Thoracoscopic traction technique in long gap esophageal atresia: entering a new era

Abstract

Objective: To describe the evolution from delayed management of long gap esophageal atresia to thoracoscopic treatment directly after birth without the placement of a gastrostomy.

Background: Long gap esophageal atresia remains a challenge for pediatric surgeons. Over the years, several techniques have been described to deal with the problem of the distance between the proximal and distal esophagus. More recently, a traction technique has been advocated. With the advent of minimal invasive surgery, the thoracoscopic elongation technique has been developed.

Methods: Retrospective description of a single-center experience with the thoracoscopic treatment of patients with long gap esophageal atresia over a 7-year period.

Results: Between 2007 and May 2014, 10 children with long gap esophageal atresia were treated by thoracoscopic elongation technique. In two children, the procedure failed. Eight children successfully underwent thoracoscopic traction with delayed primary anastomosis. Initially, all patients had a gastrostomy. During the course, the technique evolved into delayed primary anastomosis directly after birth without the use of a gastrostomy.

Conclusion: Thoracoscopic elongation technique in long gap esophageal atresia not only is feasible, but can nowadays also be performed directly after birth without the use of a gastrostomy. With this development, we have entered a new era in the management of long gap esophageal atresia.

Keywords: Esophageal atresia; Long gap; Thoracoscopy; Traction technique.

Fig. 1

Mobilization of proximal esophagus. O = proximal esophagus, V = trachea with onlying vagal nerve

Fig. 2

Mobilization of distal esophagus out of hiatus. O = distal esophagus coming through the esophageal hiatus, A = aorta

Fig. 3

Traction sutures with a clip close to the esophageal pouches

Fig. 4

Diagram of traction technique. A Distance at start of traction. B Elongation of the two pouches over the days of traction

Fig. 5

X-thorax after application of traction sutures. There is still a distance of 17.3 mm

Fig. 6

X-thorax after 5 days. The clips of the proximal and distal pouch have reached each other (arrow)

Fig. 7

Advancing nasogastric tube after anastomosis of posterior wall. p = proximal esophagus, d = distal esophagus, c = feeding tube