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

Mariusz Sroka; Robin Wachowiak; Marcin Losin; Agnieszka Szlagatys-Sidorkiewicz; Piotr Landowski; Piotr Czauderna; John Foker; Holger Till

doi:10.1055/s-0033-1333891

European Journal of Pediatric Surgery, Table of Contents

Eur J Pediatr Surg 2013; 23(01): 003-007
DOI: 10.1055/s-0033-1333891

Original Article

Georg Thieme Verlag KG Stuttgart · New York

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

Mariusz Sroka

¹Department of Surgery and Urology for Children and Adolescents, Medical University of Gdansk, Gdansk, Poland

,

Robin Wachowiak

²Department of Paediatric Surgery, University of Leipzig, Leipzig, Germany

,

Marcin Losin

¹Department of Surgery and Urology for Children and Adolescents, Medical University of Gdansk, Gdansk, Poland

,

Agnieszka Szlagatys-Sidorkiewicz

³Department of Paediatrics, Gastroenterology, Hepatology, Medical University of Gdansk, Gdansk, Poland

,

Piotr Landowski

³Department of Paediatrics, Gastroenterology, Hepatology, Medical University of Gdansk, Gdansk, Poland

,

Piotr Czauderna

¹Department of Surgery and Urology for Children and Adolescents, Medical University of Gdansk, Gdansk, Poland

,

John Foker

⁴Department of Surgery, University of Minnesota Medical School, Minneapolis, Minnesota, United States

,

Holger Till

²Department of Paediatric Surgery, University of Leipzig, Leipzig, Germany

⁵Department of Paediatric and Adolescent Surgery, University of Graz, Graz, Austria

› Author Affiliations

Abstract

Introduction 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).

Materials and Methods 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.

Results 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.

Conclusion 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.

Keywords

long gap - esophageal atresia - Foker - Kimura - multicenter

Full Text

References

References
1 Tovar JA, Fragoso AC. Current controversies in the surgical treatment of esophageal atresia. Scand J Surg 2011; 100 (4) 273-278
2 Friedmacher F, Puri P. Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome. Pediatr Surg Int 2012; 28 (9) 899-906
3 Foker JE, Linden BC, Boyle Jr EM, Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg 1997; 226 (4) 533-541 , discussion 541–543
4 Foker JE, Linden BC, Boyle Jr EM, Marquardt C. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg 1997; 226 (4) 533-541 , discussion 541–543
5 Foker JE, Kendall TC, Catton K, Khan KM. A flexible approach to achieve a true primary repair for all infants with esophageal atresia. Semin Pediatr Surg 2005; 14 (1) 8-15
6 Paya K, Schlaff N, Pollak A. Isolated ultra-long gap esophageal atresia—successful use of the Foker technique. Eur J Pediatr Surg 2007; 17 (4) 278-281
7 Foker JE, Kendall Krosch TC, Catton K, Munro F, Khan KM. Long-gap esophageal atresia treated by growth induction: the biological potential and early follow-up results. Semin Pediatr Surg 2009; 18 (1) 23-29
8 Till H, Rolle U, Siekmeyer W, Hirsch W, Foker J. Combination of spit fistula advancement and external traction for primary repair of long-gap esophageal atresia. Ann Thorac Surg 2008; 86 (6) 1969-1971