DOZ047.93: Thoracoscopic multistage repair of long-gap esophageal atresia using internal traction suture technique—evolution of the method

Abstract

Abstract Treatment of long-gap esophageal atresia poses a great challenge for a surgeon. A new multistage thoracoscopic repair of long-gap esophageal atresia using internal traction technique was developed that evolved with time and growing experience. The goal of this study is to present the changes in the strategy and important technical aspects of the operative method based on a retrospective analysis of performed surgeries. Methods and Materials Thirty-five cases of newborns with long-gap esophageal atresia (type A-26 cases and B-9 cases exclusively) were operated thoracoscopically between 2008 and 2019 using internal traction technique in different pediatric surgery centers (Poland–28, Czech–1, Ukraine–1, Switzerland–2, Egypt–2, Russia–1). The idea of the internal traction technique was to place the suture between thoracoscopically mobilized esophageal pouches and keep a static tension between them for a period of time. Patients were operated on as early as it was possible after birth. Results Of the 35 newborns operated on using internal traction 2 patients died before the final stage from not surgically-related causes. Two patients had complications that required neck fistula and had later Collis–Nissen and colon interposition, respectively. One case is awaiting the final procedure. For 31 cases the final esophageal anastomosis was completed in two stages–16 cases, three stages–9, four stages–2, five stages–2, and six stages–1. At the beginning the time between stages was planned for 4 weeks (for some cases it was even longer) and it was shortened for the last three cases to 5 days. It allowed avoiding gastrostomy in two cases. The internal traction was modified from using two traction loops to one traction loop with two slipping knots on each branch of the loop. The clips were applied transversely through the tip of each pouch and part of the traction loop to prevent disruption and pouch perforation. It also allowed increasing of the created static traction force. Conclusion Results of the study may indicate that in a majority of long-gap esophageal atresia it is possible to preserve the native esophagus by a thoracoscopic approach using an internal traction suture technique. Shortened time between stages allowed completion of the final esophageal anastomosis with gastrostomy avoidance.