quiz pure esophageal atresia

[Ahmed Nabil]

A newborn infant presents with pure esophageal atresia. A gastrostomy is performed and a contrast study reveals a five vertebral body distance between the proximal and distal esophageal pouches.

Which of the following approaches will result in the shortest time to definitive anastomosis for patients with long gap esophageal atresia?

A delayed primary repair

B the application of traction sutures (Foker technique)

C gastric pull up

D colon interposition

E serial extrathoracic proximal esophageal advancement (Kimura technique)

[Admin]

b

correct

The multiple different strategies that exist for the management of long gap esophageal atresia attest to the difficulty of treating these children. Since the esophagus will eventually elongate spontaneously, gastrostomy with delayed primary anastomosis has historically been the most common management approach. This process can take several months and frequently results in oral aversion.

Myotomies of the esophageal wall (spiral or serial) can be used to lengthen the esophagus but offer limited additional length and can result in full thickness injury and subsequent diverticula.

Foker described a technique employing sutures to apply traction to both ends of the esophagus stimulating longitudinal growth. The author’s series report near uniform success at salvaging the native esophagus with a lower risk of complications and shorter time to anastomosis. These results have been difficult to widely reproduce. Modifications of the technique (e.g. multiple sutures, use of prosthetic tunnels, manometry monitoring of suture tension) have addressed the potential complications (e.g. suture disruption, pouch entrapment, need for repeat thoracotomy) and subjective variability of the procedure.

Alternatively, Kimura described lengthening by serial mobilization and advancement of an upper pouch spit fistula. Series describe good results at the cost of a prolonged course and multiple operations.

Esophageal replacement with a gastric pull up (i.e. transposition), gastric tube, colonic or jejunal interposition have been employed in complicated patients or when the distal esophagus is absent. Long term follow-up studies indicate that most patients rate their functional results at fair or better. Colonic interposition, in particular, seems to have a high incidence of long term complications. These procedures are not currently routinely performed in newborns. In this patient with pure esophageal atresia the small size of the stomach would not likely allow a primary gastric pull up in the neonatal period.

Regardless of the approach used higher rates of anastomotic leak, stricture, malnutrition and significant gastroesophageal reflux should be anticipated.

[Gunduz Aghayev]

d

[Admin]

think again my dear

[Gunduz Aghayev]

May be I didn't understand question properly. Esophageal substitution recommended after 1 year, when child can had upright position. Delayed primary repair and Foker technique in case of 5 vertebral body esophageal gap - i don't think this is possible. Kimura multistage elongation took 5 month in my patient. Gastric pull up can be done early.

[Sharon]

b

[Admin]

b

correct

The multiple different strategies that exist for the management of long gap esophageal atresia attest to the difficulty of treating these children. Since the esophagus will eventually elongate spontaneously, gastrostomy with delayed primary anastomosis has historically been the most common management approach. This process can take several months and frequently results in oral aversion.

Myotomies of the esophageal wall (spiral or serial) can be used to lengthen the esophagus but offer limited additional length and can result in full thickness injury and subsequent diverticula.

Foker described a technique employing sutures to apply traction to both ends of the esophagus stimulating longitudinal growth. The author’s series report near uniform success at salvaging the native esophagus with a lower risk of complications and shorter time to anastomosis. These results have been difficult to widely reproduce. Modifications of the technique (e.g. multiple sutures, use of prosthetic tunnels, manometry monitoring of suture tension) have addressed the potential complications (e.g. suture disruption, pouch entrapment, need for repeat thoracotomy) and subjective variability of the procedure.

Alternatively, Kimura described lengthening by serial mobilization and advancement of an upper pouch spit fistula. Series describe good results at the cost of a prolonged course and multiple operations.

Esophageal replacement with a gastric pull up (i.e. transposition), gastric tube, colonic or jejunal interposition have been employed in complicated patients or when the distal esophagus is absent. Long term follow-up studies indicate that most patients rate their functional results at fair or better. Colonic interposition, in particular, seems to have a high incidence of long term complications. These procedures are not currently routinely performed in newborns. In this patient with pure esophageal atresia the small size of the stomach would not likely allow a primary gastric pull up in the neonatal period.

Regardless of the approach used higher rates of anastomotic leak, stricture, malnutrition and significant gastroesophageal reflux should be anticipated.

[Ibtahim]

B