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Long-gap Esophageal Atresia
Educational content from recorded physician discussions — not medical advice. Always talk to your child's care team about your child's situation.
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Routine esophageal biopsies should be performed during endoscopy in TEF patients to screen for eosinophilic esophagitis, even in the absence of overt symptoms. — Phil, Aerodigestive & Esophageal Surgery - The Unsalvageable Esophagus & Cases · 46:53
Aerodigestive & Esophageal Surgery - The Unsalvageable Esophagus & Cases
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Join the multidisciplinary team from Cincinnati Children's Hospital as they review the complexities in the management of Tracheal Esophageal Fistula (TEF). This fast paced live event will feature case presentations, video, and panel discuss
video1:41:09 · Nov 2018
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
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Pediatric surgeons Dr. Daniel Von Allmen and Dr. Todd Ponsky from Cincinnati children's Hospital discussing the technique for treating long gap esophageal atresia. For additional info please visit: https://www.youtube.com/c/CincinnatiChildr
podcast10:56 · Jan 2022
Journal of Pediatric Surgery Article Review: February 2023, BAPS issue
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We’re featuring new Journal of Pediatric surgery articles this week to bring you some of the latest news! This week we are discussing three articles from the February 2023 issue, the BAPS issue
We talked to the editor Dr. Mark Davenport
podcast12:32 · Apr 2023
Long Gap Discussion: EA & TEF
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Dr. Todd Ponsky moderates a panel discussion on the work-up of long gap esophageal atresia.
video10:16 · Jan 2019
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Long-gap esophageal atresia (LGEA) is defined by a gap ≥2 vertebral bodies or ~2 cm, though accurate measurement is challenging—blind probing can push the diaphragm cephalad, overestimating the gap . Primary anastomosis is attempted when feasible; if tension is excessive, placing the ends on internal traction for one week often permits successful delayed closure due to stretch-induced growth [e738-c2, e1077-c15]. Even 2–4 mm esophageal ends will grow into serviceable conduits under traction . The Foker technique (external traction sutures) and van der Zee thoracoscopic variant both exploit this principle [e4791-c2, e4791-c5]. However, these approaches carry significant morbidity: median ICU stays of 70–110 days, prolonged paralysis, and only 10–67% achieving full oral nutrition depending on primary vs. secondary repair [e4791-c8, e4791-c9].
When primary repair is not achievable by 6–8 weeks or the gap exceeds 5–6 vertebrae, esophageal replacement is indicated [e1077-c8, e1077-c9]. Options include gastric pull-up, colonic interposition (full-length or segmental), and small bowel interposition . Segmental colonic interposition preserves the native GE junction, reducing long-term redundancy and permitting future anti-reflux surgery at the native junction [e738-c5, e738-c6]. Full-length colon interposition risks progressive tortuosity and poor drainage [e4791-c14, e738-c47]. Gastric pull-up is recommended as first-line replacement by some groups . Complications are nearly inevitable; the goal is effective anticipation and multidisciplinary management .
- LGEA is defined as gap ≥2 vertebral bodies; accurate measurement requires endoscopy or fluoroscopy to avoid overestimation from diaphragmatic displacement during blind probing.
- Internal traction for one week after initial mobilization permits delayed anastomosis via stretch-induced growth, even from 2–4 mm esophageal ends.
- Foker and van der Zee techniques achieve 96% intact esophagus in de novo cases but require median ICU stays of 70–110 days with prolonged paralysis.
- Esophageal replacement is indicated if primary repair is not achievable by 6–8 weeks or gap exceeds 5–6 vertebrae; options include gastric pull-up and colonic interposition.
- Segmental colonic interposition preserves the native GE junction, reducing long-term redundancy and permitting future anti-reflux surgery, but requires two anastomoses and thoracotomy.
For patients & families
Long-gap esophageal atresia means the two ends of the food pipe are too far apart to connect right away. Doctors measure the gap using special cameras or X-rays with contrast dye [e738-c1, e1077-c4, e1077-c6]. If the gap is about 2 centimeters or less, surgeons can often bring the ends together during an operation . Sometimes they put gentle tension on the ends for a week, which helps them stretch and grow closer together so they can be connected at a second operation [e738-c2, e1077-c15, e4791-c3]. If the gap stays too wide after several weeks of waiting—usually more than 5 or 6 vertebrae by 6 to 8 weeks—doctors may recommend replacing the esophagus with a piece of the child's own colon or stomach [e1077-c8, e1077-c9, e4791-c10, e4791-c11]. These replacement operations are major procedures but can allow children to eat normally over time [e738-c59, e4791-c9]. The medical team watches closely for complications like narrowing (strictures), leaks, or breathing problems, which are common but can be managed [e738-c60, e738-c10]. Every child's situation is unique, and the care team will explain which approach is safest for your baby.
Long-gap esophageal atresia means the two ends of the food pipe are too far apart to connect right away. Doctors measure the gap using special cameras or X-rays with contrast dye [e738-c1, e1077-c4, e1077-c6]. If the gap is about 2 centimeters or less, surgeons can often bring the ends together during an operation . Sometimes they put gentle tension on the ends for a week, which helps them stretch and grow closer together so they can be connected at a second operation [e738-c2, e1077-c15, e4791-c3]. If the gap stays too wide after several weeks of waiting—usually more than 5 or 6 vertebrae by 6 to 8 weeks—doctors may recommend replacing the esophagus with a piece of the child's own colon or stomach [e1077-c8, e1077-c9, e4791-c10, e4791-c11]. These replacement operations are major procedures but can allow children to eat normally over time [e738-c59, e4791-c9]. The medical team watches closely for complications like narrowing (strictures), leaks, or breathing problems, which are common but can be managed [e738-c60, e738-c10]. Every child's situation is unique, and the care team will explain which approach is safest for your baby.
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Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
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.
clinicalDaniel von Allmen0:46 ↗
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.
Host summaryRod Gerardo summarizes what Dr. Daniel von Allmen said — not the host's own clinical position1:08 ↗
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.
clinicalDaniel von Allmen2:10 ↗
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.
clinicalDaniel von Allmen2:10 ↗
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.
Host summaryRod Gerardo summarizes what Dr. Daniel von Allmen said — not the host's own clinical position2:39 ↗
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.
Host summaryRod Gerardo summarizes what Dr. Daniel von Allmen said — not the host's own clinical position2:39 ↗
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.
Host summaryDaniel von Allmen summarizing a resource — not the host's own clinical position3:15 ↗
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.
Host summaryDaniel von Allmen summarizing a resource — not the host's own clinical position3:15 ↗
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.
Host summaryDaniel von Allmen summarizing a resource — not the host's own clinical position3:15 ↗
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.
Host summaryDaniel von Allmen summarizing a resource — not the host's own clinical position4:36 ↗
The colon can be used as an interposition for esophageal replacement.
clinicalDaniel von Allmen4:36 ↗
In colonic interposition, the piece of colon chosen is based on the blood supply and the diameter needed.
Host summaryRod Gerardo summarizes what Dr. Daniel von Allmen said — not the host's own clinical position5:08 ↗
In colonic interposition, a pyloroplasty is performed to help with gastric emptying.
Host summaryRod Gerardo summarizes what Dr. Daniel von Allmen said — not the host's own clinical position5:08 ↗
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.
clinicalDaniel von Allmen8:00 ↗
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.
opinionDaniel von Allmen8:17 ↗
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.
clinicalDaniel von Allmen8:17 ↗
Colonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well.
opinionDaniel von Allmen8:17 ↗
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.
clinicalDaniel von Allmen9:03 ↗
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.
Host summaryRod Gerardo summarizes what Dr. Daniel von Allmen said — not the host's own clinical position9:27 ↗
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.
opinionDaniel von Allmen9:56 ↗
Journal of Pediatric Surgery Article Review: February 2023, BAPS issue
In Poland, thoracoscopic esophageal atresia repair has been performed exclusively since 2005
Host summaryEllen Encisco summarizing the discussion — not the host's own clinical position1:38 ↗
The first thoracoscopic esophageal atresia procedure took almost 4 hours, but with experience it became a 1-hour procedure
Host summaryEllen Encisco summarizing the discussion — not the host's own clinical position1:54 ↗
Dr. Patkowski's team has had no conversions from thoracoscopic to open approach since beginning the technique
Host summaryEllen Encisco summarizing the discussion — not the host's own clinical position1:59 ↗
All esophageal atresia cases in Dr. Patkowski's center have been managed by one team using only the thoracoscopic approach since the beginning
Host summaryEllen Encisco summarizing the discussion — not the host's own clinical position2:06 ↗
Centralizing care for esophageal atresia patients is important even if transportation costs are higher, because complication costs are much higher
Host summaryEllen Encisco summarizing the discussion — not the host's own clinical position2:58 ↗
Dr. Patkowski's center handles 15 to 20 esophageal atresia cases per year, which provides sufficient volume for good experience
Host summaryEllen Encisco summarizing the discussion — not the host's own clinical position3:06 ↗
The Centre in Rocklaw has become the referral center for esophageal atresia and long gap esophageal atresia cases from the whole of Poland
clinicalMark Davenport3:38 ↗
Centers of excellence for esophageal atresia are showing better outcomes
clinicalTodd Ponsky4:13 ↗
Centralization of esophageal atresia care would be difficult to implement in the United States healthcare system
opinionTodd Ponsky4:26 ↗
In the Sheffield study, 47% of Hirschsprung disease patients needed a stoma before primary pull-through
epidemiologicalGovind Murthi5:35 ↗
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