Long-gap Esophageal Atresia Research Articles

Poly-ε-caprolactone mesh as a scaffold forin vivotissue engineering in rabbit esophagus

Repair of long-gap esophageal atresia is associated with a high degree of complications. Tissue engineering on a scaffold of a bioresorbable material could be a solution. The aim of the present study was to investigate the in vivo tissue engineering of smooth muscle cells and epithelium on a poly-ε-caprolactone mesh in rabbit esophagus. Twenty female rabbits had a window of 0.6 × 1 cm cut in the abdominal part of the esophagus. The defect was covered with a poly-ε-caprolactone mesh. The rabbits were killed on postoperative day 28-30, and mesh with surrounding esophagus was removed for histological examination. Fifteen rabbits survived the trial period. Six had no complications and had the mesh in situ. They all had ingrowth of epithelial and smooth muscle cells and an almost completely degraded mesh. Nine rabbits developed pseudo-diverticula. It proved possible to engineer both epithelial and smooth muscle cells on the poly-ε-caprolactone mesh in spite of a fast mesh degradation. The latter may be the explanation to the development of pseudo-diverticula; this is a problem that needs attention in future experimental trials.

An Approximation Technique for Primary Anastomosis (Gazi Method) In Selected Cases of Long Gap Esophageal Atresia

An Approximation Technique for Primary Anastomosis (Gazi Method) In Selected Cases of Long Gap Esophageal Atresia The authors describe a technique of approximation and primary repair (Gazi method) for selected long gap esophageal atresia (LEA).Five infants underwent repair for LEA. The distal fistula was divided and oversewn. The upper and lower ends of the esophagus were dissected and excessively mobilized. Both of the esophageal ends were grabbed approximately 1 cm away from the anastomotic line with gentle tissue forceps to reduce the tension.

Early Regenerative Response in the Intrathoracic Porcine Esophagus—The Impact of the Inflammation

In order to improve the treatment of children born with long-gap esophageal atresia, a porcine model was developed for studying esophageal regrowth using a bridging graft composed of a silicone stented Biodesign mesh. The aim of the study was to investigate how leakage and contact between the native muscle and Biodesign mesh affected the early healing response. Resection of 3 cm of intrathoracic esophagus was performed in 10 newly weaned piglets. They were fed through a gastrostomy 8-10 days prior to sacrifice. In order to achieve nonleaking anastomoses, the silicone stent and suturing technique had to be adjusted between the first four and second six piglets. The technical adjustment decreased leakage. A nonleaking anastomosis could not be achieved when the native muscle layers were sewn less central on the bridging graft compared with the mucosa. If there was leakage, the inflammatory response increased, with islets of perivascular T-lymphocytes and infiltration of macrophages in the native muscle layers. In the bridging area, new vessels were seen in the submucosa in 9 of 10 piglets between 4 and 10 days after surgery. Smooth muscle cells also appeared to move from the cut muscle edges of both the muscularis mucosa and the lamina muscularis and were seen as a layer of several cells under newly formed mucosa. Double staining of the basal membrane of the ingrowing vessels and the pericytes showed that the basal membrane was thinner over some of the pericytes, but there was no accumulation of immature-looking cells in the submucosa of the bridging area. In this porcine model, where esophageal regrowth was studied by using a bridging graft composed of a silicone stented Biodesign mesh, we can conclude that leakage increased the inflammatory response in early healing. Ingrowth of new vessels was seen in the bridging area and movement of smooth muscle cells was found under newly formed mucosa.

Intramural injection with botulinum toxin significantly elongates the pig esophagus

Background/PurposeSurgical treatment of long-gap esophageal atresia (LGEA) is challenging. Methods which facilitate stretching of the esophageal pouches may allow primary anastomosis. Botulinum toxin type A (BTX-A) blocks acetylcholine release in neuromuscular junctions, thereby causing muscle relaxation. We hypothesized that intramural injections with BTX-A into the esophageal wall of piglets would significantly elongate the tissue upon stretch. MethodsTwenty-four piglets were randomized to receive BTX-A of placebo (saline). After one hour, the esophagus was removed en bloc and tested in a stretch-tension device. ResultsThe mean esophageal elongation was 84% (range 83–101) in the BTX-A-group and 65% (50–78) in the control group. The mean difference between the two groups was 18%, which was significant (p<0.001). ConclusionIntramural injections with botulinum toxin type A elongate the esophagus significantly. Clinically, this could be a potential method to achieve primary anastomosis in LGEA. Additional clinical studies are necessary to evaluate the method before it can be generally recommended.

Early results of an objective feedback-directed system for the staged traction repair of long-gap esophageal atresia

PurposeTreatment of long-gap esophageal atresia challenges pediatric surgeons. Dr. Foker described utilization of external traction sutures to promote in-vivo growth through tension-induced lengthening, but reproducibility of this technique is difficult. We describe a safe and reproducible traction system using transduction of hydrostatic pressure as a surrogate for tension. MethodsWe conducted a multi-institutional review of patients treated with this system from 2005 to 2012. All children had sutures applied to both pouches with continuous measurement of associated hydrostatic pressures (tension). Main outcome measures were days to delayed primary repair and thoracotomies prior to primary repair. ResultsSeven children were included. Median time to delayed repair was 15days (range: 6–47days). Three patients required repeat thoracotomies owing to mechanical entrapment of a pouch, all identified early by this system. All required postoperative dilations. Three had self-limited postdilation leaks, and there was one operation-related leak. ConclusionsThis system provides reproducible traction application, facilitating staged primary repair by preventing major failures through limiting excessive traction and guides re-exploration for trapped segments. Larger studies are needed to determine the optimal tension protocol, prevent postoperative leaks, while decreasing the need for dilations and time to enteral feeding.

Dilated ureter for esophageal substitution: A preliminary experimental study in the rat

Esophageal replacement using digestive organs such as the colon, stomach, or jejunum has been used to treat long-gap esophageal atresia and caustic esophageal strictures. Nevertheless, it presents a major challenge. Here, we report a preliminary experimental study that examined the use of a free dilated ureter as an option for esophageal substitution in a transplantation rat model. Ten 28-week-old male donor rats underwent distal ureteral ligation for 4 weeks, and the total dilated ureters were recovered. In each of the ten recipient 20-week-old male rats, a ureter was transplanted through the mediastinum into the esophageal bed, without vascular anastomosis. All rats received cyclosporine and cotrimoxazole for 10 days. On postoperative day 10, the rats were sacrificed, and the transplanted ureters were evaluated macroscopically and histopathologically. All procedures were achieved. In the early postoperative period, three transplanted rats died. Upon macroscopic evaluation, no evidence of complications was observed, and all transplanted ureters exhibited apparently good firm tissue. Histopathological examination showed a viable ureteral structure with good vascularity, low inflammation, and regenerated epithelium in all rats. As an option for esophageal substitution, heterotopic ureteral transplantation can be performed directly into the mediastinal location of the esophagus, without vascular anastomosis in a rat model. In the future, free dilated ureters might be useful for esophageal grafting or patching in humans; however, this procedure must be validated in additional large animal models before being attempted in humans.

Type-A long-gap esophageal atresia treated by thoracoscopic esophagoesophagostomy after sequential extrathoracic esophageal elongation (Kimura’s technique)

We report four cases of long-gap esophageal atresia (LGEA) treated with thoracoscopic esophagoesophagostomy (TEE) after sequential extrathoracic esophageal elongation (SEEE: Kimura's technique). All initially had gastrostomy, then SEEE. The proximal end of the esophagus was introduced into the apex of the thorax under direct vision during TEE. Mean birth weight was 1.9 kg. Mean gestational age was 35.0 weeks (range 30-39); mean age at initial esophagostomy was 43.2 days (range 15-110); SEEE was performed for a mean of 3 times (range 2-4) at mean intervals of 5.3 months (range 2-10), with the upper esophageal segment lengthened by a mean of 2.1 cm each time (range 1.1-3.5). Mean age and weight at TEE were 22.3 months and 9.8 kg, respectively. Gap was initially 4.5 vertebrae (range 4-5). Mean operating time was 9.6 h. TEE was successful in 3; 1 required thoracotomy, then re-anastomosis after 11 months of anastomosis leakage; 2 cases with post-TEE anastomosis leakage were treated conservatively. Postoperatively, all cases required fundoplication and esophageal dilatation (2, 3, 5, 8 times, respectively). At mean follow-up of 3.6 years, 2 eat normally and 2 eat minced food. TEE after SEEE appears to be a feasible option for treating LGEA.

Laparoscopic Transhiatal Esophagectomy and Gastric Pull-Up in Long-Gap Esophageal Atresia: Description of the Technique in Our First 10 Cases

The definition accepted for the largely controversial and multiple criteria condition known as long-gap esophageal atresia (LGEA) is "inability to achieve primary end-to-end anastomosis," particularly in the presence of a tracheo-esophageal fistula. In this article we report our technique of laparoscopic transhiatal esophagectomy and gastric pull-up (TEGPUL) in LGEA, based on the open approach of Spitz. Differences between TEGPUL and the original technique are the absence of a pyloromyotomy, the peel-away technique, the gastric pull-up through the distal esophagus, and its extracorporeal section. We performed the technique in 10 patients: 6 girls and 4 boys. Six had esophageal atresia type III (60%), three had esophageal atresia type I (30%) and one had esophageal atresia type II (10%). Mean time in surgery was 4.43 hours (range, 3.3-7 hours). Average stay in the pediatric intensive care unit was 5.9 days (range, 3-25 days). Average time under mechanical ventilation was 4.6 days (range, 2-8 days). Average total hospital stay was 19.4 days (range, 11-40 days). Oral feeding began at 15.6 days (range, 5-30 days). We believe these steps and the early realization of the technique will reduce the morbidity and mortality among these patients and decrease the number of contraindications to gastric pull-up. Nevertheless, a valid conclusion will require more studies with a larger number of patients and longer follow-up.

Esophageal transplantation in the rat

PurposeEsophageal replacement surgery has been used to treat long-gap esophageal atresia, caustic esophageal stricture, and esophageal avulsion. Here, we report total esophageal transplantation in rats without vascular anastomosis as an option for esophageal replacement surgery. MethodsFourteen total segments of esophageal transplants were harvested from 24-week-old male Sprague–Dawley rats using a harvesting procedure. The segments were transplanted through the mediastinum in the esophageal bed of 15-week-old male Sprague–Dawley rats without adjacent vascular anastomosis using the transhiatal pull-up technique. The ends of the transplanted esophagus were ostomized using cervical and abdominal esophagostomies. An immunosuppressive-treated (IT) group (n = 7) received cyclosporine and cotrimoxazole for 10 days, while an untreated (UT) group (n = 7) received only cotrimoxazole for 10 days. On post-operative day 10, the rats were sacrificed, and the transplant and recipient esophagi were evaluated macroscopically and histopathologically. ResultsAll transplantations were successful and all transplanted rats survived. Upon macroscopic evaluation, no evidence of complications was observed and all transplanted esophagi in the two groups appeared to exhibit excellent firm tissue; however, mild necrosis was observed in the cervical end of the transplant in one rat in the IT group. Histopathologic examination showed a viable esophageal structure in all rats. Inflammation and muscular atrophy were lower in the IT group than in the UT group, whereas vascularity was higher in the IT group than in the UT group. ConclusionTotal esophageal transplantation was performed directly without vascular anastomosis into recipients in a rat model. This procedure should be done in larger animal models before being attempted in humans.

Retrospective cohort study of long‐gap oesophageal atresia

Long-gap oesophageal atresia (LGOA) remains a rare variant of a relatively common congenital malformation. Objectives of this study were to review the short-term results including survival, length of stay and post-operative complications for infants with LGOA managed at a single centre in addition to their growth and neurodevelopmental assessment. Retrospective review of the case notes of all infants admitted with oesophageal atresia to our institution from January 2001 to May 2011. Infants with LGOA were selected based on pre-defined criteria. Demographic and clinical variables and details of follow-up visits including developmental assessments were extracted from their case notes. Of 101 infants with oesophageal atresia, 15 fulfilled the criteria for LGOA. Overall survival was 80%. Median length of stay was 83 days. Additional congenital anomalies were present in nine (60%). A fall in weight centile during hospitalisation or outpatient follow-up signifying growth failure was seen in a majority with 11 of 13 patients showing this phenomenon. Follow-up at our institution ranged from 6 months to 9 years. Developmental assessments (Bayley-III) commenced in August 2006 were available in four patients (age 5-13 months) and were abnormal in all, with particular delay in the gross motor domain. Infants with LGOA spend a long time in hospital. They remain at significant risk of growth failure during hospitalisation and following discharge. There appears to be a risk of developmental delay that warrants close monitoring.

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.

Long-gap esophageal atresia: traction-growth and anastomosis - before and beyond

Long-gap esophageal atresia (LGEA) is still a major surgical challenge. Options for esophageal reconstruction include the use of native esophagus or esophageal replacement with stomach, colon, or small intestine. Nonetheless, there is a consensus among most pediatric surgeons that the preservation of the native esophagus is associated with better postoperative outcomes. Thus, every effort should be made to conserve the native esophagus. The present study is aimed at critically reporting our experience focused on a standardized protocol based on the preoperative assessment of the gap in all cases and reviewing the present literature because no consensus is available regarding many aspects of LGEA (from definition to treatment). All newborn infants treated since 1995 for esophageal atresia (EA), regardless of type, were included in the present study. Identification of LGEA patients (gap ≥3 vertebral bodies) was performed based on preoperative esophageal gap measurement. The selected patients were grouped based on EA type (A/B vs. C/D) and whether they were referred from an outside institution or not. Postoperative outcome was compared. Statistical analysis was performed with the Fisher's exact test and Mann-Whitney test as appropriate, with P < 0.05 considered statistically significant. Two hundred and nineteen patients have been consecutively treated between 1995 and 2012 with the following EA subtypes: type: A 25 (11.4%); B 6 (2.7%); C 182 (83.1%); D 3 (1.4%); E 3 (1.4%). Fifty-seven patients (26%) were classified as LGEA: type A-B, 31 (54.4%); type C-D, 26 (45.6%). Twenty seven (47%) of these patients were referred after at least one failed attempt at esophageal correction: type A-B, 15 (55%); type C-D, 12 (45%). Only one patient ultimately required esophageal substitution, with an overall survival rate of 94%. A standardized perioperative protocol enhances the possibility of preserving the native esophagus in cases of LGEA. Gap measurement can be accurately defined before surgery in all patients with EA. Esophageal anastomosis (either immediate or delayed repair) is almost always feasible; esophageal substitution should only be considered after a rigorous attempt at achieving end-to-end esophageal anastomosis.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula in neonates, first decade's experience

The first thoracoscopic esophageal atresia with tracheoesophageal fistula (EATEF) repair was performed in March of 2000. This report evaluates the results and evolution of the technique in a single surgeons' experience after the first decade of thoracoscopic EATEF repair. From March 2000 to September 2012, 52 consecutive patients with type 3 EATEF, and an additional nine patients with pure esophageal atresia (EA) were repaired by or under the direct supervision of a single surgeon. Patient weight ranged from 1.2 to 3.8 kg (mean 2.6 kg). Twenty-two patients had significant associated congenital anomalies. The repairs were performed using three ports. The fistula was ligated using a single endoscopic clip, and the anastomosis was performed using a single layer of interrupted sutures. A transanastomotic tube and chest drain were left in all cases. Fifty-one of the 52 procedures were completed successfully thoracoscopically. Operative times ranged from 50 to 120 minutes (average 85 minutes). There were three clinical leaks, one in an EATEF and two in patients with long-gap pure EA, all resolved with conservative therapy. Oral feedings were started on day 5 in all other patients. Twelve of 61 patients required dilations (1-9), and 18 required a Nissen fundoplication for severe reflux. One patient required a thoracoscopic aortopexy for severe tracheomalacia. All patients are currently on full oral feedings. No patient has any evidence of chest wall asymmetry, winged scapula, or clinically significant scoliosis. There have been no recurrent fistulas. Thoracoscopic EA repair has proven to be an effective and safe technique. Initial experience resulted in a higher stricture rate, but this improved with experience and changes in technique. The results are superior to that of documented open series and avoid the morbidity of an open thoracotomy.

The Foker Technique (FT) and Kimura Advancement (KA) for the Treatment of Children with Long-Gap Esophageal Atresia (LGEA): Lessons Learned at Two European Centers

We present the experiences from two European centers performing the Foker technique (FT) of esophageal lengthening by axial traction and the Kimura advancement (KA) method of lengthening the upper pouch by extrathoracic resiting a spit fistula (SF) in children with long-gap esophageal atresia (LGEA, gap length > 5 cm). A total of 15 children were treated (8 pure EA, 6 lower tracheoesophageal fistula [TEF], and 1 upper TEF). Gaps ranged from 5 to 14 cm. Nine children already had a SF. Patients were grouped according to the presence of a SF and the subsequent surgical strategy: Group A (no SF, n = 6) received FT on both pouches. Group B (with SF, n = 6) received KA of SF and FT of the lower pouch. Group C (with SF, n = 3) received closure of the SF and subsequent Foker traction (CSFT) on both pouches. Group A: Primary repairs for all six children (mean age 3 months, gap length 6.5 cm) after a mean traction time of 3 weeks and a mean of 2.1 thoracotomies (range 2 to 3). Dilations were required in three out of six for anastomotic strictures with one perforation during the second dilation. Group B: All six children (mean age 16.4 months, gap length 9.5 cm) had a primary anastomosis, although for two it was significantly delayed (48 and 143 weeks traction time) because of infections. The number of thoracotomies ranged from 2 to 8 (mean 3.6). Leaks occurred in five out of six anastomoses (responsive to conservative management). Two children developed severe strictures, which required the anastomosis to be redone. In group C (mean age 10.6 months, gap length 6.5 cm), several major complications occurred. The three SF closures leaked (one iatrogenic) causing severe mediastinitis. CSFT was successful in only one case and the other two children had an esophageal replacement (stomach, jejunum). No deaths occurred in the series. FT of both pouches (group A) resulted in primary repairs of all six LGEA patients. The combination of KA and FT (group B) resulted in an equivalent rate of primary repairs, but with an increased number of thoracotomies and rate of complications compared with group A. CSFT (group C) resulted in a high failure rate. More data are needed (we propose a multicenter registry) to elucidate the safety and efficacy of each elongation technique and to establish an algorithm with clearer inclusion and exclusion criteria.

Modern outcomes of oesophageal atresia: Single centre experience over the last twenty years

Aim of the StudyThe aim of this study was assessment of the contemporary outcomes of oesophageal atresia (OA) in a national paediatric surgical centre. Patients and MethodsA review of the hospital records of all patients who underwent repair of oesophageal atresia (OA) in our institute between 1991 and 2011 was performed. ResultsThe study included 130 consecutive infants with OA: types A (n=4, 3%), B (n=2, 2%), C (n=110, 85%), D (n=5, 4%), and E (n=9, 7%). Median follow-up was 8.8 (range 0.1–21) years. Twenty-nine (22%) infants had cardiac and 76 (58%) other anomalies, and seventeen (13%) had a long-gap OA. The final repair was primary (n =113, 87%) or delayed (n=3) end-to-end anastomosis, oesophageal replacement (n=8) (6%) with gastric tube (n=4) or with jejunum interposition (n=4), and closure of the trachea-oesophageal fistula (Type E, n=9). Oesophageal continuity was achieved in all patients. Overall mortality was 3/130 (2%) and caused by gastric perforation (n=1), prolonged apnoeic spell (n =1), and food asphyxiation (n=1). Oral feeds were achieved in 121 (94%) children. Eight (6%) children remain dependent on feeding ostomy. Long-gap OA was a major predictor of post-repair complications. ConclusionThe modern outcome for infants with OA is characterized by an extremely low hospital mortality and satisfactory oesophageal function, enabling full oral feeds in the vast majority of children.

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.

Long-Gap Esophageal Atresia: a Meta-Analysis of Jejunal Interposition, Colon Interposition, and Gastric Pull-Up

There is still no consensus about the optimal surgical approach for esophageal replacement in the case of long-gap esophageal atresia (LGEA) or extensive corrosive strictures. The aim of this article was to perform a meta-analysis comparing the most widely used techniques for esophageal replacement in children: jejunal interposition (JI), colon interposition (CI), and gastric pull-up (GPU). Review of the English-language literature published in the past 5 years about esophageal replacement in children was done. The focus was on postoperative survival rate, morbidity (gastrointestinal complications such as anastomotic stenosis/leakage and respiratory complications such as pneumothorax, pneumonia, and atelectasis), and long-term follow-up when available. Among long-term gastrointestinal outcomes were dysphagia, reflux, and dumping; among long-term respiratory outcomes were recurrent pneumonia and recurrent aspiration leading to chronic lung disease. Data were computed by Comprehensive Meta-Analysis software (Version 2.2.064). A total of 15 studies (4 comparative retrospective, 8 retrospective, and 3 prospective) including 470 patients (264 LGEA) were identified; 344 (73%) patients underwent CI, 99 (21%) GPU, and 27 (6%) JI. Among these 15 studies, 9 provided data about long-term follow-up. Proper prospective comparative studies are lacking. GPU and CI appear comparable regarding postoperative mortality, anastomotic complications, and graft loss. On the long-term, GPU seems to be associated with a higher respiratory morbidity but fewer gastrointestinal complications than CI. Based on this article only two series provide data about JI, and they show highly divergent results. JI appears to be a valid replacement technique when performed by experienced centers; however larger numbers are needed to assess the outcomes of this procedure.

Successful two-stage thoracoscopic repair of long-gap esophageal atresia using simple internal traction and delayed primary anastomosis in a neonate: report of a case

The optimal method of treating long-gap esophageal atresia has not been established; however, the native esophagus is recognized as one of the best materials to use for bridging a long gap. Several case reports describe long-gap esophageal atresia being treated successfully via thoracotomy, by applying external traction sutures to the proximal and distal ends of the esophagus, thereby gradually elongating the esophagus prior to delayed primary anastomosis. However, this method carries a risk of infection and disruption of the esophageal ends. We devised a simple method of internal traction for esophageal elongation, which we performed as a two-step thoracoscopic procedure to treat a neonate with long-gap esophageal atresia.

Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome

Management of newborns with long-gap esophageal atresia (LGEA) remains a challenge for pediatric surgeons. Since spontaneous growth of the esophageal segments occurs without mechanical stretching, initial gastrostomy followed by delayed primary anastomosis (DPA) comprises treatment in most LGEA patients. This meta-analysis aimed to investigate the complications and long-term outcome in patients with LGEA managed by DPA. A systematic literature search was conducted for relevant articles published between 1981 and 2011, and a meta-analysis of complications and long-term outcome was performed. Forty-four articles presented data on 451 newborns with LGEA managed by DPA. Most common variants were pure LGEA (194/451) and LGEA with tracheoesophageal fistula (257/451). Initial gap lengths ranged from 1.9 to 7.0 cm. At the time of DPA, performed at a mean of 11.9 weeks (range 0.5-54.0), the gap had decreased to 0.5-3.0 cm. Mean follow-up was 5.5 years (range 0.5-27.0). Frequent complications were anastomotic leaks/strictures, gastroesophageal reflux (GER), esophagitis and dysphagia. Relative risk for strictures was significantly higher in patients who previously had a leak (p < 0.0001) or GER (p < 0.0001). Patients with GER also had a significantly higher risk for esophagitis (p = 0.0283) and dysphagia (p = 0.0174). The majority of patients could eat without swallowing difficulties at follow-up. DPA provides good long-term functional results. However, the high incidence of GER and associated strictures requires early intervention to prevent feeding problems.

A modified Foker’s technique for long gap esophageal atresia

External traction using the Foker's technique enables elongation in the esophageal segments within days, and allows the primary repair of the long gap. This article presents our modified Foker's technique which was easily applicable for long-gap esophageal atresia.