Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement

Published: 2022-01-04

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Inside this episode

Kai, the Library's AI content creator, listened to this episode and mapped who's speaking, the chapters, key claims, and cases. Every item links to the exact moment in the recording.

AI-enriched

Who's speaking

Rod Gerardo — host
Dan Von Allman — guest

Chapters

0:00Defining and Measuring Long Gap Esophageal Atresia — Introduction to long gap esophageal atresia and Cincinnati Children's protocol for gap measurement using interventional radiology after initial G-tube placement and fluoroscopy.
2:10Esophageal Elongation Techniques — Review of Foker, van der Zee, and Kimura techniques for esophageal preservation through traction-induced growth, including clinical outcomes data showing 96% success in primary cases with significant ICU requirements.
4:36Esophageal Replacement Options — Discussion of gastric transposition and colonic interposition as alternatives when elongation fails, with detailed surgical technique demonstration of colonic interposition including anastomoses and pyloroplasty.
8:00Complications and Revisions — Management of colonic interposition complications including dilation, tortuosity, and sigmoid redundancy, with discussion of revision techniques and the growth versus stretch mechanism debate.

Key claims

0:46Long gap esophageal atresia is defined by absence of gas in the abdomen on initial imaging — Dan Von Allman
0:46Cincinnati Children's uses a standardized interventional radiology protocol for measuring the esophageal gap, performed a couple of weeks after initial G-tube placement — Dan Von Allman
2:10Stretch is a very strong promoter of growth, and structures placed under tension will grow over time — Dan Von Allman
2:10The cardiovascular system develops in utero using tension-based growth mechanisms — Dan Von Allman
1:08In the Foker technique, surgeons tie sutures to both esophageal ends, externalize them through the chest wall, and progressively tighten them with spacers until the ends approximate — Rod Gerardo
2:10The van der Zee technique uses the same traction concept as Foker but is performed thoracoscopically with all tension maintained inside the thorax — Rod Gerardo
2:10The Kimura technique creates a spit fistula that is progressively moved down the chest wall to stretch the proximal pouch toward the distal pouch — Rod Gerardo
2:10The Kimura technique is not used often anymore — Rod Gerardo
3:15A 2015 Boston series reported 96% success rate achieving intact esophagus in primary Foker cases — Dan Von Allman
3:15In secondary Foker cases (patients with previous operations), success rate was approximately two-thirds — Dan Von Allman
3:15Primary Foker cases had median ICU stay of 70 days with median two weeks of paralysis — Dan Von Allman
3:15Secondary Foker cases had median ICU stay of 110 days with median one month of paralysis — Dan Von Allman
3:15About two-thirds of primary Foker repair patients achieved full oral nutrition — Dan Von Allman
3:15About 10% of secondary Foker repair patients achieved full oral nutrition — Dan Von Allman
4:12The surgical dictum states that every effort should be made to conserve the native esophagus as no other conduit can replace its function satisfactorily — Rod Gerardo
4:36The INOEA surgical group recommends gastric pull-up as the first option for esophageal replacement — Dan Von Allman
4:36In gastric transposition, the esophageal stump is divided at the esophageal hiatus, the fundus is mobilized and pulled up through either anterior or posterior mediastinum — Dan Von Allman
4:36Colon can be used as an interposition conduit for esophageal replacement — Dan Von Allman
5:08The choice of colon segment for interposition is based on blood supply and required diameter — Rod Gerardo
5:08In colonic interposition, the colon is passed behind the stomach while maintaining blood supply — Rod Gerardo
5:08Pyloroplasty is performed during colonic interposition to help with gastric emptying — Rod Gerardo
8:00Common problems with colonic interposition include dilation and tortuosity, with sigmoid redundancy often developing just above the diaphragm — Dan Von Allman
8:17Traditional teaching held that colonic interposition redundancy cannot be fixed safely due to risk to blood supply — Dan Von Allman
8:17Passing the colonic interposition posterior to the stomach leaves the vascular pedicle along the spine, allowing safe mobilization and revision — Dan Von Allman
8:17Sigmoid redundancy in colonic interposition can be revised transhiatally by dividing the gastroduodenal anastomosis, mobilizing the redundant segment, and re-anastomosing to the stomach — Dan Von Allman
9:01Colonic interposition can achieve extraordinary length, sufficient to reach from pharynx to stomach in cases of extensive caustic injury — Dan Von Allman
9:01Gastric pull-up is difficult to perform when anastomosis to the pharynx is required — Dan Von Allman
9:56The short interval between traction initiation and anastomosis (less than five days in some cases) raises questions about whether the mechanism is growth or stretch — Rod Gerardo
9:56There is good physiologic data that tension is a growth promoter in organs other than the esophagus — Dan Von Allman
9:56The mechanism of esophageal elongation (growth versus stretch) is not definitively known and requires further basic science research — Dan Von Allman

Open questions

Is the mechanism of esophageal elongation in traction techniques primarily tissue growth or tissue stretch, given the short time intervals (less than 5 days) between traction initiation and successful anastomosis?
What are the optimal timing and criteria for transitioning from elongation attempts to replacement strategies in long gap esophageal atresia?

This episode was analyzed and enriched by Kai, the Library's AI content creator. Every item links to the moment it comes from — click a timestamp to listen in context.

Long Gap Esophageal Atresia: Elongation Versus Replacement Outcomes and Technique

The essential version of this episode — what it covers, the points that matter most, and what it changes for you. Written by Kai from the episode transcript and reviewed before publishing.

For specialists · Core brief · AI-written, human-reviewed

Defining and Measuring the Gap

Long gap esophageal atresia is defined by absence of gas in the abdomen on initial imaging 0:46. Cincinnati Children's uses a standardized interventional radiology protocol performed a couple of weeks after G-tube placement to measure the esophageal gap consistently across patients 0:46.

Elongation Techniques

The Foker technique exploits tension-based growth: sutures tied to both esophageal ends are externalized through the chest wall and progressively tightened with spacers until the ends approximate 1:08. The physiologic basis is that stretch promotes growth, similar to cardiovascular development in utero 2:10 2:10. The van der Zee technique applies the same traction concept thoracoscopically with all tension maintained intrathoracically 2:10.

A 2015 Boston series reported 96% success achieving intact esophagus in primary Foker cases, but two-thirds success in secondary cases (previous operations) 3:15 3:15. Primary cases required median 70-day ICU stays with two weeks of paralysis; secondary cases required 110 days with one month of paralysis 3:15 3:15. Two-thirds of primary repair patients achieved full oral nutrition versus 10% of secondary cases 3:15 3:15.

Replacement Options

The INOEA surgical group recommends gastric pull-up as first-line replacement 4:36. The esophageal stump is divided at the hiatus, and the mobilized fundus is pulled through anterior or posterior mediastinum 4:36.

Colonic interposition offers extraordinary length—sufficient to reach from pharynx to stomach in extensive caustic injuries where gastric pull-up is difficult 9:01 9:01. The colon is passed posterior to the stomach with pyloroplasty performed to facilitate gastric emptying 5:08 5:08. Common problems include dilation and sigmoid redundancy above the diaphragm 8:00. Contrary to traditional teaching that redundancy cannot be safely revised 8:17, passing the conduit posterior to the stomach positions the vascular pedicle along the spine, allowing safe transhiatal mobilization and revision by dividing the gastroduodenal anastomosis 8:17 8:17.

Unresolved Questions

Whether esophageal elongation represents true growth or stretch remains unclear, particularly given the short interval between traction initiation and anastomosis in some cases 9:56 9:56. While tension promotes growth in other organs 9:56, definitive mechanistic data for esophagus is lacking 9:56.

Takeaways from this story

Primary Foker repair achieves 96% intact esophagus but requires median 70-day ICU stay with two weeks paralysis
Secondary Foker cases have two-thirds success rate, 110-day ICU stay, and only 10% achieve full oral nutrition
Colonic interposition redundancy can be safely revised transhiatally when conduit is passed posterior to stomach
Colon interposition provides sufficient length for pharyngeal anastomosis in extensive caustic injuries

Topic overview

A discussion of surgical management options for long gap esophageal atresia, focusing on when the distance between proximal and distal esophageal segments is too great for primary anastomosis. The speakers review gap measurement protocols, esophageal elongation techniques (Foker, van der Zee, and Kimura methods), and esophageal replacement options using gastric transposition or colonic interposition. Clinical outcomes data from a 2015 Boston series show 96% success in primary cases with median ICU stays of 70 days. The discussion includes technical details of colonic interposition and management of complications such as redundancy and tortuosity.

Key takeaways

Primary Foker repair achieves 96% success but requires median 70-day ICU stay and 2 weeks paralysis; only 2/3 reach full oral feeds. (3:15)
Secondary Foker cases have worse outcomes: 2/3 success, 110-day ICU stay, 1-month paralysis, and only 10% achieve full oral nutrition. (3:15)
Colonic interposition redundancy can be safely revised transhiatally when passed posterior to stomach, preserving spinal vascular pedicle. (8:00)
INOEA recommends gastric pull-up first for replacement, but colon interposition offers superior length for pharyngeal anastomosis. (4:36)
Esophageal elongation mechanism (growth vs. stretch) remains unclear despite physiologic data supporting tension-based growth in other organs. (2:10)

Keywords

long gap esophageal atresia tracheoesophageal fistula caustic injuries sigmoid redundancy tortuosity Foker technique van der Zee technique Kimura technique gastric transposition gastric pull-up colonic interposition G-tube placement fluoroscopy primary anastomosis pyloroplasty

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Transcript

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Hi, I'm Rod Gerardo, research resident at Cincinnati Children's Hospital Medical Center. And a few weeks ago we talked about esophageal atresia and trachea esophageal fistula. We talked about the diagnosis and surgical management, but one piece of the puzzle that we didn't get to touch on. What happens when that space between the proximal and distal esophagus is just too long? Or what we call a long gap. So today we're going to talk about long gap esophageal atresia with Dr. Dan Von Allman. He's the surgeon in chief at Cincinnati Children's Hospital Medical Center. And the first thing we should probably touch on is how do you even know if that gap is too long in the first place? Our method here is that if we have a child with no gas in the abdomen and we take them to the OR and put a G-tube in, many times we'll do, we'll put something up the distal esophagus at that point and just get a fluoro shot. But then we'd wait a couple of weeks and we have our patients go down to interventional radiology where we have a protocol for measuring the gap. Okay, so at Cincinnati Children's they have a protocol for how exactly they measure that gap. So it's the same for every patient. So then once you find out that you have a gap, you've got some options. They all have advantages and disadvantages. As we all know, we like to try to preserve the esophagus if we can. And certainly John Fokker and David, who's been on, and Kimura have described great elongation techniques that can be used to try to get the, to preserve the native esophagus and get the two ends together. First, let's talk about the Fokker technique. In this procedure, the surgeon, through an open incision, will tie a suture to either end of the esophagus. Then they'll bring those sutures out through the chest wall and close the incision. Then they take those two free ends of the suture and tie them together in a knot. Then they place spacers underneath the knot periodically, about every day or so, until the two ends come together and they take the patient back to the operating room for a primary anastomosis. The physiology, which I believe in intensely, is that stretch is a very strong promoter of growth. And then if you put things on tension, they will actually grow over time. That's how the cardiovascular system develops in utero. And I did some research early in my career looking at lung growth and using pressure to grow lungs. So, but the philosophy here 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. Okay, next we'll talk about the van der Zee technique. It's the same concept, except it's done thoracoscopically. And there are no external sutures. So all of the tension is inside the thorax. And lastly, the chimera technique, which really isn't used all that often anymore. The idea here is you first create a spit fistula. And then periodically, you move that fistula down the chest wall over time to stretch the proximal pouch, bringing it closer to the distal pouch to be able to create an anastomosis. Now, if we look specifically at the Fokker technique, there is some good literature to support this technique. Here's Dr. Von Allman. There was a great article published by the Boston Group 2015. Divides the cases into two groups, a primary group and a secondary group. Secondary being patients who had had operations previously in the primary group, being cases that they saw de novo. Obviously, you look at the result of getting the esophagus together and intact esophagus in 96% of patients in the primary group, about two thirds of patients in the secondary group. But these procedures are not without some morbidity. And you look at the ICU stay is a median of 70 days with a couple of weeks being paralyzed for the primary group and 110 days for the secondary group with a month of being paralyzed. About two thirds of patients with the primary repair were able to get the full oral nutrition and about 10% of the patients who had the secondary repair. If you want the article, I'm going to link it below. So scroll down under the media player, you could open it up. We were all taught the dictum that every effort should be made to conserve the native esophagus as no other conduit can replace its function in transporting food from the oral cavity to the stomach satisfactorily. So all of these techniques are great. But what if none of them really work? Then what do we do? Great question, Rod. You could use the stomach. That would be called a gastric transposition. The surgical group from the INOEA, their recommendation, the recommendation for the first option is a gastric pull up. You divide the esophageal stump at the esophageal hiatus and mobilize the fundus and pull the fundus up and you can pull it up either in the anterior or posterior mediastinum. You can actually use the colon as an interposition as well. I personally was trained to do colon interpositions. And just how exactly does Dr. Von Allman do this colonic interposition? Well, to answer that, we had this awesome video created by the Cincinnati Children's Media Lab. And they were gracious enough to share this with you so that you can learn. So we're going to start off with two incisions. First is your midline abdominal incision. And second is your cervical incision. Because think about it, that's where we're going to be doing these anastomosis. Now, once you gain access to the abdomen, like Dr. Von Allman said, the piece of colon that we choose is really based on the blood supply and the diameter that you're going to need. Now, once you have that piece of colon you're going to use for the interposition, Dr. Von Allman pulls that behind the stomach, maintaining the blood supply and obviously making sure that you don't make it too tortuous. So we're going to remove the stapled ends of both the proximal esophagus and the, I guess now proximal colon part of the interposition are removed. And then we can do our proximal anastomosis, which is what you see here. And then the distal anastomosis, same thing. So remove the stapled end of the colon, create the gastrotomy, and we're going to do our distal anastomosis similarly, as you can see here. Boom. There you have it. But we're not done. So next, to help with gastric emptying, we're going to do a pyloroplasty, which is again depicted here. And then finally, we have to re-approximate the two aligned ends of the colon that we took. So same thing, remove the stapled portion, and you're going to do your colo-colo anastomosis. And like with any other anastomosis, the key here is preserving the blood supply. Once that arterial supply is confirmed, then we know that we're in a good place to finish this surgery out. And now we're going to show you the side-by-side comparison on the left, the long gap esophageal latresia. On the right, the colon interposition. So thank you again to the Cincinnati Children's Media Lab. Scroll down under the media player. We're going to link some more videos that they've made. Now, the downside to using colon. Common problems with this are that they dilate and they can become tortuous. It's not uncommon to get kind of a sigmoid sink drain deformity just above the diaphragm. All right. Dr. Von Allman, how do you avoid that? Dr. Von Allman, I was taught initially that you can't fix that and that it's too dangerous and that you'll risk the blood supply to the colon interposition. But I found that actually that's not really true. I pass the interposition posterior to the stomach, which leaves the vascular pedicle along the spine. And you can mobilize the colon. You can divide the gastric dual aporotomy, divide the colon attachment to the stomach, and then mobilize that sigmoid redundancy transhiatally, and then reinestimose the colon to the stomach. So I wouldn't pretend to say that these don't need to be revised sometimes, but it is not impossible to revise them and the kids tend to do pretty well. But the good thing about using the colon? Dr. Von Allman, You can get extraordinary length on this. And Mike and I have done a few cases for kids who had disasters, multiple operations elsewhere, who had caustic injuries that were involved all the way up to the pharynx, where we had to do a lot of work just on the pharynx to get that open, and then literally sew the colon interposition to the pharynx and then down to the stomach, which is obviously tough to do with a gastric pull-up. Dr. Von Allman, And then here's some images of a colonic conduit in the OR, as well as a contrast image. Now, keep in mind that this video is from a live webinar. So here's a question from the interactive audience. Anas Sheikha brings up a great point. He says, you know, is this growth or stretch? Looking at the short interval between the time of traction and anastomosis, which is less than five days, is this stretching or growing? Because this will impact the results and likely reflects on the complications. We'd love to hear the comments for the experts on that. Dr. Von Allman, I don't think we know we should do the studies to understand that. But I would say that this gets back to David van der Zee's comment about, go have a cup of coffee and come back and it'll be fine. Clearly, that's not growth, that's stretch. And yet there's very good physiologic data that tension is a growth promoter, not necessarily in the esophagus, but in other organs. So I think that it's an area ripe for a little more basic science. So there you have it. A little advice from Dr. Dan Von Allman about what to do when you have esophageal atresia and the gap is just too long to put together right then and there. So if you like this episode, go ahead and subscribe to our YouTube channel, follow us on social media, download the Stay Current Pediatric Surgery app. And until next time, remember knowledge should be free. and I can go. I have a more and a really good time, to be a more. I have a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, to be a really good time, m'a, a really good time, a really good time, a really good time,

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