A single centre experience using internal traction sutures in managing long gap oesophageal atresia

Abstract

Aim: Thoracoscopically placed internal traction sutures (ITS) for the initial management of long gap oesophageal atresia (LGOA), not amenable to primary anastomosis, was first described in 2015. Here we describe our experience using ITS both thoracoscopically and at thoracotomy where the gap between upper and lower oesophagus is too wide for primary anastomosis.

Method: The case notes of all infants treated with ITS for oesophageal atresia (01/10/2015 to 01/12/2019) were reviewed. Gaps considered too wide for an anastomosis had ITS placed between the two pouches as described by Patkowski in 2015. All patients were gastrostomy fed. Patients returned to theatre with an expectation to complete the anastomosis or re-tighten the traction sutures.

Results: Seven patients (4 OA, 1 OA with proximal fistula, 2 OA/distal TOF) median birthweight 2.28 kg (1.2-3.6 kg) were managed using ITS. Median gap length 4.5 (3-9) vertebral bodies. ITS were placed thoracoscopically in 5 cases and at thoracotomy in 2 at median 46 days (1-120) old. In all cases, ITS was associated with significant intra-thoracic adhesions. Five patients leaked from the traction sutures. Four patients had a delayed primary anastomosis performed at thoracotomy and 3 required a cervical oesophagostomy. The median length of stay was 159 days (98-282). All patients started thoracoscopically eventually required thoracotomy.

Conclusion: The use of ITS in our department was associated with significant complications, particularly intra-thoracic leaks and adhesions. In our hands ITS did not improve the feasibility of thoracoscopic repair for LGOA and has been abandoned by us.

Level of evidence: Level IV Case Series.

Keywords: Minimally invasive surgery; Neonates; Oesophageal atresia; Thoracoscopy; Tracheo-oesophageal fistula.