Reconstruction of the esophagus without colon transplantation in cases of atresia

Surgical esophageal diseases in children

Pediatric age esophageal diseases are rare and complex clinical conditions. Treatment options should be individually determined for the patient. The advances in the follow-up and treatment process is the most important reason for the increase in survival time, particularly for congenital pediatric surgical diseases. This study aimed to evaluate the general characteristics of pediatric surgical esophageal diseases in light of the literature.

Delayed primary anastomosis for repair of long-gap esophageal atresia: technique revisited

The operative management of patients born with long-gap esophageal atresia (LGEA) remains a major challenge for most pediatric surgeons, due to the rarity and complex nature of this malformation. In LGEA, the distance between the proximal and distal esophageal end is too wide, making a primary anastomosis often impossible. Still, every effort should be made to preserve the native esophagus as no other conduit can replace its function in transporting food from the oral cavity to the stomach satisfactorily. In 1981, Puri et al. observed that in newborns with LGEA spontaneous growth and hypertrophy of the two segments occur at a rate faster than overall somatic growth in the absence of any form of mechanical stretching, traction or bouginage. They further noted that maximal natural growth arises in the first 8-12 weeks of life, stimulated by the swallowing reflex and reflux of gastric contents into the lower esophageal pouch. Since then, creation of an initial gastrostomy and continuous suction of the upper esophageal pouch followed by delayed primary anastomosis at approximately 3 months of age has been widely accepted as the preferred treatment option in most LGEA cases, generally providing good functional results. The current article offers a comprehensive update on the various aspects and challenges of this technique including initial preoperative management and subsequent gap assessment, while also discussing potential postoperative complications and long-term outcome.

Favorable Outcome of Electively Delayed Elongation Procedure in Long-Gap Esophageal Atresia

The ideal approach to long gap esophageal atresia is still controversial. On one hand, preserving a patient's native esophagus may require several steps and can be fraught with complications. On the other hand, most replacement procedures are irreversible and disrupt gastrointestinal physiology. The purpose of this study was to evaluate the short- and medium-term outcome of electively delayed esophageal elongation procedures before esophageal reconstruction in patients with long-gap esophageal atresia. Since the neonatal esophagus grows over-proportionally and can increase its wall thickness in the first few months of life, we hypothesized that postponing the elongation steps until 3 months of age would lead to a lower complication rate. We thus retrospectively recorded complications such as mediastinitis, anastomotic leakage, stricture formation, or gastroesophageal reflux requiring surgery, and compared it to reported outcomes. In our treatment protocol, patients born with long-gap esophageal atresia underwent gastrostomy placement and were sham fed until 3 months of age. We then assessed the gap between the esophageal ends and started serial elongation procedures. We only proceeded to the reconstruction of the esophagus when its length allowed a tension-free anastomosis. From April 2013 to April 2019, we treated 13 Patients with long-gap esophageal atresia. Nine patients without prior surgical procedures underwent Foker procedures. Four patients arrived with a pre-existing cervical esophagostomy and thus underwent Kimura's procedure, two of them with a concomitant Foker elongation of the lower pouch. Esophageal reconstruction was feasible in all patients, while none of them developed mediastinitis at any point in their treatment. We managed the only anastomotic leak conservatively. Almost half of the patients did not require any further intervention following reconstruction, while three patients required multiple (≥5) anastomotic dilatations. All but one patient achieved full oral nutrition. Only one child required a fundoplication to manage gastroesophageal reflux symptoms. Electively delayed esophageal elongation procedures in patients with long-gap esophageal atresia allowed preservation of the native esophagus in all patients. The approach had low peri-procedural morbidity, and patients enjoy favorable functional outcomes. Therefore, we suggest considering this method in the management of patients with long-gap esophageal atresia.

Magnet-Assisted Hydraulic Bougienage for Correction of Long-Gap Esophageal Atresia

OBJECTIVE

An infant born with long-gap esophageal atresia has its esophagus separated into two pouches, and typically undergoes multiple open-chest surgeries for esophageal reconstruction. In this paper, we study a possible approach for less invasive correction of long-gap esophageal atresia.

METHODS

Our technique utilizes a magnet-tipped catheter with a piston on the end to push the esophageal pouch from the inside. The attractive magnetic force helps the catheter stretch the esophageal pouches, while the hydraulic piston prevents the magnet from applying too large force. The piston also enables estimation of the esophageal tension based on the hydraulic pressure measurement.

RESULTS

We have built a prototype system and performed bench-level tests on an esophageal mock-up. A hydraulic dither is applied to the piston to average out seal friction, thereby improving the tension estimation performance.

CONCLUSION

The bench-level tests demonstrate that the prototype bougienage system gives a reliable low-frequency estimate of the esophageal tension in real-time, and also enables longitudinal bougienage by a desired amount of load, e.g., 2N, for various gap sizes.

SIGNIFICANCE

This study provides a foundation for the next step of designing a system for use on actual patients.

Esophageal replacement

This article focuses on esophageal replacement as a surgical option for pediatric patients with end-stage esophageal disease. While it is obvious that the patient׳s own esophagus is the best esophagus, persisting with attempts to retain a native esophagus with no function and at all costs are futile and usually detrimental to the overall well-being of the child. In such cases, the esophagus should be abandoned, and the appropriate esophageal replacement is chosen for definitive reconstruction. We review the various types of conduits used for esophageal replacement and discuss the unique advantages and disadvantages that are relevant for clinical decision-making.

Long-term health-related quality of life after complex and/or complicated esophageal atresia in adults and children registered in a German patient support group

BACKGROUND

Health-related quality of life (HRQoL) after esophageal atresia (EA) repair is postulated to be good. However, little is known about the long-term results after repair of complex and/or complicated EA regarding HRQoL. We investigated long-term HRQoL after delayed anastomosis, esophageal replacement, major revisions, or multiple dilatations in patients registered in a support group.

METHODS

Patients registered in the German patient support group database (KEKS) were enrolled and allocated to subgroups according to surgical treatment and age. HRQoL was evaluated using validated questionnaires (GIQLI, WHO-5, KIDSCREEN27).

RESULTS

Complete follow-up (mean 14.5 ± 9.8 years) was available for 90/92 patients. Patients were allocated to subgroups delayed anastomosis (n=28), esophageal replacement (n=27), major revisions (n=15), and multiple dilatations (n=20). Adult patients presented with impaired well-being according to WHO-score and gastrointestinal function (GIQLI). In contrast, HRQoL of children was comparable to controls in most KIDSCREEN27-dimensions. Delayed anastomosis was associated with most-favourable HRQoL. Regarding physical well-being, these children scored significantly better than controls [64.01 ± 10.40 vs. 52.36 ± 8.73;p=0.0011], children after replacement [51.40 ± 5.70;p=0.008], revisions [52.04 ± 6.97;p=0.026], and multiple dilatations [50.22 ± 9.67,p=0.04].

CONCLUSIONS

HRQoL after complex and/or complicated EA is excellent in children registered in a patient support group. In adults, disease-specific symptoms negatively affect HRQoL. Our data indicate that saving the esophagus may achieve the best HRQoL.

Image-guided esophageal anastomosis in esophageal atresia

Infants with tracheoesophageal fistulas may present with complex cardiac disease that may obviate or disrupt a safe operative repair. Here we present a case of an infant who developed cardiac instability during esophageal atresia repair, precluding formal anastomosis after approximation of the distal and proximal esophageal segments. Postoperatively, anastomosis of the esophagus was achieved using an image-guided technique with subsequent dilation. This approach may provide an alternative approach for establishment of esophageal continuity in patients who are high-risk operative candidates.

Delayed primary anastomosis for management of long-gap esophageal atresia: a meta-analysis of complications and long-term outcome

PURPOSE

Management of newborns with long-gap esophageal atresia (LGEA) remains a challenge for pediatric surgeons. Since spontaneous growth of the esophageal segments occurs without mechanical stretching, initial gastrostomy followed by delayed primary anastomosis (DPA) comprises treatment in most LGEA patients. This meta-analysis aimed to investigate the complications and long-term outcome in patients with LGEA managed by DPA.

METHODS

A systematic literature search was conducted for relevant articles published between 1981 and 2011, and a meta-analysis of complications and long-term outcome was performed.

RESULTS

Forty-four articles presented data on 451 newborns with LGEA managed by DPA. Most common variants were pure LGEA (194/451) and LGEA with tracheoesophageal fistula (257/451). Initial gap lengths ranged from 1.9 to 7.0 cm. At the time of DPA, performed at a mean of 11.9 weeks (range 0.5-54.0), the gap had decreased to 0.5-3.0 cm. Mean follow-up was 5.5 years (range 0.5-27.0). Frequent complications were anastomotic leaks/strictures, gastroesophageal reflux (GER), esophagitis and dysphagia. Relative risk for strictures was significantly higher in patients who previously had a leak (p < 0.0001) or GER (p < 0.0001). Patients with GER also had a significantly higher risk for esophagitis (p = 0.0283) and dysphagia (p = 0.0174). The majority of patients could eat without swallowing difficulties at follow-up.

CONCLUSION

DPA provides good long-term functional results. However, the high incidence of GER and associated strictures requires early intervention to prevent feeding problems.

Long-term results of delayed primary anastomosis for pure oesophageal atresia: a 27-year follow up

The management of a newborn with pure oesophageal atresia continues to be challenging. We started treating babies with pure oesophageal atresia by delayed primary anastomosis in 1977. The purpose of this study was to review the long-term outcome in infants with pure oesophageal atresia (EA) treated by delayed primary anastomosis with special emphasis on gastroesophageal reflux (GOR) related morbidity. The medical charts of all patients treated by delayed primary anastomosis between 1977 and 2004 were retrospectively reviewed. All survivors were followed up with completion of a questionnaire and personal/phone interviews. There were 26 patients in total admitted during the 27-year study period with the diagnosis of pure oesophageal atresia. Three died prior to surgery due to associated anomalies; two had almost no distal oesophageal segment and underwent oesophageal replacement surgery. The remaining 21 children were treated with delayed primary anastomosis and made up our study group. There were four deaths (19%) in this group, and all were prior to 1980. The median gestational age was 35.5 weeks and the median birth weight was 2.6 kg; median initial gap was 3.7 cm and median preoperative gap was 1.5 cm; median age at operation was 80 days and the median hospital stay was 5.5 months. The median follow-up period was 13.5 years. Fourteen children (66%) developed symptomatic gastroesophageal reflux and nine of these needed fundoplication (43%). Sixteen children developed strictures at the anastomotic site; ten responded to repeated dilatations while six needed resection and reanastomosis. At the time of this study, 15 out of the 17 survivors (88%) were on normal diet with no respiratory problems and 2 (12%) were dependent on gastrostomy feeds. Our long-term follow-up data shows that the delayed primary anastomosis provides excellent functional results in patients born with pure oesophageal atresia. The high incidence of gastroesophageal reflux and associated morbidity requires early intervention to prevent ongoing feeding problems due to oesophagitis and stricture formation.

Congenital anomalies of the esophagus

Normal anatomy, embryology, and congenital anomalies of the esophagus are discussed in this article. The classification, epidemiology, embryology, diagnosis, and management, including outcome following repair of esophageal atresia with or without an associated tracheoesophageal fistula, are described. The diagnosis and management of less common anomalies, such as congenital esophageal stenosis and congenital esophageal duplication, are outlined.

Delayed blind-pouch apposition, guide wire placement, and nonoperative establishment of luminal continuity in a child with long gap esophageal atresia

Delayed primary esophago-esophagostomy is the most physiologically attractive approach to establish luminal continuity in children with pure esophageal atresia. However, excessive tension on the mobilized esophageal ends can lead to anastomotic separation and severe leakage. To circumvent these complications, the blind pouches of a 2(1/2)-month-old child were approximated unopened when, during the extrapleural thoracotomy, a conventional anastomosis was not feasible. A suture was passed through the tip of the 2 ends and made to exit through the mouth and the gastrostomy. After healing occurred, the suture was replaced under fluoroscopic control by a Seldinger-type wire. A vein dilator then was passed over the wire, establishing the continuity between the esophageal segments. Subsequent dilatations increased the anastomosis to the desired diameter. Leakage and an additional thoracotomy were avoided, and the hospital stay was shortened. The child, now 6 years old, is well and swallows normally.

Multistaged extrathoracic esophageal elongation procedure for long gap esophageal atresia: Experience with 12 patients

PURPOSE

This study evaluates the multistaged extrathoracic esophageal elongation procedure performed on 12 babies with long gap esophageal atresia over 15 years.

METHODS

Eight babies had pure esophageal atresia, 2 had proximal tracheoesophageal fistula (TEF), and 2 had distal TEF. The gaps ranged between 2 and 7 vertebral bodies. Proximal esophagostomy, TEF ligation, and gastrostomy were performed initially. The proximal esophagus is elongated 2 to 3 cm each time by translocating the esophagostomy distally along the anterior chest wall at 2- to 3-month intervals. Sham-fed milk is collected in an ostomy bag and refed via the gastrostomy. The definitive esophageal reconstruction is performed at 5 to 24 months of age.

RESULTS

Only one elongation was required in 4 babies, 2 were needed in 5, 3 in 2, and 5 in 1 patient. All patients tolerated sham feeding well. After esophageal restoration, 3 patients had minor leakage. All (12 of 12) patients had anastomotic stenosis requiring multiple dilatations, of which, 3 needed resection of stricture. Eleven patients had gastroesophageal reflux that required fundoplication. Follow-up was possible in 11 patients for 4 months to 14 years after esophageal restoration. Seven early patients are eating normally.

CONCLUSION

Multistaged extrathoracic esophageal elongation is effective in stretching the proximal esophagus to bridge 2 to 7 vertebral bodies.

Long-gap oesophageal atresia

The various options for the management of long-gap oesophageal atresia are discussed. Of 89 infants treated, 27 had isolated atresia, 6 distal atresia with proximal fistula, and 56 atresia with distal fistula. The preferred approach for the former two groups was oesophageal replacement via gastric transposition. Recently, delayed primary anastomosis has been attempted after 6-12 weeks. For wide-gap atresia with distal fistula, primary anastomosis under marked or extreme tension with elective paralysis and mechanical ventilation for 5 days postoperatively achieved highly successful results in 39 infants. There were no major anastomotic disruptions and only 7 minor leaks. Strictures developed in 72% of cases and gastro-oesophageal reflux in 54%, 66% of whom required antireflux surgery. There was only 1 death in the 43 patients undergoing oesophageal replacement (none after gastric transposition, n = 34). A highly satisfactory outcome was achieved in 85%-90% of infants undergoing a replacement procedure.

Delayed primary anastomosis for esophageal atresia: 18 months' to 11 years' follow-up

In 1977 we started treating babies with isolated esophageal atresia by delayed primary anastomosis and in 1981 reported our early experience in five cases treated between 1977 and 1979. Since 1979, 11 further consecutive cases have been managed by initial gastrostomy followed by delayed primary esophageal anastomosis. Their mean gestation was 35 weeks (range, 28 to 40 weeks) and mean birth weight was 2,040 g (range, 1,140 to 2,720 g). The esophageal gap between the two ends when assessed initially at fluoroscopy ranged from 2.2 to 4.5 cm (mean, 3.2 cm). Age at delayed primary anastomosis ranged from 6 to 20 weeks. Anastomotic leak occurred in three babies in the immediate postoperative period and all were successfully managed conservatively. Eight of the 11 patients developed anastomotic strictures; seven cases required 1 to 5 esophageal dilatations. One patient who did not respond to multiple esophageal dilatations required resection of an esophageal stricture. One patient died at 15 months of age of unrelated causes. The 10 surviving patients have been followed-up from 18 months to 11 years. At follow-up, seven patients were eating normally. Three patients had swallowing difficulties and all three were found to have esophageal strictures on barium swallow, two of them also had gross esophageal reflux and hiatus hernia. The height and weight in the 10 patients varied from 3rd centile to 75th centile. Delayed primary anastomosis is feasible in cases of isolated esophageal atresia and the patient's own esophagus is the best. A more aggressive approach should be applied to gastroesophageal reflux in these patients.

Wide gap esophageal atresia: a new method to elongate the upper pouch

A new surgical method is presented for overbridging wide gap esophageal atresia. The method is based on the fact that the atretic upper pouch has an excellent longitudinal blood supply, and is two to three times wider than the lower pouch. Muco-muscular flap is created, which is anastomosed to the lower esophagus.

A staged approach to long gap esophageal atresia employing a spiral myotomy and delayed reconstruction of the esophagus: an experimental study

In beagle dogs, the cervical esophagus was divided 5 cm cranial to the thoracic inlet employing a stapler. The distal esophageal stump was attached to the external surface of the trachea. A spiral myotomy (2 1/2 revolutions) was made in a 3-cm long segment constituting the distal end of the proximal esophageal segment. This was twisted on a bias with the muscle edges approximated by interrupted stitches to cover the denuded submucosal layer. With moderate traction, this segment could be elongated to a length of 5 cm. A subcutaneous tunnel was created in the anterior chest to accommodate the reconstructed proximal esophageal segment (under slight traction), with its distal end forming a cutaneous esophagostomy. A gastrostomy was created using a Gauderer button (Bard Interventional Products, Billerica, MA) for feeding. After 3 weeks, the proximal esophageal segment was mobilized and removed from the subcutaneous tunnel. The distal esophageal segment was freed from the trachea and 5 to 8 cm of its proximal end was excised. The proximal (myotomized) esophagus was brought down to the stump of the remaining distal esophagus and an anastomosis formed in an end-to-end fashion. Oral feeding was reestablished within 1 week. Prolonged ingestion, observed soon after operation, gradually improved. During a period of 1 to 6 months after the operation, motility of the myotomized segment was tested by barium swallow and manometry. There was neither diverticulum formation nor stenosis. Transit of contrast material in the myotomized segment was smooth and rapid. Manometry demonstrated preservation of motility in the myotomized segment of the esophagus.(ABSTRACT TRUNCATED AT 250 WORDS)

Cervical repair of esophageal atresia

This report describes three neonates with Type IIIb3 esophageal atresia treated by primary repair utilizing a combined thoracic and cervical approach.

Gastric transposition for esophageal replacement in children

Esophageal replacement by total gastric transposition was performed on 34 infants (32 with esophageal atresia) in the 5.5-year period from January 1981 to June 1986. There were three deaths (9%), two occurring in the early postoperative period, with the third occurring 1 year after surgery from persistent chronic respiratory problems. Fourteen infants had a totally uncomplicated course and have not required further admissions. Thirteen infants had early postoperative problems including six with delayed gastric emptying, four with anastomotic strictures requiring dilatation, and two with radiologic anastomotic leaks. Four late complications consisted of two adhesion intestinal obstructions, a perforation related to a jejunal feeding tube, and a child in whom malabsorption subsequently developed. An excellent result has been obtained in 24 infants, four doing well with only minor problems with feeding, and two are fair experiencing persisting difficulties. These results compare favorably with a large previous experience in colon interposition.

The outcome of colonic replacement of the esophagus in children

An analysis of 112 children undergoing colonic replacement of the esophagus over a 30-year period is presented. The indication for esophageal replacement was atresia in 92 children and intractable stricture (peptic, caustic, or congenital) in 20. The procedure consisted of a transthoracic replacement of the entire esophagus in 82 cases and a partial replacement in 18, while a retrosternal replacement was used in ten cases. Two colon loops had to be abandoned prior to reconstruction due to irreversible ischemic damage. There were 15 deaths (13.4%)--all in the atresia group. Failure of the colonic graft was encountered in 16 patients (14.3%) and accounted for six of the deaths. Leakage of the proximal esophago-colonic anastomosis occurred in 54 cases (48.2%). Strictures of this anastomosis developed in 34 cases (30.3%). A total of 20 patients required operative revision of the anastomosis. The final outcome was excellent in 43 of 77 cases followed up for up to 24 years postoperatively (55.9%), good in 27 cases (35%), and only fair in seven cases (9.1%).

Current surgical strategies in long-gap esophageal atresia with regard to endoscopic anastomosis

Elongation procedures for long-gap esophageal atresia are discussed. Elongation treatment according to Howard and Myers was performed in seven cases. Primary anastomosis following advance treatment could be carried out five times and esophageal elongation and anastomosis by means of the olive-and-thread method in two cases. Resulting stenoses were dilated. Endoscopic thread insertion and olive bougienage resulted in severe stenosis in two cases. This method should therefore be reserved for longer distances.

Esophagus replacement by free, autologous jejunal mucosa transplantation in long-gap esophageal atresia

There is apparently no ideal operative technique in the treatment of long-gap esophageal atresia, as is shown by the plurality of operative procedures described in the literature. Our own technique is presented, based on vaginal replacement by free, deserosized jejunal segments according to Wilfingseder. In addition, the muscularis propria layer was removed to improve trophic supply of the transplant which occurs initially only by diffusion. The free transplanted jejunal mucosa segments prevented transmural contamination of the mediastinum within the esophageal defect. Former animal experiments on beagles, as well as clinical experience with two newborn babies with long-gap esophageal atresia, showed that splinting for 4-6 weeks--beyond the time of the most intense wound contraction--and subsequent dilatation treatment could prevent circular and longitudinal shrinking of the transplants, thus avoiding stenosis. Histological findings revealed that on the average free-transplanted jejunal mucosa/submucosa tubes 8 cm long in dogs and 5 cm long in babies formed tubes of granulation tissue with the surrounding mediastinum, lined by persistent jejunal epithelium and partly by ingrowing esophageal epithelium. The two babies died 1/4 and 1 year following the operation, from their severe associated malformations. This, however, enabled us to do a thorough morphological examination of the interposed transplants and to document the complete healing. The advantages of the method described are primarily definitive bridging of the defect, less problems and risks as compared with elongation methods, and possibly shorter hospitalization.

Experiences in the treatment of esophageal atresia with Rehbein's olive technique

During the past few years four children with esophageal atresia without lower fistula were treated with the thread-and-olive method according to Rehbein. Our experiences indicate that excellent results can be achieved if the thread is inserted early, endoscopically, and olive bougienage is performed at short intervals. Tracheoscopy should be mandatory prior to the start of treatment, since we observed an upper fistula in three of four cases. Endoscopic thread insertion may lead to perforation of the main bronchus; control tracheo-bronchoscopy must therefore be done immediately following insertion. Perforation of the main bronchus turned out to be harmless, so the maneuver can be repeated after a few days. Two of the four infants died of congenital malformations. Therapy was not related to the fatal outcome in either case. One of the survivors has practically normal esophageal motor function with proven propulsive peristalsis. Esophageal stenosis had to be resected in the second survivor; this was followed by massive gastroesophageal reflux with esophagitis and disturbed gastric motility, rendering subsequent fundoplication and pyloroplasty necessary.

Esophageal replacement with colon in children: functional results and long-term growth

Twenty-three children consecutively undergoing colon interposition for esophageal replacement were evaluated with barium swallows, clinical interviews, and questionnaires. Fourteen patients underwent colon interposition because of caustic burns of the esophagus only or of the hypopharynx and esophagus. Nine children had long-segment esophageal atresia or esophageal atresia with tracheoesophageal fistula and are included in our operative group. The mean follow-up was 12.8 years for all patients. Strictures, leaks, and colon ischemia at the proximal anastomosis represent the major morbidity for the operative procedure. Analysis of growth charts reveals that patients who ingest lye tend to remain in the 50th percentile after colon transplant, while patients with esophageal atresia or tracheoesophageal fistula who had been in the 12th percentile preoperatively improved to the 33rd percentile after successful transplantation. Radiographic examinations, functional results, and growth curves demonstrated excellent results in 20 patients. Although the choice of a conduit for esophageal replacement is controversial, the surgeon can expect good long-term function and growth with the use of colon in children.

Esophageal atresia: primary results of 500 consecutively treated patients

During 1947-1978, 500 patients with esophageal atresia and/or tracheoesophageal fistula were treated at the Children's Hospital, University of Helsinki. The proportion of different types of anomaly followed the usual distribution, the commonest being the type with distal fistula (88.2%). For analysis, the patients were divided into five phases, each consisting of 100 consecutively treated patients. The hospital mortality decreased from 81% in the first phase to 15% in the last phase. No patients were excluded, not even those cases with lethal associated anomalies. Many more severe cases were treated in the last two phases than in the first three. Patients with distal fistula were examined separately as were the patients without a fistula and those with only a tracheoesophageal fistula. With time, early diagnosis and early referral for treatment became a rule. This led to the policy that nearly all patients in the last phase had an early operation without staging. Gastrostomy was not considered necessary when early anastomosis was possible. In the last phase, only the transpleural approach was used and single-layer end-to-end anastomosis was favored. As a whole, the type of approach or anastomosis did not have significant effect on the results, except that the Sulamaa-type end-to-side anastomosis had the highest frequency for refistula. With time there was only a slight decrease in the incidence of anastomotic leak, but significant improvement in its management. Refistula as an early complication was seen only once in the last phase. As all anastomoses were routinely dilated, severe strictures were uncommon; there were only six in the series. The factor that probably improved the prognosis the most was better pulmonary care. The improved prognosis was also due to earlier referral, modern anesthesia, and intensive care. Postoperative pulmonary complications dropped from 92% in the first phase to 40% in the last. They were the most common single cause of death in the early series but caused no deaths among the last 100 patients with no associated anomalies. Low birth weight was an important prognostic factor early in the series but in the last phase the survival rate of under-2500-gm infants with no associated anomalies was 88%. The presence of severe associated anomalies remains the most important single cause of death of an esophageal atresia patient today. Some patients (eg, trisomy 18) are beyond the possibilities of surgical treatment. To improve the prognosis of the others, efforts in the treatment of their associated (especially cardiovascular) anomalies must be made. In the treatment of esophageal atresia itself, improvement may still be achieved in the number of patients using their own esophagus without replacement procedures. Finally, a new prognostic classification of esophageal atresia patients is suggested, excluding pneumonia as an index factor in the Waterston classification.

Spontaneous anastomosis of the esophagus in esophageal atresia

An operative technique is described for the management of babies with esophageal atresia, where primary anastomosis is either impossible or unsuccessful. The procedure has been performed on six patients. One infant subsequently required resection of a resultant stricture, and one developed a recurrent tracheoesophageal fistula. All six infants required several esophageal dilatations. No patient required dilatation beyond the age of 5 months and all are now swallowing normally and thriving.

Colon interposition or gastric tube? Follow-up study of colon-esophagus and gastric tube-esophagus patients

Between 1963 and 1980, 34 elective esophageal reconstructions were performed on 29 esophageal atresia patients. Five patients needed two reconstructions. Among 20 colon replacement procedures there were 2 early deaths and three transplants failed. In 14 gastric tube reconstructions there was no mortality, but two tubes failed. The mean follow-up age of the 15 colon esophagus patients was 11.8 yrs, while for the 12 gastric tube patients it was 5.6 yrs. One death occurred during the follow-up period in each group. Late complications occurred in 7/15 of the colon and 3/12 of the gastric tube groups. Most of the serious complications occurred within 3 yr after surgery. The previously reported malabsorption following colon interposition seemed to be transient. At follow-up all but 3 patients with no significant other anomalies were within two standard deviations of the mean of height and weight. All were satisfied with their new esophagus. Nine out of 14 of the colon and 7/11 of the gastric tube groups were without symptoms, the others having only minor complaints. It is concluded that both colon replacement and gastric tube are satisfactory methods for esophageal reconstruction, and the long-term function seems equally good. However, the gastric tube procedure is easier to perform, has less mortality and fewer complications than colon replacement.

Endoscopic esophageal anastomosis

This paper describes four cases of esophageal atresia without a lower fistula in which a perlon thread was inserted through the two esophageal segments by an endoscopic method. With the aid of the thread and two metal olives the segments were drawn closer together and finally a communication was established without an operation. The method of introducing the thread and the olive technique are demonstrated in a series of drawings, and the results achieved in the case of four children are also presented.

Delayed primary anastomosis following spontaneous growth of esophageal segments in esophageal atresia

Between 1977 and 1979, five consecutive cases of esophageal atresia had delayed primary esophageal anastomosis at ages ranging from 5 1/2 to 18 wk. Serial growth studies of the two esophageal segments were performed under fluoroscopic screening. It was observed that spontaneous growth of esophageal segments occurs in the absence of any stretching or bougienage of the esophageal ends.

The value of circular myotomy for esophageal atresia

The joining of widely separated proximal and distal esophageal segments in esophageal atresia remains a challenging problem. Livaditis introduced the operation of circular myotomy as an effective means of bridging such a wide gap. Three babies with esophageal atresia were successfully treated in this manner at the Hospital for Sick Children, Toronto, during the 1st 6 mo of 1976. No alterations in blood supply of the upper esophageal pouch were observed, and elongations of at least 1 cm per myotomy were obtained. No unusual postoperative radiographic observations were noted. Our small clinical experience suggests that circular myotomies aid in reducing long esophageal gaps in some infants with esophageal atresia, thus permitting primary esophageal anastomosis.

Colon interposition for the replacement of the esophagus in children

Thirty-two new cases of colon interposition for esophageal reconstruction are presented. Only one late death occurred in this series, which was unrelated to the colon interposition. Fifteen severe complication were observed in five patients with preexisting esophageal atresia and previously complicated courses following disastrous primary esophageal repairs. The most common complication was pneumonia which occurred 13 times. Five late strictures responded well to dilatation or revision. Long-term weight gain was compared between a group of colon transplant patients and a group of patients with repaired esophageal atresia. Although the esophageal atresia group followed the 25th percentile and the colon interposition group followed the 3rd percentile on the growth curve, no significant difference existed in weight gain over 12 yr.

Electromagnetic bougienage to lengthen esophageal segments in congenital esophageal atresia

Some cases of esophageal atresia, either with or without tracheoesophageal fistula, are not suited for primary anastomosis. To avert the need for colon interposition in two such infants, intermittent electromagnetic force was used to pull together "bullets" placed in the esophageal ends. This method elongated and enlarged the esophageal segments enough to accomplish their anastomosis later. This approach appears feasible to use for infants whose esophageal malformation does not permit primary repair. It may also be applicable to cases of imperforate anus with a hight pouch.