Kimura extrathoracic esophageal elongation for the treatment of complex esophageal atresia: Primary versus secondary treatment when other strategies failed

Abstract

IntroductionThe Kimura´s extrathoracic esophageal elongation (KEEE) procedure uses upper esophageal pouch traction to induce its growth, as an alternative to repair long gap esophageal atresia (LGEA). It can be used as a first option in the neonatal period (primary Kimura) or as a rescue procedure when another strategy fails (secondary Kimura).The aim of our study is to compare the results of the primary versus secondary Kimura procedure after unsuccessful Puri procedure or end-to-end esophageal anastomosis. MethodsThe present work is a retrospective review of patients with complex esophageal atresia (CEA) who underwent Kimura procedure at our institution from 1997 to 2021. We divided the patients into two groups, primary group: patients who underwent primary Kimura extrathoracic esophageal elongation (KEEE), esophagostomized in the first surgical intervention; and secondary group: those who underwent secondary KEEE, esophagostomized due to complications of the primary end-to-end anastomosis (EEA), or due to failure of preservation of native esophagus (PNE) techniques. Demographic variables (gestational age, birth weight, type of esophageal atresia (EA) and associated malformations) and evolution variables related to the elongations and reconstruction (days of mechanical ventilation (MV), days of hospitalization and complications of the anastomosis, feeding/oral aversion, need for nutritional support, gastroesophageal reflux disease (GERD), and mortality) were evaluated. ResultsDuring the 24-year period, 31 patients were evaluated, nine patients belonged to the primary group (of which 7 were reconstructed) and the remaining twenty-two to the secondary group (of which 12 completed the procedure).Regarding demographic variables, there was a statistical difference in gestational age (p = 0.016). Regarding the variables associated with the elongations, there was a statistically significant lower number of elongations (p = 0.0547), longer hospitalization time (p = 0.045) and more complications (p = 0.027) for the secondary group. Regarding the final reconstruction, the primary group had a significantly shorter postoperative hospital stay (p = 0.03), and also fewer days on MV, although these variables did not reach a statistically significant difference.Two patients died before the final reconstruction (one from each group). DiscussionWe believe that KEEE is a useful tool for both primary treatment and rescue in case of failure of other esophageal preservation strategies. In addition, it allows preserving the native esophagus and also performing esophageal replacement strategies with other organs if it fails. Level of evidenceAccording to the Journal of Pediatric Surgery this research corresponds to type of study level III for retrospective comparative study.