short hospital stay. It is suitable for cases of esophageal gap between 3-5 cm.

 

 

1 Reismann M, Granholm T, Ehrén H. Partial gastric pull-up in the treatment of patients with long-gap esophageal atresia. World J Pediatr 2015;11:267-271.

2 von Allmen D, Wijnen RM. Bridging the gap in the repair of long-gap esophageal stresia: still questions on diagnostics and treatment. Eur J Pediatr Surg 2015;25:312-317.

3 Foker JE, Linden BC, Boyle EM Jr, Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg 1997;226:533-541, discussion 541-543.

4 Kimura K, Soper RT. Multistaged extrathoracic esophageal elongation for long gap esophageal atresia. J Pediatr Surg 1994;29:566-568.

5 Kimura K, Nishijima E, Tsugawa C, Collins DL, Lazar EL, Stylianos S, et al. Multistaged extrathoracic esophageal elongation procedure for long gap esophageal atresia: Experience with 12 patients. J Pediatr Surg 2001;36:1725- 1727.

6 Bairdain S, Hamilton TE, Smithers CJ, Manfredi M, Ngo P, Gallagher D, et al. Foker process for the correction of long gap esophageal atresia: Primary treatment versus secondary treatment after prior esophageal surgery. J Pediatr Surg 2015;50:933-937.

7 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/s12519-016-0010-5