Long Gap Discussion: EA & TEF

Um, any comments on that while we're going to in a minute pull up your slides? I wasn't, I wasn't sure of what that gadget he had that he was measuring pressure on in the esophagus. My only comment on the technique is he still is putting the probe in blindly, so it could be cardia in the stomach. Yeah, so you don't know. You know, one of the things about the stomach and the diaphragm of an, of an infant is it's like a rubber balloon. You can push that diaphragm all the way up to the upper part of the chest cavity without causing any damage or perforation and not know it. And that's why there's been so many mistakes made in measuring the gap. And that's why I came up with the idea many, many years ago of using the little neonatal uh gastroscope to absolutely know where you were. And as you can see, I think in the movie that I showed before Doctor Bagalan, The GE junction in these esophageal atresias, you know, pure, pure long gap esophageal atresia, is very tiny. You can see that to get into that area, even under direct vision with a scope, you've got to manipulate the scope a little bit because it tends to flip out of it. And that's the, that's the problem with blindly measuring these gaps. OK, um, yeah, go ahead, Professor Bagalo. Yeah, you are perfectly right. So two little criticisms. The first one is that with using endoscope you can't measure the boost force you apply to your endoscope. So you can measure objectively, I mean in a comparable with a comparable method, the force. The second one is, of course. You are right when you say that the injunction is very delicate, so you have to wait at least 15 days before doing the first measurement. And of course before doing the measurement with the Heger number 4, no more, you, you look at the cardiac by an endoscopy a little. Endoscope to be sure that the cardiac is there because sometimes as you told me more than once, cardiac is not there at all. There are some babies without any cardiac, so I think that the combination of the two ideas to look at the cardiac but then to push and to measure your force with an objective method. Probably should be the most, the most interesting method to have a real idea of our gap. 30 seconds, 20 seconds left, and then we're going to move on. One other thing I'd like to point out that if you do a contrast study at let's say 3 weeks after you put a gastrostomy into one of these babies and you put the baby even in Trendbellenberg, etc. You may not fill. You may not fill that distal esophageal segment completely. So again, it'll give you a false sense of what the real gap is. Doctor Bland, last comment. Yeah, you're right. The, the, the reason why I showed you the x-ray of the upper GI was only to see you, the big difference in the gap measurement. I never do upper GI to measure the gap because you are perfectly. Right about the gasses of a jet reflux, but it was only to show how big a difference there is in the 3 different methods of gap measurement and to share only 1 m between all 3rd level centers to be comparable. That's actually, Mark, put the cameras back on for 1 2nd before we show Dr. Korn's slides. I want to quickly go through and then we're going to see Dr. Korn's approach. I'm going to fly through the faculty here. Give me a 1 minute or 32nd summary of what you do. So, Professor Spitz, baby's born, they have a gasless abdomen. You do a, I'm assuming you put in a G tube. What's your approach? Do you wait several months? Do you do Doctor Folker's technique? Do you, uh, do you, um, try to get the ends together sooner? What, what, what is your, uh, what are your options? I, I would not do a cervical esophagostomy immediately. I would wait, uh, a good couple of weeks for assessing the, the gap, and I've usually done that with a HA or a urethral dilator, uh, under fluoroscopic control. And once at that stage, the gap is more than, uh, 5 or 6 vertebrae, at 4 or 4 to 6 weeks, I would probably opt for a replacement. OK. Uh, Miguel. We put a laparoscopic gastrostomy and then every 2 weeks we measure the gap until we are able to see less than 2 virtual bodies and if it's not working up to 8 weeks, we start thinking about replacements. OK, uh, Professor Bagalo. Uh, only the gastrostomy at birth and then gap measurement every 15 days, did the 6 weeks, uh, and generally that, at that moment, it's possible to do a, uh, delayed anastomosis. That's only for inborn babies. That's different for referrals with, uh, an esophageal esophagostomy, uh, cervical esophagostomy, of course, but I think the question is not about referrals. OK. Um, Holger? I'm. How do you approach these newborns with a pure resia, long gap? Well, you know, that's a long story. Let me first give me the 32nd version. Now the first support is, um, uh, I very much enjoy the technique that Annie showed, and I do endoscope all of my patients now with a long gap just to intubate the lower esophagusphincter, see not only how long it is, but also, uh, what's the quality of the lumen. OK, then what I do is I wait like I mentioned earlier, and I clip the fistula. I leave it attached, knowing that Jack is right. It may re-canalize, so I'm careful, but then I wait and observe whether there's spontaneous growth, and then I assess him like you showed before. He got in the upper pouch, endoscope in the lower pouch, and if it's less than 3 vertebral broad centimeters, I go for a primary repair. And if not, then the story starts. All right, we'll get and we're gonna get to that. That's why I want to move forward, so Jack. So, uh, we have uh interventional radiology put in our G tube, as I mentioned. Uh, we check the gap actually in interventional radiology, they, uh, use a wire that goes through the G tube and they can thread it up into the esophagus so they can be sure that they're actually in the esophagus. And we check that every month or so. And I give them up to about 3 months to grow close enough together. If they're not close enough together at that point, then, uh, you know, we'll talk about what to do with that in the next session, I think. Jean Martin, any other comments? OK, we'll get him. I, I see you're on the phone. Do you hear us, Jean Martin? Yeah, he had to run down to the clinic. He had to take care of patients. Yes, he did. Sorry about that. What do you guys do there? We would basically do what you've described above. I'm a 2nd year fellow, but we wouldn't do anything different than previously mentioned. OK, so then, uh, and Dr. Folker. Well, I'm not sure how much heresy you want, but, um, uh, you know, we put in a G tube, uh, the interventional radiologist will get a, uh, tube up into the lower esophagus. We do an unstressed gappogram, a little contrast above. contrast into the lower end and it gives you an idea of what you're up against. If it's just a tiny thing, then it's going to need a period of growth. If it's fairly good size. Then once the child is of reasonable size, 3 3.5 kg sturdy, then we'd go ahead with the operation. The operation is quite flexible. Once you have things dissected out and they, the two ends are together or, or being pulled together, um, but not open. And you judge that it's more attention than you want, and that's a very individual thing. I mean, all of this is will vary by the surgeon, then put it on internal traction, wait a week. And you'll be surprised at how much growth has been achieved and you can put it together. If it's just a tiny end, and we've had ends that are, you know, 2 or 3 or 4 millimeters, but all the information is there. If you put those on, on traction, they will grow and they grow into quite a serviceable esophagus. It's really amazing. You're tapping into biology here, um. So we don't worry too much about what the gap is to start with. We do it unstressed. Don't put things in. Don't push, because, as I believe Arnie said, and our first patient from Boston showed it, they said gap of 2 centimeters, and all they were doing was pushing the diaphragm up well into the chest, and it was just a little 5 or 6 millimeter nubbin. Uh, so it's very deceptive doing it that way. But, you know, we have a very flexible approach when you do the operation, and you can do amazing things by stimulating growth and, and be flexible. You don't have to go ahead with the primary repair just because you've mobilized the two ends.