# Long-gap Esophageal Atresia — GCMD Library living collection

Updated: n/a · 4 episodes · 88 cited statements

## Episodes
### Resources
- [Aerodigestive & Esophageal Surgery - The Unsalvageable Esophagus & Cases](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738) — video · 1:41:09 · [machine version](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738.md)
- [Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791) — podcast · 10:56 · [machine version](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791.md)
- [Journal of Pediatric Surgery Article Review: February 2023, BAPS issue](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580) — podcast · 12:32 · [machine version](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580.md)
- [Long Gap Discussion: EA & TEF](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077) — video · 10:16 · [machine version](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=0) Introduction and first long-gap case: 4-month-old with type C TEF (Ep 1)
- [3:50](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=230) Experimental approaches: endoscopic Foker and magnets (Ep 1)
- [7:44](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=464) Segmental colonic interposition for long-gap atresia (Ep 1)
- [13:22](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=802) 16-year-old with failed small bowel interposition and proximal stricture (Ep 1)
- [19:57](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1197) 2-year-old with recalcitrant anastomotic stricture after multiple Foker procedures (Ep 1)
- [25:23](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1523) Stricture management: dilation frequency, needle knife, steroids, and stents (Ep 1)
- [39:42](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2382) Timing of anti-reflux surgery in recalcitrant strictures (Ep 1)
- [51:10](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3070) Case: 16-year-old with high cervical stricture and intact distal esophagus (Ep 1)
- [66:46](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4006) Multidisciplinary evaluation protocol for complex esophageal cases (Ep 1)
- [78:10](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4690) Case: 16-year-old with multiple TEFs, non-continuous esophagus, and tracheal defects (Ep 1)
- [90:52](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5452) Alternative approach: posterior tracheopexy and pericardial patch (Ep 1)
- [99:43](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5983) Summary and closing reflections (Ep 1)
- [0:00](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=0) Gap Measurement Techniques and Pitfalls (Ep 4)
- [3:46](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=226) Institutional Approaches to Long-Gap EA Management (Ep 4)
- [7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462) Flexible Operative Strategy and Internal Traction (Ep 4)
- [0:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=0) Introduction and Gap Measurement Protocol (Ep 2)
- [1:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=68) Esophageal Elongation Techniques (Ep 2)
- [3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) Foker Technique Outcomes and Morbidity (Ep 2)
- [4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276) Esophageal Replacement Options and Colonic Interposition Technique (Ep 2)
- [8:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=480) Complications and Advantages of Colonic Interposition (Ep 2)
- [9:56](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=596) Growth vs Stretch Mechanism Discussion (Ep 2)
- [0:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=4) Introduction and Episode Overview (Ep 3)
- [1:01](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=61) Thoracoscopic Esophageal Atresia Repair (Ep 3)
- [4:55](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=295) Stoma Use in Hirschsprung Disease (Ep 3)
- [8:40](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=520) Preoperative Soap Bathing to Prevent Surgical Site Infections (Ep 3)
- [11:31](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=691) Closing and Summary (Ep 3)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- For long-gap esophageal atresia, a gap of 2 vertebral bodies or approximately 2 centimeters is considered close enough to attempt primary anastomosis. — Dan (guideline) [Ep 1 · 5:44](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=344)
- If primary anastomosis cannot be achieved at initial operation, placing the ends on tension for one week and then re-operating often allows successful closure due to stretch. — Dan (clinical) [Ep 1 · 5:51](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=351)
- In experimental porcine models of endoscopic Foker (using olive beads and wire traction), pressure necrosis at the anastomotic site is the suspected cause of death. — Todd Ponsky (clinical) [Ep 1 · 6:32](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=392)
- Intraluminal magnetic anastomosis is being developed as a minimally invasive approach to long-gap atresia, with the goal of reducing pressure necrosis compared to bead-based traction. — Todd Ponsky (clinical) [Ep 1 · 7:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=420)
- Segmental colonic interposition (preserving distal native esophagus) reduces the risk of long-term redundancy and tortuosity compared to full-length colon interposition from cervical esophagus to stomach. — Dan (clinical) [Ep 1 · 9:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=540)
- Segmental interposition preserves the native gastroesophageal junction, allowing potential future anti-reflux surgery at the normal GE junction rather than at a colonic-gastric anastomosis. — Dan (clinical) [Ep 1 · 9:22](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=562)
- Segmental colonic interposition requires two anastomoses (one in chest, one in neck) and a thoracotomy, making it a morbid operation, but it is theoretically 'one and done.' — Dan (clinical) [Ep 1 · 9:44](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=584)
- Sometimes surgeons try too hard to salvage the native esophagus, and children may do better with esophageal replacement, especially when chronic aspiration from recurrent TEFs or strictures causes severe pulmonary disease. — Dan (opinion) [Ep 1 · 11:24](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=684)
- When mobilizing a distal esophageal pouch off tension (e.g., from prevertebral fascia), the pouch retracts and becomes much shorter than it appeared pre-operatively. — Dan (clinical) [Ep 1 · 12:53](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=773)
- On CT scan, if the dilated esophagus lies immediately posterior to the malacic trachea, any esophageal distention (food bolus, stent) will compress the trachea. If the esophagus deviates to the left, tracheal compression is less likely. — Bob (clinical) [Ep 1 · 48:58](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2938)
- Needle knife incision of esophageal strictures is effective for short, well-defined, non-circumferential scar bands. It should be avoided on the anterior wall in patients with prior TEF due to proximity to the trachea. — Phil (clinical) [Ep 1 · 35:13](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2113)
- Patients born with tracheoesophageal fistula, especially those with esophageal atresia, are at significantly higher risk for eosinophilic esophagitis, a non-acid inflammatory condition that causes strictures if untreated. — Phil (epidemiological) [Ep 1 · 46:14](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2774)
- Eosinophilic esophagitis in infants is effectively managed with elemental formula, which works in approximately 95% of cases. — Phil (clinical) [Ep 1 · 47:14](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2834)
- Routine esophageal biopsies should be performed during endoscopy in TEF patients to screen for eosinophilic esophagitis, even in the absence of overt symptoms. — Phil (guideline) [Ep 1 · 46:53](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2813)
- In patients with recalcitrant anastomotic strictures and documented reflux, treating reflux with fundoplication may allow the stricture to heal. However, this approach risks making subsequent esophageal mobilization more difficult if replacement is ultimately needed. — Dan (clinical) [Ep 1 · 43:07](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2587)
- Medical acid suppression (PPI) reduces gastric acid but does not stop reflux itself. A mechanical barrier (fundoplication) is required to prevent reflux of bile and other irritants. — Phil (clinical) [Ep 1 · 44:13](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2653)
- Substernal colonic interposition avoids thoracotomy and is useful when the chest is heavily scarred from prior operations. However, it requires sacrificing the entire native esophagus. — Dan (clinical) [Ep 1 · 10:27](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=627)
- When performing segmental colonic interposition, the choice of right vs. left colon is based on intraoperative assessment of the marginal artery; the side with better vascularity is selected. — Dan (clinical) [Ep 1 · 66:15](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3975)
- Redundant colonic interposition can be revised by shortening the conduit at the distal anastomosis, dividing small branches along the colonic wall while preserving the vascular arcade. — Dan (clinical) [Ep 1 · 72:54](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4374)
- Covered esophageal stents (8 mm diameter) are now available for pediatric use and may be effective for temporizing strictures or leaks. They are partially covered to reduce migration and perforation risk. — Phil (clinical) [Ep 1 · 38:45](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2325)
- In complex esophageal cases, a combined operating room evaluation with rigid bronchoscopy, flexible bronchoscopy, and EGD (often with two scopes simultaneously) provides comprehensive anatomic assessment and is safer than sequential procedures. — Dan (clinical) [Ep 1 · 78:10](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4690)
- Contrast studies through the endoscope under fluoroscopy are routinely performed before attempting wire passage or dilation to confirm anatomy and avoid perforation. — Phil (clinical) [Ep 1 · 78:53](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4733)
- Esophageal bypass (leaving native esophagus in situ) is a viable option when resection would create an unreconstructible tracheal defect. A fundoplication is performed to prevent reflux into the residual esophageal pouch. — Dan (clinical) [Ep 1 · 86:54](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5214)
- When performing esophageal bypass, leaving a tracheoesophageal fistula open allows native esophageal secretions to drain into the airway, preventing mucocele formation in the residual pouch. — Bob (clinical) [Ep 1 · 87:49](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5269)
- Children who have been unable to swallow for years may continue to spit reflexively even after successful esophageal reconstruction. It can take weeks to months for them to relearn swallowing. — Dan (clinical) [Ep 1 · 88:42](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5322)
- Magnetic compression anastomosis (magnamosis) has been used successfully for gastrojejunostomy but is unproven in the esophagus. The main limitations are the distance magnets can attract across and the lack of mucosal lining in the resulting anastomosis. — Todd Ponsky (clinical) [Ep 1 · 30:25](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1825)
- For a spit fistula to avoid recurrent TEF, the distal esophageal stump must be fully mobilized down to the diaphragm and separated from the trachea, not just divided and dropped. — Todd Ponsky (clinical) [Ep 1 · 74:05](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4445)
- In patients with multiple prior thoracotomies and fused ribs, exposure can still be achieved by 'chipping away' at the fused ribs, though the field is narrow and the lung is at risk of injury from scarring. — Dan (clinical) [Ep 1 · 29:25](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1765)
- Placing endoscopes from above and below during thoracoscopic stricture resection allows identification of the stricture by transillumination ('go to the light'). — Todd Ponsky (clinical) [Ep 1 · 26:28](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1588)
- Cervical esophageal strictures at the thoracic inlet are difficult to resect via neck approach because the esophagus is fixed substernally and cannot be mobilized adequately for tension-free anastomosis. — Dan (clinical) [Ep 1 · 17:07](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1027)
- Contrast esophagrams can underestimate the true diameter of a stricture if the proximal esophagus is dysmotile and does not generate enough pressure to distend the lumen. Balloon dilation under endoscopy provides a more accurate assessment. — Phil (clinical) [Ep 1 · 18:46](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=1126)
- Serial bougie dilation (e.g., Maloney or Savary dilators) is less effective than balloon dilation for esophageal strictures. Balloon dilation applies radial force and can crack scar tissue without requiring needle knife incision. — Todd Ponsky (clinical) [Ep 1 · 41:47](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2507)
- In long-gap atresia, some surgeons use a Hagar dilator to measure the gap, but this may not reach the true end of the distal pouch. A flexible scope is more reliable for accurate gap measurement. — Todd Ponsky (clinical) [Ep 1 · 2:21](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=141)
- Interventional radiology can perform gap studies using a catheter with contrast injection to confirm the catheter is at the top of the pouch, then apply stretch to measure the gap under tension. — Dan (clinical) [Ep 1 · 2:35](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=155)
- In long-gap atresia, if the distal pouch has been tacked to the prevertebral fascia at the initial operation, it will not mobilize adequately for primary repair unless the tack is surgically released. — Dan (clinical) [Ep 1 · 4:44](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=284)
- Esophageal replacement options for long-gap atresia include reverse gastric tube, gastric pull-up, colon interposition, and small bowel interposition. — Dan (guideline) [Ep 1 · 5:12](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=312)
- Long-term complications of full-length colonic interposition include progressive tortuosity and poor drainage, which can be mitigated by using shorter segmental interpositions. — Dan (clinical) [Ep 1 · 9:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=540)
- Mobilizing the gastroesophageal junction to achieve length for primary esophageal anastomosis effectively creates a hiatal hernia and predisposes to reflux. — Todd Ponsky (clinical) [Ep 1 · 54:12](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3252)
- In a patient with a high cervical stricture and intact distal esophagus, primary resection and reanastomosis is theoretically possible but may be under significant tension and at risk of leak or re-stricture. — Dan (clinical) [Ep 1 · 59:20](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3560)
- A combined neck and abdominal approach (two surgeons working simultaneously) significantly reduces operative time for complex esophageal reconstructions, which is important given the prolonged anesthesia these cases require. — Dan (clinical) [Ep 1 · 63:40](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3820)
- When performing colonic interposition to the cervical esophagus, the colon can be brought substernally if the chest is too scarred for thoracotomy, even if a segmental interposition is planned. — Dan (clinical) [Ep 1 · 66:59](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4019)
- Proximal esophageal anastomoses in the neck are at higher risk of leak when the native esophagus is scarred, short, and of poor quality. Leaks typically heal with conservative management (drainage, stenting). — Dan (clinical) [Ep 1 · 68:16](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4096)
- Colonic interposition that appears appropriately short in the operating room may become redundant postoperatively due to the natural elasticity and lengthening of the colon over time. — Dan (clinical) [Ep 1 · 68:57](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4137)
- When the proximal esophagus is essentially absent (less than 1 cm), anastomosis can be performed to the hypopharynx by having the surgeon place fingers in the patient's mouth, push down to the base of the hypopharynx, and sew the conduit to the surgeon's fingers from below. — Dan (clinical) [Ep 1 · 75:31](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4531)
- In patients with multiple tracheoesophageal fistulas and a non-continuous esophagus, attempting resection may create an unreconstructible posterior tracheal defect. Esophageal bypass is a safer alternative. — Dan (clinical) [Ep 1 · 86:54](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5214)
- Residual esophageal secretions in a bypassed esophageal pouch are minimal and typically drain via a persistent TEF, preventing mucocele formation without requiring esophagectomy. — Dan (clinical) [Ep 1 · 87:42](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5262)
- Patients with bypassed esophagus and colonic interposition can achieve full oral intake and normal quality of life, including eating solid foods like pizza. — Dan (clinical) [Ep 1 · 89:02](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5342)
- At Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology. — Daniel von Allmen (clinical) [Ep 2 · 0:46](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=46)
- Stretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero. — Daniel von Allmen (clinical) [Ep 2 · 2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130)
- The philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together. — Daniel von Allmen (clinical) [Ep 2 · 2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130)
- The colon can be used as an interposition for esophageal replacement. — Daniel von Allmen (clinical) [Ep 2 · 4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276)
- Common problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm. — Daniel von Allmen (clinical) [Ep 2 · 8:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=480)
- Von Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true. — Daniel von Allmen (opinion) [Ep 2 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497)
- Von Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach. — Daniel von Allmen (clinical) [Ep 2 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497)
- Colonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well. — Daniel von Allmen (opinion) [Ep 2 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497)
- You can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up. — Daniel von Allmen (clinical) [Ep 2 · 9:03](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=543)
- Von Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science. — Daniel von Allmen (opinion) [Ep 2 · 9:56](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=596)
- The Centre in Rocklaw has become the referral center for esophageal atresia and long gap esophageal atresia cases from the whole of Poland — Mark Davenport (clinical) [Ep 3 · 3:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=218)
- Centers of excellence for esophageal atresia are showing better outcomes — Todd Ponsky (clinical) [Ep 3 · 4:13](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=253)
- Centralization of esophageal atresia care would be difficult to implement in the United States healthcare system — Todd Ponsky (opinion) [Ep 3 · 4:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=266)
- In the Sheffield study, 47% of Hirschsprung disease patients needed a stoma before primary pull-through — Govind Murthi (epidemiological) [Ep 3 · 5:35](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=335)
- Of 20 patients who needed post-pull-through stoma formation, 7 occurred within 30 days and 13 occurred after 30 days — Govind Murthi (epidemiological) [Ep 3 · 6:19](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=379)
- Most post-pull-through stomas after 30 days were needed because of constipation or soiling — Govind Murthi (clinical) [Ep 3 · 6:28](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=388)
- The Sheffield study represents real life surgical reporting and reflects overall management of Hirschsprung's disease within the UK — Mark Davenport (opinion) [Ep 3 · 6:35](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=395)
- The Sheffield Hirschsprung management sequence does not reflect typical practice in the United States — Beth Rymeski (opinion) [Ep 3 · 7:09](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=429)
- In US practice, most Hirschsprung patients undergo either neonatal pull-through or are sent home on irrigations for pull-through in the first couple of months of life — Beth Rymeski (clinical) [Ep 3 · 7:20](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=440)
- In US practice, pre-pull-through diversion is only done for delayed presentation with perforation or complicated cardiac babies — Beth Rymeski (clinical) [Ep 3 · 7:39](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=459)
- The Tanzania study used trained carers to direct the method of cleansing, concentrating on areas known to harbor commensal and pathogenic bacteria — Mark Davenport (clinical) [Ep 3 · 9:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=544)
- Before implementing preoperative bathing in Tanzania, almost every pediatric surgery patient developed a wound infection — Beth Rymeski (clinical) [Ep 3 · 10:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=641)
- After implementing preoperative baths in Tanzania, wound infection rates dropped to nearly zero — Beth Rymeski (clinical) [Ep 3 · 10:56](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=656)
- The Tanzania soap bathing trial was well designed, analyzed in substantial detail, and has implications for low to middle income countries where surgical site infections are a major problem — Mark Davenport (opinion) [Ep 3 · 11:04](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=664)
- Blind probing of the distal esophagus in long-gap EA can inadvertently push the diaphragm of an infant all the way up to the upper chest cavity without causing perforation, leading to overestimation of the gap. (clinical) [Ep 4 · 0:04](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=4)
- The gastroesophageal junction in pure long-gap esophageal atresia is very tiny and requires manipulation of the scope to enter, as it tends to flip out. (clinical) [Ep 4 · 0:04](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=4)
- Using an endoscope to measure the gap does not allow objective measurement of the boost force applied, unlike using a Hegar dilator with force measurement. — Bagalo (clinical) [Ep 4 · 1:20](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=80)
- Gap measurement should wait at least 15 days after gastrostomy placement before the first measurement, using a Hegar number 4 dilator after endoscopic confirmation of the cardia location. — Bagalo (clinical) [Ep 4 · 1:20](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=80)
- Some babies with long-gap EA have no cardia at all. — Bagalo (clinical) [Ep 4 · 1:20](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=80)
- A contrast study performed at 3 weeks after gastrostomy placement, even in Trendelenburg position, may not fill the distal esophageal segment completely, giving a false sense of the real gap. (clinical) [Ep 4 · 2:51](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=171)
- Professor Spitz would not perform a cervical esophagostomy immediately in a gasless abdomen case, but would wait a couple of weeks to assess the gap using a Hagar or urethral dilator under fluoroscopic control. — Spitz (clinical) [Ep 4 · 4:00](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=240)
- Professor Spitz would opt for esophageal replacement if the gap is more than 5 or 6 vertebrae at 4 to 6 weeks. — Spitz (clinical) [Ep 4 · 4:00](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=240)
- Miguel's approach is to place a laparoscopic gastrostomy, measure the gap every 2 weeks until it is less than 2 vertebral bodies, and start thinking about replacement if this is not achieved by 8 weeks. — Miguel (clinical) [Ep 4 · 4:48](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=288)
- Professor Bagalo performs gastrostomy at birth and gap measurement every 15 days until 6 weeks, at which point delayed anastomosis is generally possible for inborn babies. — Bagalo (clinical) [Ep 4 · 5:10](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=310)
- Holger endoscopes all long-gap patients to intubate the lower esophageal sphincter and assess both the length and quality of the lumen. — Holger (clinical) [Ep 4 · 5:41](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=341)
- Holger clips the fistula and leaves it attached, waiting to observe for spontaneous growth, then assesses with endoscope in both upper and lower pouches; if the gap is less than 3 vertebral bodies or centimeters, he proceeds with primary repair. — Holger (clinical) [Ep 4 · 5:41](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=341)
- Jack's institution has interventional radiology place the G-tube and check the gap using a wire threaded through the G-tube into the esophagus, checking every month and allowing up to 3 months for the ends to grow close enough together. — Jack (clinical) [Ep 4 · 6:44](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=404)
- Dr. Folker's institution performs an unstressed gappogram with contrast above and into the lower esophagus to assess the gap, and proceeds with operation once the child is 3 to 3.5 kg and sturdy if the lower esophageal segment is fairly good size. — Holger (clinical) [Ep 4 · 7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462)
- If after mobilization the tension is judged to be more than desired, Dr. Folker places the esophageal ends on internal traction and waits one week, during which significant growth is achieved and the ends can then be anastomosed. — Holger (clinical) [Ep 4 · 7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462)
- Even esophageal ends that are 2 to 4 millimeters in size, when placed on traction, will grow into a serviceable esophagus. — Holger (clinical) [Ep 4 · 7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462)
- Dr. Folker's first patient from Boston was reported to have a gap of 2 centimeters, but this was due to pushing the diaphragm up into the chest; the actual distal esophagus was only a 5 to 6 millimeter nubbin. — Holger (clinical) [Ep 4 · 7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Esophageal stents can compress the adjacent trachea, especially in children with tracheomalacia or when the esophagus lies directly posterior to the trachea. Always perform bronchoscopy after stent placement. — Em Gootee summarizing the discussion [Ep 1 · 48:18](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2898)
- Chronic esophageal foreign bodies (e.g., coins lodged for weeks) can cause posterior tracheal bulge and present as refractory asthma or bronchiolitis, often diagnosed late because chest X-rays are not routinely obtained in asthma protocols. — Em Gootee summarizing the discussion [Ep 1 · 50:20](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=3020)
- For recalcitrant esophageal strictures, weekly dilations (3–4 cycles) prevent fibroblasts from bridging and allow the stricture to scar open rather than closed. — Em Gootee summarizing the discussion [Ep 1 · 36:29](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2189)
- Kenalog (steroid) injection after stricture dilation is preferred over mitomycin. Mitomycin at high concentrations (up to 5 mg/mL) causes tissue necrosis and has not shown superior outcomes compared to steroids. — Em Gootee summarizing the discussion [Ep 1 · 33:28](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2008)
- Feeding via gastrojejunal tube with gastric drainage (GJ/G) is a temporizing measure to reduce reflux into the esophagus while managing a refractory stricture. — Em Gootee summarizing the discussion [Ep 1 · 45:47](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=2747)
- Posterior tracheopexy (pexing the trachea to the anterior spine) combined with bovine pericardial patch for tracheal defects is an alternative to esophageal bypass, but pericardial patches can fail and create large tracheal defects. — Em Gootee summarizing the discussion [Ep 1 · 94:15](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5655)
- Tissue-engineered tracheal homografts with pre-epithelialization are under development in multiple centers (London leading) but are not yet ready for routine clinical use. — Em Gootee summarizing the discussion [Ep 1 · 92:06](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5526)
- Tracheal homografts (dead trachea implants) have been performed but are associated with difficult postoperative courses lasting several months. — Em Gootee summarizing the discussion [Ep 1 · 91:42](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5502)
- Manubrial resection for high esophageal strictures provides less exposure than expected because the clavicles limit the width of the resection corridor. — Em Gootee summarizing the discussion [Ep 1 · 16:38](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=998)
- David Vanderzee described a thoracoscopic technique for long-gap atresia: place traction sutures on both ends, externalize them on buttons without tightening, wait 3–4 days, return to OR to break adhesions and re-tension, then perform delayed anastomosis. — Dan summarizing the discussion [Ep 1 · 4:19](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=259)
- Covered esophageal stents can temporize anastomotic leaks and allow healing while maintaining luminal patency. Stent removal is typically planned after several weeks. — Em Gootee summarizing the discussion [Ep 1 · 70:42](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=4242)
- Long-term surveillance of bypassed esophagus includes periodic CT scans to rule out mucocele and endoscopic evaluation via the persistent TEF if needed. — Em Gootee summarizing the discussion [Ep 1 · 93:15](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5595)
- Complications are nearly inevitable in complex esophageal reconstruction. The goal is not to eliminate complications but to anticipate and manage them effectively through a multidisciplinary team approach. — Em Gootee summarizing the discussion [Ep 1 · 99:43](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-the-unsalvageable-esophagus-cases-738?t=5983)
- In the Foker technique, the surgeon ties sutures to either end of the esophagus through an open incision, brings them out through the chest wall, ties them together in a knot, and places spacers underneath periodically (about every day) until the ends come together for primary anastomosis. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 1:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=68)
- The van der Zee technique uses the same concept as Foker but is done thoracoscopically with no external sutures, so all tension is inside the thorax. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 2:39](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=159)
- The Kimura technique involves creating a spit fistula and periodically moving it down the chest wall over time to stretch the proximal pouch closer to the distal pouch, but is not used all that often anymore. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 2:39](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=159)
- In the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients. — Daniel von Allmen summarizing a resource [Ep 2 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195)
- In the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed. — Daniel von Allmen summarizing a resource [Ep 2 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195)
- In the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition. — Daniel von Allmen summarizing a resource [Ep 2 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195)
- The surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum. — Daniel von Allmen summarizing a resource [Ep 2 · 4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276)
- In colonic interposition, the piece of colon chosen is based on the blood supply and the diameter needed. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308)
- In colonic interposition, a pyloroplasty is performed to help with gastric emptying. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308)
- The short interval between time of traction and anastomosis (less than five days) raises the question of whether the mechanism is stretching or growth, which will impact results and likely reflects on complications. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 9:27](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=567)
- In Poland, thoracoscopic esophageal atresia repair has been performed exclusively since 2005 — Ellen Encisco summarizing the discussion [Ep 3 · 1:38](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=98)
- The first thoracoscopic esophageal atresia procedure took almost 4 hours, but with experience it became a 1-hour procedure — Ellen Encisco summarizing the discussion [Ep 3 · 1:54](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=114)
- Dr. Patkowski's team has had no conversions from thoracoscopic to open approach since beginning the technique — Ellen Encisco summarizing the discussion [Ep 3 · 1:59](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=119)
- All esophageal atresia cases in Dr. Patkowski's center have been managed by one team using only the thoracoscopic approach since the beginning — Ellen Encisco summarizing the discussion [Ep 3 · 2:06](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=126)
- Centralizing care for esophageal atresia patients is important even if transportation costs are higher, because complication costs are much higher — Ellen Encisco summarizing the discussion [Ep 3 · 2:58](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=178)
- Dr. Patkowski's center handles 15 to 20 esophageal atresia cases per year, which provides sufficient volume for good experience — Ellen Encisco summarizing the discussion [Ep 3 · 3:06](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=186)
- In the stoma cohort, 38 patients had ileostomies and the remaining had colostomies — Ellen Encisco summarizing the discussion [Ep 3 · 5:41](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=341)
- The most common indication for initial stoma in Hirschsprung disease was washout failure, accounting for nearly 40% of cases — Ellen Encisco summarizing the discussion [Ep 3 · 5:46](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=346)
- Sheffield primarily performs Duhamel pull-throughs while Cincinnati primarily performs Swenson procedures for Hirschsprung disease — Ellen Encisco summarizing the discussion [Ep 3 · 8:10](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=490)
- The Tanzania soap bathing study included 252 patients, with 114 receiving a preoperative bath with plain soap — Cecilia Gigena summarizing the discussion [Ep 3 · 9:23](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=563)
- In the soap bathing group, 11.4% developed surgical site infections compared to 40.6% in the control group — Cecilia Gigena summarizing the discussion [Ep 3 · 9:26](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=566)
- Preoperative soap bathing reduced the odds of surgical site infections by 80% — Cecilia Gigena summarizing the discussion [Ep 3 · 9:43](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=583)
- Length of stay in the soap bathing intervention group was 12 days compared to 22 days in the non-intervention group — Mark Davenport summarizing the discussion [Ep 3 · 9:53](https://library.globalcastmd.com/watch/journal-of-pediatric-surgery-article-review-february-2023-baps-issue-6580?t=593)

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