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Izadi S, Smithers J, Shieh HF, Demehri FR, Mohammed S, Hamilton TE, Zendejas B. The History and Legacy of the Foker Process for the Treatment of Long Gap Esophageal Atresia. J Pediatr Surg 2024; 59:1222-1227. [PMID: 38184432 DOI: 10.1016/j.jpedsurg.2023.12.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 12/13/2023] [Accepted: 12/17/2023] [Indexed: 01/08/2024]
Abstract
Historically, children afflicted with long gap esophageal atresia (LGEA) had few options, either esophageal replacement or a life of gastrostomy feeds. In 1997, John Foker from Minnesota revolutionized the treatment of LGEA. His new procedure focused on "traction-induced growth" when the proximal and distal esophageal segments were too far apart for primary repair. Foker's approach involved placement of pledgeted sutures on both esophageal pouches connected to an externalized traction system which could be serially tightened, allowing for tension-induced esophageal growth and a delayed primary repair. Despite its potential, the Foker process was received with criticism and disbelief, and to this day, controversy remains regarding its mechanism of action - esophageal growth versus stretch. Nonetheless, early adopters such as Rusty Jennings of Boston embraced Foker's central principle that "one's own esophagus is best" and was instrumental to the implementation and rise in popularity of the Foker process. The downstream effects of this emphasis on esophageal preservation would uncover the need for a focused yet multidisciplinary approach to the many challenges that EA children face beyond "just the esophagus", leading to the first Esophageal and Airway Treatment Center for children. Consequently, the development of new techniques for the multidimensional care of the LGEA child evolved such as the posterior tracheopexy for associated tracheomalacia, the supercharged jejunal interposition, as well as minimally invasive internalized esophageal traction systems. We recognize the work of Foker and Jennings as key catalysts of an era of esophageal preservation and multidisciplinary care of children with EA.
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Affiliation(s)
- Shawn Izadi
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Jason Smithers
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Hester F Shieh
- Department of Surgery, Johns Hopkins All Children's Hospital, St. Petersburg, FL, USA
| | - Farokh R Demehri
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Somala Mohammed
- Department of Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Thomas E Hamilton
- Division of General, Thoracic and Fetal Surgery, The Children's Hospital of Philadelphia, Philadelphia, PA, USA
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Reddy S, Jester I, Soccorso G, Pachl M, Gavens E, Patel H, Arul GS. Thoracoscopic external traction suture elongation for the management of long-gap oesophageal atresia: a two-centre experience. Pediatr Surg Int 2024; 40:135. [PMID: 38767779 DOI: 10.1007/s00383-024-05707-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/21/2024] [Indexed: 05/22/2024]
Abstract
AIM Van der Zee (VdZ) described a technique to elongate the oesophagus in long-gap oesophageal atresia (LGOA) by thoracoscopic placement of external traction sutures (TPETS). Here, we describe our experience of using this technique. METHOD Retrospective review of all LGOA + / - distal tracheo-oesophageal fistula (dTOF) cases where TPETS was used in our institutions. Data are given as medians (IQR). RESULTS From 01/05/2019 to 01/03/2023, ten LGOA patients were treated by the VdZ technique. Five had oesophageal atresia (Gross type A or B, Group 1) and five had OA with a dTOF (type C, Group 2) but with a long gap precluding primary anastomosis. Age of first traction procedure was Group 1 = 53 (29-55) days and Group 2 = 3 (1-49) days. Median number of traction procedures = 3; time between first procedure and final anastomosis was 6 days (4-7). Four cases were converted to thoracotomy at the third procedure. Three had anastomotic leaks managed conservatively. Follow-up was 12-52 months. All patients achieved oesophageal continuity and were orally fed; no patient required an oesophagostomy. CONCLUSION In this series, TPETS in LGOA facilitated delayed primary anastomoses and replicated the good results previously described but, in addition, was successful in cases with dTOF. We believe traction suture placement and tensioning benefit from being performed thoracoscopically because of excellent visualisation and the fact that the tension does not change when the chest is closed. Surgical and anaesthetic planning and expertise are crucial. It is now our management of choice in OA patients with a long gap with or without a distal TOF.
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Affiliation(s)
- Snigdha Reddy
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - Ingo Jester
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Max Pachl
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | | | - Hetal Patel
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK
| | - G Suren Arul
- Birmingham Women's and Children's NHS Foundation Trust, Birmingham, UK.
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Borselle D, Davidson J, Loukogeorgakis S, De Coppi P, Patkowski D. Thoracoscopic Stage Internal Traction Repair Reduces Time to Achieve Esophageal Continuity in Long Gap Esophageal Atresia. Eur J Pediatr Surg 2024; 34:36-43. [PMID: 38154482 DOI: 10.1055/a-2235-8766] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2023]
Abstract
OBJECTIVE Management of long gap esophageal atresia (LGOA) is controversial. This study aims at comparing the management of LGOA between two high-volume centers. METHODS We included patients with LGOA (type A and B) between 2008 and 2022. Demographics, surgical methods, and outcomes were collected and compared. RESULTS The study population involved 28 patients in center A and 24 patients in center B. A surgical approach was thoracoscopic in center A, only for one patient was open for final procedure. In center B, 3 patients were treated only thoracoscopically, 2 converted to open, and 19 as open surgery. In center A primary esophageal anastomosis concerned 1 case, two-staged esophageal lengthening using external traction 1 patient, and 26 were treated with the multistaged internal traction technique. In 24 patients a full anastomosis was achieved: in 23 patients only the internal traction technique was used, while 1 patient required open Collis-Nissen procedure as final management. In center B primary anastomosis was performed in 7 patients, delayed esophageal anastomosis in 8 patients, esophageal lengthening using external traction in 1 case, and 9 infants required esophageal replacement with gastric tube. Analyzed postoperative complications included: early mortality, 2/28 due to accompanied malformations (center A) and 0/24 (center B); anastomotic leakage, 4/26 (center A) treated conservatively-all patients had a contrast study-and 0/24 (center B), 1 case of pleural effusion, but no routine contrast study; recurrent strictures, 13/26 (center A) and 7/15 (center B); and need for fundoplication, 5/26 (center A) and 2/15 (center B). Age at esophageal continuity was as a median of 31 days in center A and 110 days in center B. Median time between initial procedure and esophageal anastomosis was 11 days in center A and 92 days in center B. CONCLUSION Thoracoscopic internal traction technique reduces time to achieve esophageal continuity and the need for esophageal substitution while maintaining a similar early complication rate.
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Affiliation(s)
- Dominika Borselle
- Department of Paediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
| | - Joseph Davidson
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom of Great Britain and Northern Ireland
| | - Stavros Loukogeorgakis
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom of Great Britain and Northern Ireland
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NIHR, London, United Kingdom of Great Britain and Northern Ireland
| | - Paolo De Coppi
- Great Ormond Street Institute of Child Health, University College London, London, United Kingdom of Great Britain and Northern Ireland
- Department of Specialist Neonatal and Paediatric Surgery, Great Ormond Street Hospital for Children, NIHR, London, United Kingdom of Great Britain and Northern Ireland
| | - Dariusz Patkowski
- Department of Paediatric Surgery and Urology, Wroclaw Medical University, Wroclaw, Poland
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Phillips L, Jaffray B. What Proportion of Children With Complex Oesophageal Atresia Require Oesophageal Lengthening Procedures? J Pediatr Surg 2024; 59:187-191. [PMID: 37968153 DOI: 10.1016/j.jpedsurg.2023.10.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 10/09/2023] [Indexed: 11/17/2023]
Abstract
INTRODUCTION Babies with oesophageal atresia (OA) who cannot achieve a primary anastomosis (complex OA) may be treated by attempted oesophageal lengthening. We contrast reported outcomes of lengthening with our experience of managing complex OA. PATIENTS AND METHODS A consecutive series treated in an English regional centre was completed. Outcomes of interest were the rate of retention of the native oesophagus, complications requiring thoracotomy, rates of anastomotic leak, stricture, fundoplication, and mortality. Possible explanatory variables were the surgical techniques applied. RESULTS 29/215 (13%) OA were complex, and 25/207 survived to repair. 14/25 (56%) had no distal fistula, pure OA, while 11/25 (44%) had a long gap with distal fistula. 18/25 (72%) had delayed primary anastomosis, while 7/25 (28%) required oesophageal replacement. However, 2 of the replacements were salvage procedures following failed traction. Only 4/207 (2%) of OA were potentially treatable by traction. Salvage surgery was required in 2/23 (9%) complex OA not subjected to lengthening. The native oesophagus was retained without utilising lengthening in 200/207 (97%). Amongst complex OA where traction techniques had not been attempted, the native oesophagus was retained in 18/23 (78%) of cases, with median time to oesophageal continuity of 77 days. There was no in hospital mortality following treatment of complex OA, and overall survival was identical to non-complex OA among cases surviving to anastomosis. DISCUSSION Management of complex OA without lengthening procedures leads a similar rate of retention of the native oesophagus as reports describing lengthening, but with significantly less morbidity. We see little need for oesophageal lengthening in the management of complex OA. LEVEL OF EVIDENCE IV.
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Affiliation(s)
- Laura Phillips
- The Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne, United Kingdom
| | - Bruce Jaffray
- The Great North Children's Hospital, Queen Victoria Road, Newcastle upon Tyne, United Kingdom.
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Boettcher M, Hauck M, Fuerboeter M, Elrod J, Vincent D, Boettcher J, Reinshagen K. Clinical outcome, quality of life, and mental health in long-gap esophageal atresia: comparison of gastric sleeve pull-up and delayed primary anastomosis. Pediatr Surg Int 2023; 39:166. [PMID: 37014441 PMCID: PMC10073059 DOI: 10.1007/s00383-023-05448-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/16/2023] [Indexed: 04/05/2023]
Abstract
INTRODUCTION Pediatric surgeons have yet to reach a consensus whether a gastric sleeve pull-up or delayed primary anastomosis for the treatment of esophageal atresia (EA), especially of the long-gap type (LGEA) should be performed. Thus, the aim of this study was to evaluate clinical outcome, quality of life (QoL), and mental health of patients with EA and their parents. METHODS Clinical outcomes of all children treated with EA from 2007 to 2021 were collected and parents of affected children were asked to participate in questionnaires regarding their Quality of Life (QoL) and their child's Health-Related Quality of Life (HRQoL), as well as mental health. RESULTS A total of 98 EA patients were included in the study. For analysis, the cohort was divided into two groups: (1) primary versus (2) secondary anastomosis, while the secondary anastomosis group was subdivided into (a) delayed primary anastomosis and (b) gastric sleeve pull-up and compared with each other. When comparing the secondary anastomosis group, significant differences were found between the delayed primary anastomosis and gastric sleeve pull-up group; the duration of anesthesia during anastomosis surgery (478.54 vs 328.82 min, p < 0.001), endoscopic dilatation rate (100% vs 69%, p = 0.03), cumulative time spent in intensive care (42.31 vs 94.75 days, p = 0.03) and the mortality rate (0% vs 31%, p = 0.03). HRQoL and mental health did not differ between any of the groups. CONCLUSION Delayed primary anastomosis or gastric sleeve pull-up appear to be similar in patients with long-gap esophageal atresia in many key aspects like leakage rate, strictures, re-fistula, tracheomalacia, recurrent infections, thrive or reflux. Moreover, HrQoL was comparable in patients with (a) gastric sleeve pull-up and (b) delayed primary anastomosis. Future studies should focus on the long-term results of either preservation or replacement of the esophagus in children.
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Affiliation(s)
- Michael Boettcher
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
- Department of Pediatric Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany.
| | - Marie Hauck
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mareike Fuerboeter
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Elrod
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Pediatric Surgery, University Medical Center Mannheim, University of Heidelberg, Theodor-Kutzer-Ufer 1-3, 68167, Mannheim, Germany
| | - Deirdre Vincent
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes Boettcher
- Department of Child and Adolescent Psychiatry, Psychosomatics and Psychotherapy, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Konrad Reinshagen
- Department of Pediatric Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Durkin N, De Coppi P. Management of neonates with oesophageal atresia and tracheoesophageal fistula. Early Hum Dev 2022; 174:105681. [PMID: 36242842 DOI: 10.1016/j.earlhumdev.2022.105681] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Natalie Durkin
- Stem Cells and Regenerative Medicine Section, Developmental Biology and Cancer, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom
| | - Paolo De Coppi
- Stem Cells and Regenerative Medicine Section, Developmental Biology and Cancer, Great Ormond Street Institute of Child Health, University College London, London, United Kingdom; Great Ormond Street Hospital, NHS Trust, London, United Kingdom.
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