From
StayCurrentMD
Long Gap Esophageal Atresia – How I Do It: Update Course 2018
With Dr. Dave Vanderzee · hosted by Dr. von Alman & Dr. Ray Hankey
Chapter 1 of 6 · Fundamentals
Gap assessment
Introduction and Gap Assessment Methods
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
In Utrecht, they perform traction technique in the first week after birth without gastrostomy or gap measurement, achieving success in bringing ends together within 4-5 days in all cases
Even when the distal pouch is at the level of the hiatus, traction sutures can achieve approximation in 4-5 days
Non-stress contrast study of the lower segment is always performed because the lower segment is not always normal and may have duplications or congenital strictures
EGD is performed prior to surgery to understand the lower segment anatomy
Waiting 4-6 weeks with bolus feeds thickens the lower pouch, providing more tissue integrity for anastomosis
The critical technique in Foker traction is to put sutures in with some traction and then not touch them anymore, rather than continuously increasing traction
The baby grows but the esophagus may not grow during waiting periods, potentially making the gap longer to overcome
Manipulation with bougies can cause perforations or micro-perforations leading to esophageal fibrosis that prevents movement
Taking very small bites with fine sutures in traction technique risks approximating only the muscularis while the mucosa stays behind
For anastomosis, sutures must get deep enough to include submucosa without penetrating the mucosa to avoid leaks
A scope can be placed in the esophagus during traction suture placement to ensure sutures are positioned precisely
Tubes are left through the cricopharyngeus but no farther to avoid causing leaks
Seprafilm is placed in the thorax to reduce adhesions, making re-operation easier
Rotor knots are used for traction sutures so they can be tightened at subsequent operations
With extensive mobilization of the upper pouch all the way to the thoracic inlet, gaps up to 8 vertebral bodies can be closed in one procedure
The distal pouch should be mobilized to the diaphragm but not through the hiatus to avoid severe hiatal hernia
Flexing the neck and spine creates thoracic kyphosis which can provide the last centimeter needed for difficult anastomoses
Thoracoscopic approach may result in less gap than open approach because the chest is not opened and the spine is not elongated
Treatment approaches are local and situational - gastric pull-up may be appropriate in settings without prolonged ICU capability
Getting a small amount of mucosa in the anastomotic sutures prevents trans-anastomotic mucosal layer formation which delays healing
Chest tubes must be placed at least 1 centimeter away from the esophageal anastomosis to prevent erosion
Trans-anastomotic feeding tubes increase leak rates and should be avoided
For anastomotic leaks, vacuum sponge therapy involves placing a sponge with central drainage tube across the leak under fluoroscopy at 120 cm water suction
Vacuum sponges are left in place for 5-7 days maximum to avoid difficulty with removal
The sponge is soaked in contrast before placement so it can be visualized fluoroscopically
Vacuum sponge technique has been used successfully even for high-tension anastomoses prophylactically
Contained leaks less than 1 centimeter (small diverticula) will likely resolve without intervention by avoiding high intraesophageal pressure
Free leaks into the pleura require immediate control to prevent sepsis and empyema
For recurrent tracheoesophageal fistulas, TCA ablation after creating mucosal injury with cautery and brush has over 50% success rate with a couple of treatments
Placing a scope in the esophagus during fistula ablation ensures complete treatment of the entire tract without burning past it
An endotracheal tube balloon can be inflated at the fistula level to maintain apposition of epithelialized surfaces for several days
For recurrent TEF with tracheomalacia, open repair with fistula takedown flush with trachea under bronchoscopic view plus posterior tracheopexy is preferred
Performing posterior tracheopexy at the time of TEF repair eliminates recurrences in over 100 consecutive cases
TCA treatment is limited to patients without tracheomalacia and with long oblique fistula tracts, not appropriate for flat acquired fistulas
Louis Spitz stated that the esophagus stops growing at 12 weeks
In India, Dr. Gupta teaches primary gastric pull-up in the neonatal period for long-gap esophageal atresia
Most panelists approach right-sided aortic arch cases from the right side thoracoscopically without difficulty