Download PDF
Eur J Pediatr Surg 2013; 23(03): 191-197
DOI: 10.1055/s-0033-1347916
Review
Georg Thieme Verlag KG Stuttgart · New York

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

Ahmed Nasr
1   Department of Surgery, University of Ottawa, and Division of Pediatric Surgery, Children's Hospital of Eastern Ontario, Ottawa, Ontario, Canada
,
Jacob C. Langer
2   Division of General and Thoracic Surgery, Department of Surgery, Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
› Author Affiliations
Further Information

Publication History

25 April 2013

25 April 2013

Publication Date:
29 May 2013 (online)

    Permissions and Reprints

Abstract

Background 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.

Methods 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.

Results 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.

Conclusions 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.

Keywords

esophageal atresia - mechanical traction - critical appraisal
 

  • References

  • 1 Manning PB. Long-gap esophageal atresia. Semin Thorac Cardiovasc Surg 1994; 6 (4) 216-220
    PubMedGoogle Scholar
  • 2 Lindahl H, Rintala R, Louhimo I. Oesophageal anastomosis without bougienage in isolated atresia—do the segments really grow while waiting?. Z Kinderchir 1987; 42 (4) 221-223
    PubMedGoogle Scholar
  • 3 Lafer DJ, Boley SJ. Primary repair in esophageal atresia with elongation of the lower segment. J Pediatr Surg 1966; 1 (6) 585-587
    CrossrefPubMedGoogle Scholar
  • 4 Rehbein F, Schweder N. Reconstruction of the esophagus without colon transplantation in cases of atresia. J Pediatr Surg 1971; 6 (6) 746-752
    CrossrefPubMedGoogle Scholar
  • 5 Shafer AD, David TE. Suture fistula as a means of connecting upper and lower segments in esophageal atresia. J Pediatr Surg 1974; 9 (5) 669-673
    CrossrefPubMedGoogle Scholar
  • 6 de Jong EM, de Haan MA, Gischler SJ , et al. Pre- and postnatal diagnosis and outcome of fetuses and neonates with esophageal atresia and tracheoesophageal fistula. Prenat Diagn 2010; 30 (3) 274-279
    CrossrefPubMedGoogle Scholar
  • 7 Houben CH, Curry JI. Current status of prenatal diagnosis, operative management and outcome of esophageal atresia/tracheo-esophageal fistula. Prenat Diagn 2008; 28 (7) 667-675
    CrossrefPubMedGoogle Scholar
  • 8 Sparey C, Jawaheer G, Barrett AM, Robson SC. Esophageal atresia in the Northern Region Congenital Anomaly Survey, 1985-1997: prenatal diagnosis and outcome. Am J Obstet Gynecol 2000; 182 (2) 427-431
    CrossrefPubMedGoogle Scholar
  • 9 Brantberg A, Blaas HG, Haugen SE, Eik-Nes SH. Esophageal obstruction-prenatal detection rate and outcome. Ultrasound Obstet Gynecol 2007; 30 (2) 180-187
    CrossrefPubMedGoogle Scholar
  • 10 Stringel G, Lawrence C, McBride W. Repair of long gap esophageal atresia without anastomosis. J Pediatr Surg 2010; 45 (5) 872-875
    CrossrefPubMedGoogle Scholar
  • 11 Holland AJ, Ron O, Pierro A , et al. Surgical outcomes of esophageal atresia without fistula for 24 years at a single institution. J Pediatr Surg 2009; 44 (10) 1928-1932
    CrossrefPubMedGoogle Scholar
  • 12 Cowles RA, Coran AG. Gastric transposition in infants and children. Pediatr Surg Int 2010; 26 (12) 1129-1134
    CrossrefPubMedGoogle Scholar
  • 13 Myers NA, Beasly SW, Auldist AW , et al. Oesophageal atresia without fistula-anastomosis or replacement. Pediatr Surg Int 1987; 1987 (2) 216-222
    PubMedGoogle Scholar
  • 14 Spitz L, Ruangtrakool R. Esophageal substitution. Semin Pediatr Surg 1998; 7 (2) 130-133
    CrossrefPubMedGoogle Scholar
  • 15 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
    CrossrefPubMedGoogle Scholar
  • 16 Hands LJ, Dudley NE. A comparison between gap-length and Waterston classification as guides to mortality and morbidity after surgery for esophageal atresia. J Pediatr Surg 1986; 21 (5) 404-406
    CrossrefPubMedGoogle Scholar
  • 17 Brown AK, Tam PKH. Measurement of gap length in esophageal atresia: a simple predictor of outcome. J Am Coll Surg 1996; 182 (1) 41-45
    PubMedGoogle Scholar
  • 18 Dessanti A, Caccia G, Iannuccelli M, Dettori G. Use of “Gore-Tex surgical membrane” to minimize surgical adhesions in multistaged extrathoracic esophageal elongation for esophageal atresia. J Pediatr Surg 2000; 35 (4) 610-612
    CrossrefPubMedGoogle Scholar
  • 19 Holder TM, Ashcraft KW, Sharp RJ, Amoury RA. Care of infants with esophageal atresia, tracheoesophageal fistula, and associated anomalies. J Thorac Cardiovasc Surg 1987; 94 (6) 828-835
    PubMedGoogle Scholar
  • 20 Engum SA, Grosfeld JL, West KW, Rescorla FJ, Scherer III LR. Analysis of morbidity and mortality in 227 cases of esophageal atresia and/or tracheoesophageal fistula over two decades. Arch Surg 1995; 130 (5) 502-508 , discussion 508–509
    CrossrefPubMedGoogle Scholar
  • 21 Louhimo I, Lindahl H. Esophageal atresia: primary results of 500 consecutively treated patients. J Pediatr Surg 1983; 18 (3) 217-229
    CrossrefPubMedGoogle Scholar
  • 22 Ein SH, Shandling B, Heiss K. Pure esophageal atresia: outlook in the 1990s. J Pediatr Surg 1993; 28 (9) 1147-1150
    CrossrefPubMedGoogle Scholar
  • 23 Stone MM, Fonkalsrud EW, Mahour GH, Weitzman JJ, Takiff H. Esophageal replacement with colon interposition in children. Ann Surg 1986; 203 (4) 346-351
    CrossrefPubMedGoogle Scholar
  • 24 West KW, Vane DW, Grosfeld JL. Esophageal replacement in children: experience with thirty-one cases. Surgery 1986; 100 (4) 751-757
    PubMedGoogle Scholar
  • 25 Ahmed A, Spitz L. The outcome of colonic replacement of the esophagus in children. Prog Pediatr Surg 1986; 19: 37-54
    PubMedGoogle Scholar
  • 26 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
    CrossrefPubMedGoogle Scholar
  • 27 Lai JY, Sheu JC, Chang PY, Yeh ML, Chang CY, Chen CC. Experience with distal circular myotomy for long-gap esophageal atresia. J Pediatr Surg 1996; 31 (11) 1503-1508
    CrossrefPubMedGoogle Scholar
  • 28 Ricketts RR, Luck SR, Raffensperger JG. Circular esophagomyotomy for primary repair of long-gap esophageal atresia. J Pediatr Surg 1981; 16 (3) 365-369
    CrossrefPubMedGoogle Scholar
  • 29 Kimura K, Nishijima E, Tsugawa C , et al. Multistaged extrathoracic esophageal elongation procedure for long gap esophageal atresia: Experience with 12 patients. J Pediatr Surg 2001; 36 (11) 1725-1727
    CrossrefPubMedGoogle Scholar
  • 30 Puri P, Blake N, O'Donnell B, Guiney EJ. Delayed primary anastomosis following spontaneous growth of esophageal segments in esophageal atresia. J Pediatr Surg 1981; 16 (2) 180-183
    CrossrefPubMedGoogle Scholar
  • 31 Hikida S, Tanaka Y, Tsuru T , et al. The elongation of distal esophageal pouch by mechanical bougienage for a year resulted in a tension-free anastomosis in a patient with long gap esophageal atresia: a case report. Kurume Med J 2003; 50 (3-4) 139-142
    CrossrefPubMedGoogle Scholar
  • 32 Bensoussan AL, Letourneau JN, Blanchard H. [Cure of esophageal atresia types 1 and 2. Deferred primary anastomosis. Apropos of 6 cases]. Chir Pediatr 1983; 24 (2) 109-112
    PubMedGoogle Scholar
  • 33 Ilizarov GA, Deviatov AA. [Surgical lengthening of the shin with simultaneous correction of deformities]. Ortop Travmatol Protez 1969; 30 (3) 32-37
    PubMedGoogle Scholar
  • 34 Harrison MR, Gonzales KD, Bratton BJ , et al. Magnetic mini-mover procedure for pectus excavatum III: safety and efficacy in a Food and Drug Administration-sponsored clinical trial. J Pediatr Surg 2012; 47 (1) 154-159
    CrossrefPubMedGoogle Scholar
  • 35 Tovar JA, Fragoso AC. Current controversies in the surgical treatment of esophageal atresia. Scand J Surg 2011; 100 (4) 273-278
    CrossrefPubMedGoogle Scholar
  • 36 Al-Qahtani AR, Yazbeck S, Rosen NG, Youssef S, Mayer SK. Lengthening technique for long gap esophageal atresia and early anastomosis. J Pediatr Surg 2003; 38 (5) 737-739
    CrossrefPubMedGoogle Scholar
  • 37 Till H, Muensterer OJ, Rolle U, Foker J. Staged esophageal lengthening with internal and subsequent external traction sutures leads to primary repair of an ultralong gap esophageal atresia with upper pouch tracheoesophagel fistula. J Pediatr Surg 2008; 43 (6) E33-E35
    PubMedGoogle Scholar
  • 38 Skarsgard ED. Dynamic esophageal lengthening for long gap esophageal atresia: experience with two cases. J Pediatr Surg 2004; 39 (11) 1712-1714
    CrossrefPubMedGoogle Scholar
  • 39 Hadidi AT, Hosie S, Waag KL. Long gap esophageal atresia: lengthening technique and primary anastomosis. J Pediatr Surg 2007; 42 (10) 1659-1662
    CrossrefPubMedGoogle Scholar
  • 40 Lopes MF, Reis A, Coutinho S, Pires A. Very long gap esophageal atresia successfully treated by esophageal lengthening using external traction sutures. J Pediatr Surg 2004; 39 (8) 1286-1287
    CrossrefPubMedGoogle Scholar
  • 41 Kunisaki SM, Foker JE. Surgical advances in the fetus and neonate: esophageal atresia. Clin Perinatol 2012; 39 (2) 349-361
    CrossrefPubMedGoogle Scholar
  • 42 Puri P, Blake N, O'Donnell B, Guiney EJ. Delayed primary anastomosis following spontaneous growth of esophageal segments in esophageal atresia. J Pediatr Surg 1981; 16 (2) 180-183
    CrossrefPubMedGoogle Scholar
  • 43 Puri P, Ninan GK, Blake NS, Fitzgerald RJ, Guiney EJ, O'Donnell B. Delayed primary anastomosis for esophageal atresia: 18 months' to 11 years' follow-up. J Pediatr Surg 1992; 27 (8) 1127-1130
    CrossrefPubMedGoogle Scholar
  • 44 Aziz D, Schiller D, Gerstle JT, Ein SH, Langer JC. Can ‘long-gap’ esophageal atresia be safely managed at home while awaiting anastomosis?. J Pediatr Surg 2003; 38 (5) 705-708
    CrossrefPubMedGoogle Scholar
  • 45 Bagolan P, Iacobelli Bd Bd, De Angelis P , et al. Long gap esophageal atresia and esophageal replacement: moving toward a separation?. J Pediatr Surg 2004; 39 (7) 1084-1090
    CrossrefPubMedGoogle Scholar
  • 46 Yeh SH, Ni YH, Hsu WM, Chen HL, Wu JF, Chang MH. Use of retrograde esophagoscopy in delayed primary esophageal anastomosis for isolated esophageal atresia. Eur J Pediatr Surg 2010; 20 (1) 40-44
    Article in Thieme ConnectPubMedGoogle Scholar
  • 47 Sri Paran T, Decaluwe D, Corbally M, Puri P. Long-term results of delayed primary anastomosis for pure oesophageal atresia: a 27-year follow up. Pediatr Surg Int 2007; 23 (7) 647-651
    CrossrefPubMedGoogle Scholar
  • 48 Buonuomo V, Nanni L, Canali R, Pintus C. [Esophageal atresia. Personal experience and review of the literature]. Ann Ital Chir 2007; 78 (5) 385-388
    PubMedGoogle Scholar
  • 49 Burjonrappa S, Thiboutot E, Castilloux J, St-Vil D. Type A esophageal atresia: a critical review of management strategies at a single center. J Pediatr Surg 2010; 45 (5) 865-871
    CrossrefPubMedGoogle Scholar
  • 50 De la Hunt MN, Fleet MS, Wagget J. Delayed primary anastomosis for wide-defect esophageal atresia: a 17-year experience. Pediatr Surg Int 1994; 9 (1) 21-23
    PubMedGoogle Scholar
  • 51 Gurskas P, Ivanauskas A. [Delayed primary anastomosis for esophageal atresia]. Medicina (Kaunas) 2004; 40 (Suppl. 01) 166-169
    PubMedGoogle Scholar
  • 52 Healey PJ, Sawin RS, Hall DG, Schaller RT, Tapper D. Delayed primary repair of esophageal atresia with tracheoesophageal fistula: is it worth the wait?. Arch Surg 1998; 133 (5) 552-556
    CrossrefPubMedGoogle Scholar
  • 53 Hicks LM, Mansfield PB. Esophageal atresia and tracheoesophageal fistula. Review of thirteen years' experience. J Thorac Cardiovasc Surg 1981; 81 (3) 358-363
    PubMedGoogle Scholar
  • 54 Hight DW, McGowan G, Smith J, Kent G, Alexander F. Atresia of the esophagus. New trends in the management of high-risk neonates. Arch Surg 1987; 122 (4) 421-423
    CrossrefPubMedGoogle Scholar
  • 55 Rescorla FJ, West KW, Scherer III LR, Grosfeld JL. The complex nature of type A (long-gap) esophageal atresia. Surgery 1994; 116 (4) 658-664
    PubMedGoogle Scholar
  • 56 Ruiz de Temiño M, Esteban JA, Elías J , et al. [Esophageal atresia type I. Is impossible possible?]. Cir Pediatr 2006; 19 (1) 39-45
    PubMedGoogle Scholar
  • 57 Caffarena PE, Mattioli G, Bisio G, Martucciello G, Ivani G, Jasonni V. Long-gap oesophageal atresia: a combined endoscopic and radiologic evaluation. Eur J Pediatr Surg 1994; 4 (2) 67-69
    Article in Thieme ConnectPubMedGoogle Scholar
  • 58 Golonka NR, Hayashi AH. Early ‘‘sham’' feeding of neonates promotes oral feeding after delayed primary repair of major congenital esophageal anomalies. Am J Surg 2008; 195 (5) 659-662 , discussion 662
    Google Scholar
  • 59 Lindahl H, Rintala R, Louhimo I. Oesophageal anastomosis without bougienage in isolated atresia—do the segments really grow while waiting?. Z Kinderchir 1987; 42 (4) 221-223
    PubMedGoogle Scholar
  • 60 Santos AD, Thompson TR, Johnson DE, Foker JE. Correction of esophageal atresia with distal tracheoesophageal fistula. J Thorac Cardiovasc Surg 1983; 85 (2) 229-236
    PubMedGoogle Scholar
  • 61 Séguier-Lipszyc E, Bonnard A, Aizenfisz S , et al. The management of long gap esophageal atresia. J Pediatr Surg 2005; 40 (10) 1542-1546
    CrossrefPubMedGoogle Scholar
  • 62 Ito T, Sugito T, Nagaya M. Delayed primary anastomosis in poor-risk patients with esophageal atresia associated with tracheoesophageal fistula. J Pediatr Surg 1984; 19 (3) 243-247
    CrossrefPubMedGoogle Scholar
  • 63 Wise Jr WE, Caniano DA, Harmel Jr RP. Tracheoesophageal anomalies in Waterston C neonates: a 30-year perspective. J Pediatr Surg 1987; 22 (6) 526-529
    CrossrefPubMedGoogle Scholar
  • 64 Cavallaro S, Pineschi A, Freni G, Cortese MG, Bardini T. Feeding troubles following delayed primary repair of esophageal atresia. Eur J Pediatr Surg 1992; 2 (2) 73-77
    Article in Thieme ConnectPubMedGoogle Scholar
  • 65 Sillén U, Hagberg S, Rubenson A, Werkmäster K. Management of esophageal atresia: review of 16 years' experience. J Pediatr Surg 1988; 23 (9) 805-809
    CrossrefPubMedGoogle Scholar
  • 66 Randolph JG, Newman KD, Anderson KD. Current results in repair of esophageal atresia with tracheoesophageal fistula using physiologic status as a guide to therapy. Ann Surg 1989; 209 (5) 526-530 , discussion 530–531
    CrossrefPubMedGoogle Scholar
  • 67 Festen C, Rieu PN, van der Staak FH, Severijnen RS. Long-gap esophageal atresia: experience with reconstruction in 25 patients. Eur J Pediatr Surg 1991; 1 (3) 139-141
    Article in Thieme ConnectPubMedGoogle Scholar
  • 68 Schaarschmidt K, Willital GH, Jorch G, Kerremanns J. Delayed primary reconstruction of an esophageal atresia with distal esophagotracheal fistula in an infant weighing less than 500 g. J Pediatr Surg 1992; 27 (12) 1529-1531
    CrossrefPubMedGoogle Scholar
  • 69 Alexander F, Johanningman J, Martin LW. Staged repair improves outcome of high-risk premature infants with esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 1993; 28 (2) 151-154
    CrossrefPubMedGoogle Scholar
  • 70 Boyle Jr EM, Irwin ED, Foker JE. Primary repair of ultra-long-gap esophageal atresia: results without a lengthening procedure. Ann Thorac Surg 1994; 57 (3) 576-579
    CrossrefPubMedGoogle Scholar
  • 71 Ein SH, Shandling B. Pure esophageal atresia: a 50-year review. J Pediatr Surg 1994; 29 (9) 1208-1211
    CrossrefPubMedGoogle Scholar
  • 72 Engum SA, Grosfeld JL, West KW, Rescorla FJ, Scherer III LR. Analysis of morbidity and mortality in 227 cases of esophageal atresia and/or tracheoesophageal fistula over two decades. Arch Surg 1995; 130 (5) 502-508 , discussion 508–509
    CrossrefPubMedGoogle Scholar
  • 73 Festen C. Oesophageal atresia: methods of reconstruction in cases of a “long gap”. Z Kinderchir 1981; 32 (4) 295-300
    PubMedGoogle Scholar
  • 74 Tsai JY, Berkery L, Wesson DE, Redo SF, Spigland NA. Esophageal atresia and tracheoesophageal fistula: surgical experience over two decades. Ann Thorac Surg 1997; 64 (3) 778-783 , discussion 783–784
    CrossrefPubMedGoogle Scholar
  • 75 Lessin MS, Wesselhoeft CW, Luks FI, DeLuca FG. Primary repair of long-gap esophageal atresia by mobilization of the distal esophagus. Eur J Pediatr Surg 1999; 9 (6) 369-372
    Article in Thieme ConnectPubMedGoogle Scholar
  • 76 Chahine AA, Ricketts RR. Esophageal atresia in infants with very low birth weight. Semin Pediatr Surg 2000; 9 (2) 73-78
    PubMedGoogle Scholar