Foker Procedure Research Articles

Management of long-gap esophageal atresia.

A uniquely challenging subset of infants diagnosed with esophageal atresia (EA) are those born with long-gap EA (LGEA). The common unifying feature in infants with LGEA is that the proximal and distal segments of the esophagus are too far apart to enable primary anastomosis via a single operation in the newborn period. Although any type of EA can technically result in a long gap, the Gross type A variant occurs in 8% of all EA cases and is most commonly associated with LGEA. In this review, we provide an evidence-based approach to the current challenges and management strategies employed in LGEA. There are fortunately a range of available surgical techniques for LGEA repair, including delayed primary repair, staged repair based on longitudinal traction strategies to lengthen both ends (e.g., Foker procedure, internal traction), and esophageal replacement using other portions of the gastrointestinal tract. The literature on the management of LGEA has long been dominated by single-center retrospective reviews, but the field has recently witnessed increased multi-center collaboration that has helped to increase our understanding on how to best manage this challenging patient population. Delayed primary repair is strongly preferred as the initial approach in management of LGEA in the United States as well as several European countries and is supported by the American Pediatric Surgery Association recommendations. Should esophageal replacement be required in cases where salvaging the native thoracic esophagus is not possible, gastric conduits are the preferred approach, based on the relative simplicity of the operation, low postoperative morbidity, and long-term durability. Long-term followup for monitoring of swallowing function, nutritional status, aspiration/respiratory illnesses, gastroesophageal reflux, and associated comorbidities is essential in the comprehensive care of these complex patients.

Long gap esophageal atresia repair using the foker tecnique: a 19 years experience.

Esophageal atresia (EA) with a 3-cm gap or longer and a very short distal segment represents the extreme of this disorder's spectrum, the treatment of which can be challenging. Management of newborns with long-gap esophageal atresia (LGEA) remains a challenge for pediatric surgeons. The inclusion criteria in the study were as follows: long gap esophageal atresia, Foker technique, at least 10 years follow up. We sought to examine our experiences with LGEA using Foker technique. RESULTS: From 2001 to 2020 were operated for esophageal atresia at the UOC Surgery of the AORN Santobono 290 children of whom 16 patients meet our inclusion criteria. 6 had a type I EA, 2 had a type II and 8 had a type III. Mean gap length was 4 cm (range 3-5), In 9 patients gastrostomy and Foker technique was performed in the same time (around the 1stto the 4th day of life), while in 7 patients gastrostomy was performed in 1st-2nd day of life and the Foker technique was delayed due to clinical needs with a mean of 76 days (range 26-96 days) . In the study group, 11/16 (68,75%) patients underwent multiple endoscopic dilatations ( means 5 sessions per patient); 3 out of 16 cases of early complications occurred: 2 perforations and 1 dehiscence. Gastroesophageal reflux was common during the first 6 years of life and 2 had a fundoplication due to gastroesophageal reflux disease resistant to maximal medical therapy and 1 had an esophageal diverticulum at 5 years. 7 out of 16 (43,7%) (average age 13,5 years) perform therapy cycles with pump inhibitors for an average period of 12 weeks. CONCLUSIONS: Foker procedure for esophageal lengthening in patients with LGEA was successful in mobilizing the esophagus and obtaining a repair in the majority of our patients after 12 to 15 days of traction and it should be considered in LGEA cases to preserve the native esophagus as often as possible.

The left-sided repair: An alternative approach for difficult esophageal atresia repair

Purpose: We describe a left-sided approach for long gap esophageal atresia (LGEA) repair in patients who have a large leftward upper pouch and no significant tracheomalacia, or as a salvage strategy after prior failed right-sided repairs. Methods: Retrospective review of patients who underwent repair via traction induced growth (Foker procedure [FP]) from 2014 to 2019 was performed. Surgical technique and post-operative outcomes were evaluated. Results: Of 47 LGEA patients, 18 (38%) were approached via the left side – 94% had a left aortic arch, and 22% had prior attempts at a right-sided anastomosis. More left-sided patients underwent minimally invasive repair (39% vs 7%, p = 0.007) and internal traction (50% vs 10%, p = 0.002) compared to right-sided patients. On multivariate analysis, internal traction was associated with a decreased length of paralysis (p<0.01); length of intubation and hospital stay were similar between groups. Anastomotic leak (17% vs 20%, p = 0.80) and stricture resection (6% vs 24%, p = 0.12) rates were similar. No left-sided FP patient required additional surgery for tracheomalacia, while six right-sided patients required intervention. Conclusion: Left-sided FP can be considered for LGEA patients with a large leftward upper pouch or as a salvage pathway after a failed right chest approach, with similar outcomes to the right-sided approach.

DOZ047.15: Esophageal anastomosis diameter at initial endoscopy after surgery predicts treatment outcomes in patients with esophageal atresia or stricture

Abstract Background Children with esophageal atresia (EA) are at risk for anastomotic stricture that may ultimately need surgical resection. No studies have examined the relationship between anastomotic diameter at the time of initial postop endoscopy and treatment outcomes. Methods A retrospective chart review was performed of patients with EA who underwent a Foker procedure for repair of long-gap esophageal atresia (LGEA), primary repair of EA, or stricture resection for refractory stricture who were seen between January 2016 and May 2018. A refractory stricture was defined as one requiring ≥5 dilations ≤5 months after surgery. The anastomosis diameter was estimated by the endoscopist. We divided diameter sizes into the following groups: 1–2.9 mm, 3–4.9 mm, 5–6.9 mm, 7–8.9 mm, 9–10.9 mm, and 11–14 mm. The Wilcoxon rank sum test and Fisher's exact test were used. Results Forty-five patients who had a Foker procedure, 37 who had primary repair, and 58 who had stricture resection were identified. The first EGD occurred a median of 22 days (IQR 21–28) after surgery. Among all EA patients with initial diameter of &lt;3 mm, 82% developed refractory stricture and 41% required stricture resection. Of all patients with initial diameter &lt;5 mm, 74% developed refractory stricture and 33% required stricture resection. Of patients who underwent a Foker procedure with initial diameter &lt;3 mm, 56% required stricture resection; of these patients with initial diameter &lt;5 mm, 53% required stricture resection. Among all EA patients, refractory strictures were significantly more likely in patients with smaller initial diameters (P &lt; 0.001), from 18 patients (82%) with stricture 1–2 mm to 0 patients (0%) with stricture 11–14 mm. Patients with smaller anastomoses were more likely to need stricture resection (P = 0.020); 9 patients (41%) with size 1–2 mm underwent stricture resection, while none (0%) with size 11–14 mm needed stricture resection. These differences remained statistically significant for patients who underwent a Foker procedure (P ≤ 0.001 for stricture resection and refractory stricture). Conclusion Endoscopy performed shortly after EA repair or stricture resection can help predict which patients are more likely to develop a refractory stricture or require a stricture resection.

DOZ047.13: Prophylactic endoscopic esophageal vacuum (EVAC) therapy of high-risk esophageal anastomoses in pediatric surgical patients

Abstract Summary Esophageal anastomotic leak (EAL) is a potentially severe complication of surgical procedures of the esophagus. Vacuum-assisted closure (VAC) therapy is increasingly used in the treatment of EAL, with observational studies suggesting it is a highly effective method for esophageal defect closure.1–3 It was hypothesized that prophylactic esophageal VAC (EVAC) placement at the time of new anastomosis creation may improve blood flow and healing, potentially leading to fewer EALs. Methods Between July 2015 and November 2018, patients who underwent surgery that resulted in a new esophageal anastomosis and were deemed to be high risk for anastomotic complications had a prophylactic EVAC placed at the time of surgery. Retrospective review of similar surgical procedures without prophylactic EVAC placement from January 2014 to November 2018 was performed for comparison. Results Thirteen pediatric patients had prophylactic EVAC placement at the time of esophageal repair. Procedures prompting EVAC placement included primary repair of long-gap esophageal atresia (LGEA) by the Foker technique (N = 7), stricture resection after repaired LGEA (N = 3) or type C esophageal atresia (N = 1), and stricture resection after delayed identification of a retained esophageal foreign body (N = 2). Three of 13 patients who had prophylactic EVAC placement (23.1%) experienced EAL in the post-operative period. Two patients were found to have technical failure of their EVAC leading to absence of suction, and one patient experienced delayed EAL 12 days after removal of the EVAC. In comparison, post-surgical EAL occurred in 13 of 58 patients who had the Foker procedure for LGEA and in 8 of 31 patients who had esophageal stricture resection without prophylactic EVAC placement. The rates of EAL in the prophylactic EVAC group were not significantly different from rates of EAL in either the post-surgical Foker (23.1% vs 22.4%, P = 0.999), post-stricture resection (23.1% vs 25.8%, P = 0.999), or combined post-Foker and stricture resection (23.1% vs 23.6%, P = 0.999) groups by Fisher's exact test. Conclusions Prophylactic EVAC placement does not carry increased risk of EAL compared to standard post-surgical care; however, further device refinement is needed to reduce technical failure.

Pedicled jejunal interposition for long gap esophageal atresia

Background/purposeLong gap esophageal atresia (LGEA) represents 10% of all esophageal atresias but can be complex to manage. Jejunal interposition (JI) has been recommended as the operative management of choice when esophageal ends cannot be opposed. We report our experience using the pedicled jejunal interposition technique with comparison to patients undergoing primary repair of LGEA. MethodsThis was a retrospective analysis of all patients managed for LGEA at our unit between 2003 and 2017 with comparison between pedicled jejunal interposition and primary repair. Results10 patients were treated with pedicled jejunal interposition and 9 patients underwent primary repair (including one Foker procedure performed elsewhere). Patient demographics and short term outcomes were similar between the two groups, but less anastomotic stricturing and gastroesophageal reflux were observed in the JI group. ConclusionThis is the largest published series of pedicled jejunal interposition from the UK. Our results support continued use of this procedure with good long term graft function. It is our recommendation that pedicled interposition grafts are used in all patients requiring extensive dissection or tension to achieve opposition for primary repair. Type of studyRetrospective study. Level of evidenceLevel III.

Technical Aspects in Esophageal Lengthening: An Investigation of Traction Procedures and Suturing Techniques in Swine.

Traction procedures are useful to preserve the child's own esophagus in long-gap forms of esophageal atresia. To date, it remains unclear what suture size or position of the traction sutures is optimal to account for differences in anatomy and to reduce the risk of traction sutures being torn out of the esophageal tissue. Explanted porcine esophagi (from swine aged 100-120 days and weighing 100-120 kg) were divided at the carinal level. Traction sutures were either placed circumferentially or only in the dorsal wall and the breaking strength-circumferential disruption of the muscular layer-was measured. Suture size (USP 4-0 vs. 5-0) was also evaluated in a similar way. Neither traction suture position did not influence breaking strengths between circumferentially placed traction sutures or those exclusively placed in the dorsal esophageal wall (Δ = 0.47 N, 95% confidence interval: -2.83 to 3.76 N, p = 0.771, n = 11 per group) nor differing suture sizes of USP 4-0 and USP 5-0 (Δ = 1.46 N, 95% confidence interval: -3.2 to 0.28 N, p = 0.0946, n = 9 per group) affected breaking strengths. Suture size and suture positioning do not affect mechanical stability in Foker's procedure and therefore can be adapted as needed according to patient's anatomy and size.

PS01.093: REPEAT ESOPHAGEAL STRICTURE RESECTION: WHAT FACTORS ARE MOST INFLUENTIAL?

Abstract Background The objective of this study was to identify whether paralysis time following stricture resection and tension applied at the anastomosis influenced leak rate, need for repeat stricture resection (SR), or need for an interposition graft. Methods A retrospective chart review was performed of patients undergoing esophageal stricture resection and anastomosis from October 2007 to July 2017 (IRB# P00004344). Patients who required an interposition as their primary surgery were excluded. Leak rates following stricture resection and the need for further esophageal surgery was identified. Tension groups were also delineated into mild, moderate, and high anastomotic tension. Anastomotic tension and paralysis times were analyzed by multivariable logistic regression and area under the curve (AUC) to determine factors associated with development of leaks and an increased risk of repeat SR. Results Ninety-four patients were identified; 45 were males and mean gestational age was 35 weeks. Fifty-one patients were categorized with mild tension, 35 with moderate, and 8 with high tension. Four of the 51 patients (8%) with low tension and 15/43 (35%) with moderate or high tension developed leaks (P = 0.002). Seventeen patients overall required repeat SR (18%), including 3/51 with low tension (6%) versus 14/43 (33%) with moderate or high tension (P &lt; 0.001). Additionally, 12/17 (71%) patients requiring repeat operations initially had a Foker process for their esophageal atresia. Multivariable analysis indicated that moderate/high tension (P = 0.006) and longer paralysis time (p 0.04) were predictive of a leak after initial SR (AUC = 0.720). Paralysis time of 7 + days (P = 0.05), moderate/high tension (P = 0.05) and occurrence of a leak (P = 0.002) were independent risk factors for the need for repeat SR (AUC = 0.861, 95% CI: 0.772–0.949). Of the 17 patients with repeat SR, 10 (59%) underwent a jejunal interposition. Conclusion Tension, paralysis time, and presence of a leak are independent risk factors for repeat SR. Low tension anastomoses had a significantly small incidence of repeat surgery. Esophageal replacement shoudl be considered earlier among patients who originally undergo a Foker procedure for esophageal continuity and for those whose stricture repair is placed under moderate or high tension. Disclosure All authors have declared no conflicts of interest.

Is fundoplication required after the Foker procedure for long gap esophageal atresia?

BackgroundFundoplication has been performed almost universally in children treated with the Foker procedure (FP) for long gap esophageal atresia (LGEA). We report our experience with pharmacological management and endoscopic surveillance rather than early routine fundoplication in infants treated with the FP. MethodsA retrospective chart review was performed of all children treated with the Foker procedure at our institution. ResultsNine children have undergone the FP since 2007. Median time between FP and definitive anastomoses was 22days. All nine children kept their native esophagus. There were three minor anastomotic leaks, all treated nonoperatively. All children required dilatation of anastomotic strictures (range 2–15). All have been treated with proton pump inhibitors. Three children had eosinophilic esophagitis and one had Barrett's esophagus. Only two children in this series have undergone fundoplication, which was performed for symptomatic and persistent erosive esophagitis. ConclusionThe question of early versus delayed fundoplication in LGEA patients managed with the FP remains unanswered. Our series demonstrates that it is possible to achieve good long-term outcomes when the operation is reserved for children with gastroesophageal reflux disease resistant to maximal medical therapy. Level of evidenceIV.

High incidence of fracture events in patients with Long-Gap Esophageal Atresia (LGEA): A retrospective review prompting implementation of standardized protocol

PurposeTo identify factors associated with an increased risk of fractures in Long-Gap Esophageal Atresia (LGEA) patients. Following implementation of a risk-stratified program, we hypothesized a reduction in fracture incidence within this potentially high-risk population. MethodsA retrospective review of LGEA-patients admitted between 2005 and 2014 was conducted. Symptomatic fractures with radiographic confirmation were defined as events. Univariate and multivariable analysis evaluated factors including admission weight-for-age z-score, primary versus secondary Foker process (FP), weight at Foker Stage I, days and episodes of paralysis, number of parenteral nutrition (PN) days, cumulative dose of loop diuretics adjusted for body weight and days exposed, and exposure to non-loop diuretics. A fracture-prevention protocol was initiated in 2012; incidence was evaluated pre and post-intervention. ResultsFifty-nine patients met inclusion criteria. Twenty-three (39%) patients in the entire cohort incurred at least one fracture during their hospitalization utilizing the Foker process. Given this high percentage, a targeted fracture-prevention protocol was initiated in 2012. Fracture incidence decreased from 48% prior to the protocol to 21% following the protocol (P=0.046). Several variables that were associated with an increased risk of fractures on univariate analysis included prior esophageal anastomosis attempt (P=0.008), number of separate episodes of paralysis (P=0.002), exposure to non-loop diuretics (P=0.006), cumulative loop diuretic dose (P<0.001), as well as cumulative loop diuretic over days exposed (P<0.001). Intensive care unit (ICU) stay (P=0.002) and total length of hospitalization (P<0.001) were also significantly longer among patients with a fracture. Number of separate episodes of paralysis was the only independent risk factor for the development of a fracture; patients having more than 3 episodes of paralysis had an estimated risk of fracture 15 times higher than those patients paralyzed only once or twice (O.R. 15.87, 95% C.I.: 1.47–171.23, P=0.008). ConclusionEpisodes of paralysis appeared to be the most significant risk factor for fractures in patients with LGEA who underwent the Foker procedure. The incidence of symptomatic fractures decreased significantly following implementation of a standardized protocol in this series of LGEA patients with continued prospective evaluation.

Imaging of long gap esophageal atresia and the Foker process: expected findings and complications

Long gap esophageal atresia (EA) is characterized by esophageal segments that are too far apart for primary anastomosis. Surgical repair utilizing interposition grafts or gastric transposition are often employed. The Foker staged lengthening procedure is an alternative surgical method that utilizes continuous traction on the esophagus to induce esophageal growth and allow for primary esophageal anastomosis. This pictorial review presents the step-by-step radiographic evaluation of the Foker procedure and illustrates the radiographic findings in the most commonly encountered complications in our cohort of 38 patients managed with this procedure from January 2000 to June 2012.

Mechanical Traction Techniques for Long-Gap Esophageal Atresia: A Critical Appraisal

Long-gap esophageal atresia (EA) represents a challenging problem for pediatric surgeons, and a large number of techniques and approaches have been proposed. One of the more recent, initially published by Foker, is the use of mechanical traction to accelerate the growth of the esophageal ends and permit earlier primary anastomosis. The purpose of this study is to critically evaluate the existing literature on this topic and to compare the Foker technique to the more conventional delayed primary anastomosis. A systematic review and cumulative meta-analysis was performed, including all articles describing the Foker technique or delayed primary anastomosis. Primary outcome was complications, and secondary outcome was time to final anastomosis. Six articles on the Foker procedure met the criteria for inclusion. None were prospective or randomized. These articles represented 71 infants undergoing the Foker procedure, which were compared with 451 children from 44 studies utilizing delayed primary anastomosis. The Foker procedure was associated with a significantly lower risk of complications (leak, stricture, and gastroesophageal reflux), and with a significantly shorter time to definitive anastomosis. The use of mechanical traction appears to be at least as effective as delayed primary anastomosis for the management of long-gap EA. Future prospective studies and the establishment of a prospective registry are required to further elucidate this issue.

Oesophageal elongation with traction sutures (FOKER procedure) in a newborn baby with long-gap oesophageal atresia (LGEA): Maybe too early, maybe too dangerous?

In children with long gap oesophageal atresia (LGEA), the FOKER technique (oesophageal elongation with traction sutures) has been criticized for its high complication rate. We advocate analysing such problems to increase the safety in the future. The present case report will focus on timing. A female newborn (3000 g) with LGEA (gap of 5 cm) was delivered in an outward hospital. On day two of life, she received traction sutures on both pouches. By day five, all sutures had torn out, and a primary anastomosis was attempted. However, it leaked severely. Thus, on day ten, the oesophagus was approached from the neck converting the proximal end into a spit fistula and closing the distal end blindly. Furthermore, the gastro-oesophageal (GE-) junction was wrapped with a Teflon sling. When the baby arrived in our institution, she suffered from cavernous oesophageal masses extending from the thoracic inlet down to the diaphragm and fistulas draining them into the neck as well as into the right lung. Moreover, the Teflon sling had dislodged allowing for GE-reflux. In several stages, the oesophageal remnants were resected without any complications. Finally, Prof. Alaa Hamza performed a colonic interposition, which is working well today. In conclusion, the present case aims to caution paediatric surgeons to apply traction sutures for oesophageal elongation in newborns with LGEA.

Type A esophageal atresia: a critical review of management strategies at a single center

Purpose The purpose of was to study the short- and long-term outcomes in the management of isolated esophageal atresia with different operative strategies. Methods All patients undergoing type A atresia repair over a 15-year period were included. Demographic data, birth weight, gestational age, incidence of associated anomalies, management, and long-term outcomes were studied. Results Fifteen patients with type A atresia (9 male) were treated in the study period. The mean gestational age was 35.5 weeks (range, 27-39 weeks), and the mean birth weight was 2179 g (range, 670-3520 g). Eight babies had associated anomalies. Thirteen patients underwent gastrostomy as the initial procedure, and 2 underwent the Foker procedure. In the delayed management group, 9 patients underwent primary anastomosis, with 2 patients needing proximal pouch myotomy. Two patients underwent a Collis gastroplasty. Two patients underwent a cervical esophagostomy and a gastric tube replacement at 4 months and 1 year, respectively. Eight patients (60%) in this group had anastomotic leaks. All patients are currently on prokinetics and proton pump inhibitors. Seven required antireflux surgery. The median length of hospital admission was 4 months (range, 3-19 months). The native esophagus was preserved in 13 (85%) of 15 babies. All patients are alive, and 14 of 15 are capable of feeding orally. Conclusions Type A esophageal atresia continues to be associated with significant morbidity despite advances in surgical technique and intensive care.