# Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement — GCMD Library

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/CincinnatiChildrens/featured
https://www.jpedsurg.org/article/S0022-3468(15)00181-5/fulltext

100:00:00,360 --> 00:00:03,920Hi, Rod Gerardo, a research resident at Cincinnati Children's
200:00:03,920 --> 00:00:07,080Hospital Medical Center, and a few weeks ago, we talked about
300:00:07,080 --> 00:00:09,960esophageal atresia and tracheoesophageal fistula.
400:00:10,120 --> 00:00:12,440We talked about the diagnosis and surgical management,
500:00:12,560 --> 00:00:15,120but one piece of the puzzle that we didn't get to touch on.
600:00:15,240 --> 00:00:19,160What happens when that space between the proximal and distal
700:00:19,160 --> 00:00:23,320esophagus is just too long or what
800:00:23,320 --> 00:00:26,320we call a long gap? 
900:00:30,760 --> 00:00:31,440So today 
1000:00:31,440 --> 00:00:35,600we're going to talk about long gap esophageal atresia with Dr.
1100:00:35,600 --> 00:00:36,680Dan von Allmen. 
1200:00:36,680 --> 00:00:39,920He's the surgeon in chief at Cincinnati Children's Hospital Medical Center.
1300:00:39,960 --> 00:00:42,800And the first thing we should probably touch on is
1400:00:43,040 --> 00:00:46,320how do you even know if that gap is too long in the first place?
1500:00:46,800 --> 00:00:50,560Our method here is that if we have a child with no gas
1600:00:50,560 --> 00:00:53,240in the abdomen, we take them to the OR and put a G-Tube in.
1700:00:53,840 --> 00:00:55,040Many times will do. 
1800:00:55,040 --> 00:00:58,040We'll put something up the distal esophagus at that point
1900:00:58,040 --> 00:01:01,280and just get a Fluoro shot but then would wait a couple of weeks.
2000:01:01,280 --> 00:01:04,480And we have our patients go down to interventional radiology,
2100:01:05,000 --> 00:01:08,120where we have a protocol for measuring the gap.
2200:01:08,120 --> 00:01:12,040OK, so at Cincinnati Children's, they have a protocol for how exactly
2300:01:12,040 --> 00:01:13,280they measure that gap. 
2400:01:13,280 --> 00:01:15,200So it's the same for every patient. 
2500:01:15,200 --> 00:01:19,080So then once you find out that you have a gap, you got some options.
2600:01:19,480 --> 00:01:22,280They all have advantages and disadvantages.
2700:01:22,760 --> 00:01:26,120As we all know, we like to try to preserve the esophagus if we can.
2800:01:26,120 --> 00:01:30,080And certainly John Foker and David who's been on and Kimura
2900:01:30,360 --> 00:01:34,040have described great elongation techniques
3000:01:34,440 --> 00:01:37,800that can be used to try to get the,
3100:01:37,880 --> 00:01:40,960to preserve the native esophagus and get the two ends together.
3200:01:41,480 --> 00:01:43,680First, let's talk about the Foker technique.
3300:01:44,360 --> 00:01:45,320In this procedure, 
3400:01:45,320 --> 00:01:48,920the surgeon, through an open incision, will tie a suture to either
3500:01:48,920 --> 00:01:51,680end of the esophagus. Then they'll bring those sutures
3600:01:51,680 --> 00:01:53,680out through the chest wall and close the incision.
3700:01:54,360 --> 00:01:56,920Then they take those two free ends of the suture and tie them
3800:01:56,920 --> 00:01:58,480together in a knot. 
3900:01:58,480 --> 00:02:02,720Then they place spacers underneath the knot periodically about every day
4000:02:02,720 --> 00:02:06,800or so until the two ends come together, and they take the patient
4100:02:06,800 --> 00:02:09,640back to the operating room for a primary anastomosis.
4200:02:09,960 --> 00:02:14,000The physiology, which I believe in intensely,
4300:02:14,000 --> 00:02:17,440is that stretch is a, is a very strong promoter of growth.
4400:02:17,840 --> 00:02:20,000And that if you put things on tension. 
4500:02:20,000 --> 00:02:21,720They will actually grow over time. 
4600:02:21,720 --> 00:02:24,520That's how the cardiovascular system develops in utero.
4700:02:24,800 --> 00:02:28,800And I did some research early in my career looking at one growth and using pressure
4800:02:28,800 --> 00:02:29,840to grow one. So. 
4900:02:29,840 --> 00:02:33,560So but the philosophy here is that with traction, you can get
5000:02:33,720 --> 00:02:35,720the two ends of the esophagus to grow, 
5100:02:35,720 --> 00:02:39,120and if you can get them to grow far enough, you can put them together.
5200:02:39,920 --> 00:02:41,960OK, next we'll talk about the Van Der Zee technique.
5300:02:42,120 --> 00:02:43,360It's the same concept, 
5400:02:43,360 --> 00:02:47,240except it's done thoracoscopically and there are no external sutures.
5500:02:47,240 --> 00:02:50,320So all of the tension is inside the thorax.
5600:02:50,920 --> 00:02:55,240And lastly, the Kimura technique, which really isn't used all that often anymore.
5700:02:55,640 --> 00:03:00,600The idea here is you first create spit fistula and then periodically you move
5800:03:00,600 --> 00:03:05,000that fistula down the chest wall over time to stretch the proximal pouch,
5900:03:05,280 --> 00:03:09,080bringing it closer to the distal pouch to be able to create an anastomosis.
6000:03:09,760 --> 00:03:11,600Now, if we look specifically at the Foker 
6100:03:11,600 --> 00:03:15,000technique, there is some good literature to support this technique.
6200:03:15,440 --> 00:03:16,680Here's Dr. von Allmen. 
6300:03:16,680 --> 00:03:22,080There was a great article published by the Boston Group 2015.
6400:03:22,360 --> 00:03:26,000Divides the cases into two groups primary group and secondary
6500:03:26,000 --> 00:03:30,000groups, secondary being patients who have had operations previously.
6600:03:30,000 --> 00:03:33,920And the primary group being cases that they saw de novo.
6700:03:34,160 --> 00:03:38,360Obviously, you look at the result of getting the esophagus together,
6800:03:38,400 --> 00:03:42,160an intact esophagus in 96% of patients in the primary group.
6900:03:42,600 --> 00:03:45,480About two thirds of patients in the secondary group.
7000:03:45,920 --> 00:03:48,920But these procedures are not without some morbidity.
7100:03:48,920 --> 00:03:53,120And you look at the ICU stay is a median of 70 days, with,
7200:03:53,960 --> 00:03:56,520a couple of weeks being paralyzed for the primary group
7300:03:56,920 --> 00:03:59,640and 110 days 
7400:03:59,640 --> 00:04:03,200for the secondary group with with a month of being paralyzed.
7500:04:03,320 --> 00:04:05,320About two thirds of patients with the primary
7600:04:05,320 --> 00:04:07,960repair were able to get the full oral nutrition,
7700:04:08,320 --> 00:04:12,520and about 10 percent of the patients who had the secondary repair.
7800:04:12,920 --> 00:04:15,600If you want the article, I'm going to link it below, so scroll down
7900:04:15,680 --> 00:04:17,440under the media player, you could open it up. 
8000:04:17,440 --> 00:04:19,640We were all taught the 
8100:04:19,640 --> 00:04:22,080the dictum that every effort should be made to conserve
8200:04:22,080 --> 00:04:25,440the native esophagus, as no other conduit can replace its function
8300:04:25,440 --> 00:04:29,120in transporting food from the oral cavity to the stomach satisfactorily.
8400:04:29,760 --> 00:04:31,880So all of these techniques are great, but
8500:04:32,400 --> 00:04:35,120what if none of them really work?
8600:04:35,840 --> 00:04:38,080Then what do we do? Great question, Rod.
8700:04:38,400 --> 00:04:42,200You could use the stomach that would be called a gastric transposition.
8800:04:42,440 --> 00:04:45,240The surgical group from the INOEA
8900:04:45,840 --> 00:04:49,480Their recommendation, their recommendation for the first option
9000:04:49,480 --> 00:04:52,920as a gastric pull up, I divide the esophageal stub
9100:04:52,920 --> 00:04:56,960that the esophageal hiatus and mobilize the fundus and pull the fundus up.
9200:04:56,960 --> 00:05:01,360And you can pull it off, either in the anterior or posterior mediastinum.
9300:05:01,600 --> 00:05:04,440You can actually use the colon as an interposition as well.
9400:05:04,720 --> 00:05:07,800I personally was trained to do colon interpositions.
9500:05:08,640 --> 00:05:11,040And just how exactly does Dr.
9600:05:11,040 --> 00:05:13,760von Allmen do this colonic interposition?
9700:05:14,240 --> 00:05:18,160Well, to answer that, we had this awesome video created
9800:05:18,160 --> 00:05:22,760by the Cincinnati Children's Media Lab, and they were gracious
9900:05:22,760 --> 00:05:26,720enough to share this with you so that you can learn.
10000:05:27,400 --> 00:05:28,920So we're going to start off with two incisions. 
10100:05:28,920 --> 00:05:29,760first. 
10200:05:29,760 --> 00:05:33,880Is your midline abdominal incision and second is your cervical incision,
10300:05:33,880 --> 00:05:37,000because think about it, that's where we're going to be doing these anastomosis.
10400:05:37,520 --> 00:05:41,400Now once you gain access to the abdomen, like Dr.
10500:05:41,400 --> 00:05:45,120von Allmen said, the piece of colon that we choose is really based
10600:05:45,120 --> 00:05:49,640on the blood supply and the diameter that you're going to need.
10700:05:53,400 --> 00:05:54,320Now, once you 
10800:05:54,320 --> 00:05:57,960have that piece of colon, you're going to use for the interposition.
10900:05:58,360 --> 00:06:02,560Dr. von Allmen pulls that behind the stomach, maintaining
11000:06:02,560 --> 00:06:05,920the blood supply and obviously making sure that you don't make it
11100:06:05,920 --> 00:06:07,840too torturous. 
11200:06:08,920 --> 00:06:10,720The stapled ends of both 
11300:06:10,720 --> 00:06:13,840the proximal esophagus and the
11400:06:14,440 --> 00:06:18,760I guess now proximal colon part of the interposition are removed
11500:06:19,000 --> 00:06:22,720and then we can do our proximal anastomosis, which is what you see here.
11600:06:26,440 --> 00:06:30,040And then the distal anastomosis same things removed.
11700:06:30,040 --> 00:06:34,760The stapled end of the colon, create the gastrostomy,
11800:06:35,200 --> 00:06:39,040and we're going to do our distal anastomosis.
11900:06:39,040 --> 00:06:42,400Similarly, as you can see here. 
12000:06:45,360 --> 00:06:48,720Boom, there you have it, but we're not done.
12100:06:49,080 --> 00:06:53,040So next to help with gastric emptying,
12200:06:53,400 --> 00:06:57,720we're going to do a pyloroplasty which is again depicted here.
12300:07:06,560 --> 00:07:08,040And then finally, 
12400:07:08,040 --> 00:07:11,080we have to re approximate
12500:07:11,080 --> 00:07:15,080the two blind ends of the colon that we took.
12600:07:15,360 --> 00:07:16,480So same thing. 
12700:07:16,480 --> 00:07:19,720Remove the stapled portion and you're going to do your Colo,
12800:07:19,720 --> 00:07:23,520Colo anastomosis. 
12900:07:27,520 --> 00:07:28,280And like 
13000:07:28,280 --> 00:07:32,080with any other anastomosis, the key here
13100:07:32,080 --> 00:07:34,720is preserving the blood supply
13200:07:35,200 --> 00:07:38,080once that arterial supply is confirmed.
13300:07:38,480 --> 00:07:42,640Then we know that we're in a good place to finish this surgery out.
13400:07:46,200 --> 00:07:49,440And now we're going to show you the side by side comparison on the left,
13500:07:49,440 --> 00:07:53,640the long gap esophageal atresia on the right, the colon and interposition.
13600:07:53,640 --> 00:07:56,800So thank you again to the Cincinnati Children's Media Lab.
13700:07:57,120 --> 00:07:58,400Scroll down under the media player. 
13800:07:58,400 --> 00:08:00,640We're going to link some more videos that they've made. 
13900:08:00,640 --> 00:08:02,720Now the downside to using colon.
14000:08:02,920 --> 00:08:07,640Common problems with this are that they dilate and they can become torturous.
14100:08:07,880 --> 00:08:10,640It's not uncommon to get kind of the sigmoid
14200:08:11,520 --> 00:08:14,560sink drain deformity just above the diaphragm.
14300:08:14,800 --> 00:08:17,280All right. Dr. von Allmen, how do you avoid that?
14400:08:17,520 --> 00:08:20,320I was taught initially that that you can't fix that
14500:08:20,320 --> 00:08:21,480and that it's too dangerous 
14600:08:21,480 --> 00:08:24,160and that your risk the blood supply to the colon interposition.
14700:08:24,720 --> 00:08:27,120But I found that actually, that's not really true.
14800:08:27,320 --> 00:08:31,320I passed the interposition posterior to the stomach, which leaves
14900:08:31,320 --> 00:08:36,320the vascular pedicle along the spine, and you can mobilize the colon.
15000:08:36,320 --> 00:08:40,280You can divide the gastric, do a laparotomy, divide the
15100:08:41,560 --> 00:08:43,200colon attachment to the stomach 
15200:08:43,200 --> 00:08:47,680and then mobilize the, that sigmoid redundancy,
15300:08:48,000 --> 00:08:51,840transhiatally and then re-anastamos the colon to the stomach.
15400:08:51,840 --> 00:08:56,560So I wouldn't pretend to say that these don't need to be revised sometimes,
15500:08:56,560 --> 00:09:00,560but it is not impossible to revise them, and the kids tend to do pretty well.
15600:09:00,960 --> 00:09:05,280But the good thing about using the colon, you can get extraordinary length on this.
15700:09:05,360 --> 00:09:08,520Mike and I have done a few cases for kids who had
15800:09:09,200 --> 00:09:13,560disasters, multiple operations elsewhere, who had caustic injuries
15900:09:13,800 --> 00:09:16,000that were involved all the way up to the pharynx,
16000:09:16,000 --> 00:09:20,040where we had to do a lot of work just on the pharynx to get that open.
16100:09:20,040 --> 00:09:23,240And then literally sew the colon interposition to the pharynx
16200:09:23,240 --> 00:09:26,040and then down to the stomach, which is obviously tough to do
16300:09:26,080 --> 00:09:27,520with the gastric colon. 
16400:09:27,520 --> 00:09:31,360And then here's some images of a colonic conduit in the O.R.,
16500:09:31,360 --> 00:09:33,560as well as a contrast image. 
16600:09:33,560 --> 00:09:37,080Now, keep in mind that this video is from a live webinar.
16700:09:37,400 --> 00:09:40,160So here's a question from the interactive audience.
16800:09:40,160 --> 00:09:42,600Sheika brings up a great point he says.
16900:09:42,600 --> 00:09:44,960You know, is this growth or stretch? 
17000:09:44,960 --> 00:09:47,240Looking at the short interval between the time of traction
17100:09:47,240 --> 00:09:49,440and anastomosis, which is less than five days.
17200:09:49,480 --> 00:09:51,120Is it stretching or growing? 
17300:09:51,120 --> 00:09:54,280Because this will impact the results and likely reflects on the complication.
17400:09:54,280 --> 00:09:56,360I would love to hear the comments from the experts on that.
17500:09:56,840 --> 00:09:59,920I don't think we know we should do the studies to understand that.
17600:09:59,920 --> 00:10:03,800But I would say that this gets back to David van der Zee's comment about.
17700:10:03,800 --> 00:10:06,320Go have a cup of coffee and come back and it will be fine.
17800:10:06,400 --> 00:10:08,320Clearly, that's not growth that's stretch.
17900:10:09,760 --> 00:10:10,840And yet 
18000:10:10,840 --> 00:10:14,000there's the there's very good physiologic data.
18100:10:14,000 --> 00:10:16,640That tension is a growth promoter, 
18200:10:16,640 --> 00:10:19,280not necessarily in the esophagus, but in other organs.
18300:10:19,280 --> 00:10:24,320So I think that it's area ripe for for a little more basic science.
18400:10:24,640 --> 00:10:25,640So there you have it. 
18500:10:25,640 --> 00:10:27,360A little advice from Dr. 
18600:10:27,360 --> 00:10:31,960Dan von Allmen about what to do when you have esophageal atresia,
18700:10:31,960 --> 00:10:36,800and the gap is just too long to put together right then and there.
18800:10:36,960 --> 00:10:40,360So if you like this episode, go ahead and subscribe to our YouTube channel.
18900:10:40,360 --> 00:10:44,000Follow us on social media, download the Stay current pediatric surgery app
19000:10:44,840 --> 00:10:47,080and until next time, remember, knowledge
19100:10:47,840 --> 00:10:49,160should be free. 
19200:11:07,960 --> 00:11:11,080Now, if you're listening to this podcast, like an audio
19300:11:11,080 --> 00:11:12,920only version of this podcast, 
19400:11:12,920 --> 00:11:16,720that's totally fine, just know that we want to give you the steps of how Dr.
19500:11:16,720 --> 00:11:18,280von Allmen does this surgery. 
19600:11:18,280 --> 00:11:20,520So you got a couple options? 
19700:11:20,520 --> 00:11:22,640Scroll down under the media player, you can see a couple of links.
19800:11:22,640 --> 00:11:25,680one of them is to our YouTube page,
19900:11:25,680 --> 00:11:29,040and you can watch a video version of this podcast.
20000:11:29,440 --> 00:11:32,200And in that video version, we're going to have an animation
20100:11:32,480 --> 00:11:35,200created by the Cincinnati Children's Media Lab
20200:11:35,560 --> 00:11:38,960that walks you through the steps of this colonic interposition.
20300:11:39,720 --> 00:11:42,120Or if you just want to watch 
20400:11:42,120 --> 00:11:45,360like just that part of the video,
20500:11:45,800 --> 00:11:49,360we're going to link you to the Cincinnati Children's
20600:11:49,360 --> 00:11:53,960Media Lab's video animation of just the surgery itself.
20700:11:53,960 --> 00:11:57,560So you can click on that and watch that pop back into this audio podcast,
20800:11:57,560 --> 00:12:01,040or you can watch a video version of this whole podcast.
20900:12:01,400 --> 00:12:04,360You know, there's just so many options that we want to give you
21000:12:04,360 --> 00:12:07,480all of this content, either on YouTube or on
21100:12:07,480 --> 00:12:10,560audio podcasts or on our stay.
21200:12:10,560 --> 00:12:13,920Current in Pediatric Surgery app, which is in the Google Play Store
21300:12:13,920 --> 00:12:19,520and the Apple App Store, you got a lot of different ways you can learn from Dr.
21400:12:19,520 --> 00:12:20,640von Altman. 
21500:12:20,640 --> 00:12:21,920We're going to give them all to you. 
21600:12:21,920 --> 00:12:23,840So follow the links, do whatever you want. 
21700:12:23,840 --> 00:12:25,480But in the meantime, here's the rest of the episode. Type: podcast · 10 min · posted 2022-01-04 Canonical: https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791 ## Chapters - [0:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=0) Defining and Measuring Long Gap Esophageal Atresia - [2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130) Esophageal Elongation Techniques - [4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276) Esophageal Replacement Options - [8:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=480) Complications and Revisions ## Statements - "Long gap esophageal atresia is defined by absence of gas in the abdomen on initial imaging" — Daniel von Allmen (clinical) [0:46](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=46) - "Cincinnati Children's uses a standardized interventional radiology protocol for measuring the esophageal gap, performed a couple of weeks after initial G-tube placement" — Daniel von Allmen (clinical) [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 structures placed under tension will grow over time" — Daniel von Allmen (clinical) [2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130) - "The cardiovascular system develops in utero using tension-based growth mechanisms" — Daniel von Allmen (clinical) [2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130) - "In 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 (clinical) [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 traction concept as Foker but is performed thoracoscopically with all tension maintained inside the thorax" — Rod Gerardo (clinical) [2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130) - "The 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 (clinical) [2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130) - "The Kimura technique is not used often anymore" — Rod Gerardo (opinion) [2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130) - "A 2015 Boston series reported 96% success rate achieving intact esophagus in primary Foker cases" — Daniel von Allmen (epidemiological) [3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - "In secondary Foker cases (patients with previous operations), success rate was approximately two-thirds" — Daniel von Allmen (epidemiological) [3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - "Primary Foker cases had median ICU stay of 70 days with median two weeks of paralysis" — Daniel von Allmen (epidemiological) [3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - "Secondary Foker cases had median ICU stay of 110 days with median one month of paralysis" — Daniel von Allmen (epidemiological) [3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - "About two-thirds of primary Foker repair patients achieved full oral nutrition" — Daniel von Allmen (epidemiological) [3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - "About 10% of secondary Foker repair patients achieved full oral nutrition" — Daniel von Allmen (epidemiological) [3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - "The 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 (guideline) [4:12](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=252) - "The INOEA surgical group recommends gastric pull-up as the first option for esophageal replacement" — Daniel von Allmen (guideline) [4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276) - "In gastric transposition, the esophageal stump is divided at the esophageal hiatus, the fundus is mobilized and pulled up through either anterior or posterior mediastinum" — Daniel von Allmen (clinical) [4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276) - "Colon can be used as an interposition conduit for esophageal replacement" — Daniel von Allmen (clinical) [4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276) - "The choice of colon segment for interposition is based on blood supply and required diameter" — Rod Gerardo (clinical) [5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308) - "In colonic interposition, the colon is passed behind the stomach while maintaining blood supply" — Rod Gerardo (clinical) [5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308) - "Pyloroplasty is performed during colonic interposition to help with gastric emptying" — Rod Gerardo (clinical) [5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308) - "Common problems with colonic interposition include dilation and tortuosity, with sigmoid redundancy often developing just above the diaphragm" — Daniel von Allmen (clinical) [8:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=480) - "Traditional teaching held that colonic interposition redundancy cannot be fixed safely due to risk to blood supply" — Daniel von Allmen (opinion) [8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497) - "Passing the colonic interposition posterior to the stomach leaves the vascular pedicle along the spine, allowing safe mobilization and revision" — Daniel von Allmen (clinical) [8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497) - "Sigmoid redundancy in colonic interposition can be revised transhiatally by dividing the gastroduodenal anastomosis, mobilizing the redundant segment, and re-anastomosing to the stomach" — Daniel von Allmen (clinical) [8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497) - "Colonic interposition can achieve extraordinary length, sufficient to reach from pharynx to stomach in cases of extensive caustic injury" — Daniel von Allmen (clinical) [9:01](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=541) - "Gastric pull-up is difficult to perform when anastomosis to the pharynx is required" — Daniel von Allmen (clinical) [9:01](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=541) - "The 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 (opinion) [9:56](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=596) - "There is good physiologic data that tension is a growth promoter in organs other than the esophagus" — Daniel von Allmen (clinical) [9:56](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=596) - "The mechanism of esophageal elongation (growth versus stretch) is not definitively known and requires further basic science research" — Daniel von Allmen (opinion) [9:56](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=596) ## Transcript 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, --- Not medical advice · citation policy: https://library.globalcastmd.com/ai