Wide-gap esophageal atresia

Simple Technique of Bridging Wide Gap in Esophageal Atresia with Tracheoesophageal Fistula - "Surgical Innovation"

The survival of the patients with esophageal atresia an tracheo esophageal fistula is believed to be an epitome of the success of the neonatal surgery. Restoring the continuty of the food pipe by esophagus to esophagus anastomosis is the best option. Preservation of natural esophagus by delayed repair in a wide gap esophageal atresia is a preferred technique worldwide, however such a management required prolonged hospitalization and dedicated nursing care, which is often not available in most of the centres in India. Esophageal substitutes in wide gap requires multiple operations and have long term problems, so remains the last option. I use the technique of oblique anastomosis which had distrinct advantage over circular anastomosis in the management of esophageal atresia1. This techniqe helps in bridging wide gap to some extent & minimal stricture formation.

"Thoracic gastrostomy"--a new technique for feeding gastrostomy in wide-gap esophageal atresia and tracheo-esophageal fistula

INTRODUCTION

Initial management of wide-gap esophageal atresia and tracheo-esophageal fistula, especially in developing countries, often involves ligation of the fistula, proximal esophagostomy and a gastrostomy. The conventional gastrostomy requires an abdominal incision and has several complications. The authors present an alternative technique of 'gastrostomy' that does not require an abdominal incision.

METHOD

Through a standard right thoracotomy, the fistula is divided and tracheal end closed. If primary anastomosis is not possible due to wide gap, the lower esophageal pouch is mobilised and brought out as a stoma on the left posterior chest wall, lateral to the paraspinal muscles in the 7th or 8th intercostal space. A feeding tube is passed through the stoma into the stomach. The thorax is closed with a drain. Proximal esophagostomy is performed in the neck. The thoracic stoma is intermittently intubated for feeding until the child is ready for gastric transposition.

RESULTS

The technique was successfully used in 5 patients. Feeding through the stoma could be established in 4. One patient had stomal retraction and died of resultant sepsis. One patient has subsequently undergone gastric transposition and one more is waiting for it. Two patients died of unrelated causes before esophageal replacement could be carried out.

DISCUSSION

This is an alternative technique for feeding 'gastrostomy'. We have named the procedure as "Thoracic Gastrostomy" because the stoma is located on the chest but functions as a gastrostomy. The advantages include avoidance of a laparotomy and its complications, easy feeding by intermittent intubation, and availability of a virgin stomach for future gastric transposition.