Staged esophageal lengthening with internal and subsequent external traction sutures leads to primary repair of an ultralong gap esophageal atresia with upper pouch tracheoesophagel fistula

Primary repair of very long gap esophageal atresia (EA) with almost complete absence of thoracic esophagus has usually been thought impossible. Thus, esophageal replacement with colon or gastric interposition seemed inevitable. In contrast, J. Foker described a technique of lengthening the pouches with traction sutures and making primary repair possible. To contribute clinical experience to this discussion, we report about esophageal elongation in a child with long gap EA and an upper pouch tracheoesophageal fistula (TEF). The patient presented as a preterm baby with a long gap EA of almost 9 vertebral bodies (7 cm) and additionally TEF on the upper pouch. Initially, he was treated with a gastrostomy and replogle suction of the upper pouch. Tracheoesophageal fistula was repaired, and the upper pouch brought from the neck into the thoracic inlet. At the same time thoracotomy was performed, and the lower esophageal segment mobilized and fixed to the prevertebral fascia under moderate tension. The tension reduced the gap between both pouches to about 3.5 cm. After 4 weeks, both pouches were mobilized further. However, the remaining gap did not allow primary anastomosis at that time, so the traction sutures were reconfigured and brought out externally through the skin above and below the incision. Daily increases in tension resulted in the ends virtually touching within 10 days. Now a contrast study showed the two lumens within 5 mm of each other, and primary anastomosis was completed without difficulty. Postoperative diagnosed gastroesophageal reflux and anastomotic stricture were controlled by a Thal hemifundoplication and dilatations. In conclusion, staged esophageal lengthening may be considered for a primary repair of EA even in cases with ultralong gap and TEF.