Simple Technique of Bridging Wide Gap in Esophageal Atresia with Tracheoesophageal Fistula – “Surgical Innovation”

Abstract

The survival of the patients with esophageal atresia an tracheo esophageal fistula is believed to be an epitome of the success of the neonatal surgery. Restoring the continuty of the food pipe by esophagus to esophagus anastomosis is the best option. Preservation of natural esophagus by delayed repair in a wide gap esophageal atresia is a preferred technique worldwide, however such a management required prolonged hospitalization and dedicated nursing care, which is often not available in most of the centres in India. Esophageal substitutes in wide gap requires multiple operations and have long term problems, so remains the last option. I use the technique of oblique anastomosis which had distrinct advantage over circular anastomosis in the management of esophageal atresia1. This techniqe helps in bridging wide gap to some extent & minimal stricture formation.

INTRODUCTION

The survival of patients with esophageal atresia and tracheoesophageal fistula is believed to be an epitome of the success of the neonatal surgery.

Restoring the continuity of the food pipe by esophagus to esophagus anastomosis is the best option. Preservation of natural esophagus by delayed repair in a wide-gap esophageal atresia is a preferred technique worldwide; however, such a management requires prolonged hospitalization and dedicated nursing care which is often not available in most of the centers in India. The esophageal substitutes in wide gap require multiple operations and have long-term problems, and hence remain the last option.

In such cases, we prefer to use the technique of oblique anastomosis which had a distinct advantage over circular anastomosis in the management of esophageal atresia.[1] This technique helps in bridging wide gap to some extent with minimal stricture formation.

Technique

The technique described here is an extension of the technique of oblique anastomosis for wide-gap esophageal atresia.

The gap between two ends of esophagus is assessed after fistula ligation to judge the feasibility of esophageal anastomosis. The upper end of the esophagus is mobilized completely. The lower end of the esophagus is mobilized up to cardioesophageal junction.[2] Depending on the condition of the upper esophagus, a flap of 1.5–2 cm is raised by transverse incision dividing the blind end of the upper esophagus halfway down and the flap is turned posteriorly [Figure 1]. A vertical incision is made in the middle of the lumen of the lower esophagus anteriorly depending on the size of the lumen. The posterior end of the lower esophagus is anastomosed to the reflected flap of the upper esophagus by 3–4 interrupted 60 Vicryl sutures. In this way, the continuity of the posterior half of the esophagus is achieved. The esophagus is now an open tube anteriorly. A No. 6 nasogastric tube is passed through the nostril to stomach under vision. This open esophageal tube is closed vertically by continuous 60 Vicry suture, and the procedures are completed.

Figure 1.

The upper end of the esophagus is mobilized. The lower end of the esophagus is mobilized up to cardioesophageal junction. Upper esophagus, a flap of 1.5–2 cm is raised by transverse incision dividing the blind end of the upper esophagus halfway down and the flap is turned posteriorly. The posterior end of the lower esophagus is anastomosed to the reflected flap of the upper esophagus by 3–4 interrupted 60 Vicryl sutures. The esophagus is now an open tube anteriorly. This open esophageal tube is closed vertically by continuous 60 Vicry suture and the procedures are completed

With this technique, we may be able to bridge the gap up to 4.5 cm. The other advantage of this technique is that the configuration of the circular and longitudinal muscles’ layer of the esophagus is not disturbed.

This technique was used in four patients, one patient had a leak on the 6^th postoperative day, and the patient was treated conservatively. The fistula closed in 6 weeks of time.

One patient died on the 5^th postoperative day due to major cardiac anomalies which were diagnosed preoperatively; there was no leak. Two patients had uneventful postoperative period. The nasogastric tube was kept in situ for 15 days. Postoperative esophageal calibration was done 4–6 weeks after surgery or after the fistula had healed.

Calibration is done with 60F red rubber catheter and gradually increased up to No. 100F size of the catheter. We do not have long-term follow-up of these cases.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.