The Foker technique (FT) and Kimura advancement (KA) for the treatment of children with long-gap esophageal atresia (LGEA): lessons learned at two European centers.

We present the experiences from two European centers performing the Foker technique (FT) of esophageal lengthening by axial traction and the Kimura advancement (KA) method of lengthening the upper pouch by extrathoracic resiting a spit fistula (SF) in children with long-gap esophageal atresia (LGEA, gap length > 5 cm). A total of 15 children were treated (8 pure EA, 6 lower tracheoesophageal fistula [TEF], and 1 upper TEF). Gaps ranged from 5 to 14 cm. Nine children already had a SF. Patients were grouped according to the presence of a SF and the subsequent surgical strategy: Group A (no SF, n = 6) received FT on both pouches. Group B (with SF, n = 6) received KA of SF and FT of the lower pouch. Group C (with SF, n = 3) received closure of the SF and subsequent Foker traction (CSFT) on both pouches. Group A: Primary repairs for all six children (mean age 3 months, gap length 6.5 cm) after a mean traction time of 3 weeks and a mean of 2.1 thoracotomies (range 2 to 3). Dilations were required in three out of six for anastomotic strictures with one perforation during the second dilation. Group B: All six children (mean age 16.4 months, gap length 9.5 cm) had a primary anastomosis, although for two it was significantly delayed (48 and 143 weeks traction time) because of infections. The number of thoracotomies ranged from 2 to 8 (mean 3.6). Leaks occurred in five out of six anastomoses (responsive to conservative management). Two children developed severe strictures, which required the anastomosis to be redone. In group C (mean age 10.6 months, gap length 6.5 cm), several major complications occurred. The three SF closures leaked (one iatrogenic) causing severe mediastinitis. CSFT was successful in only one case and the other two children had an esophageal replacement (stomach, jejunum). No deaths occurred in the series. FT of both pouches (group A) resulted in primary repairs of all six LGEA patients. The combination of KA and FT (group B) resulted in an equivalent rate of primary repairs, but with an increased number of thoracotomies and rate of complications compared with group A. CSFT (group C) resulted in a high failure rate. More data are needed (we propose a multicenter registry) to elucidate the safety and efficacy of each elongation technique and to establish an algorithm with clearer inclusion and exclusion criteria.

Sroka M ，Wachowiak R ，Losin M ，Szlagatys-Sidorkiewicz A ，Landowski P ，Czauderna P ，Foker J ，Till H ... -  《-》

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.

Till H ，Muensterer OJ ，Rolle U ，Foker J ... -  《-》

Foker Technique for the Management of Pure Esophageal Atresia: Long-Term Outcomes at a Single Institution.

We present the short- and long-term outcomes in the management of pure long-gap esophageal atresia (LGEA) using the Foker technique (FT) of esophageal elongation by external axial traction at a single institution. All patients undergoing esophageal atresia (EA) repair with FT over a 10-year period were included in the study. Demographic data, birth weight, gestational age, associated anomalies, management, and short- and long-term outcomes were studied. Five patients (three males) were treated with FT in the study period, all with LGEA, with a mean birth weight of 1,926 g (range, 541-2,890 g). Four infants had associated anomalies. Primary repair after FT axial traction was achieved in four patients after a mean traction time of 13 days (range, 12-15 days). FT failed in one patient who had esophageal perforation from traumatic orogastric tube placement at birth and extensive matting of the esophagus at the time of FT attempt. The mean age at definitive esophageal anastomosis was 11.5 weeks (range, 8-14 weeks). In three of the five patients, traction sutures from the distal esophageal segment tore away, requiring a thoracotomy for replacement. One of the four patients had a confined leak at the anastomosis. All four patients developed strictures at the anastomosis, requiring serial dilations (mean 12 dilations, range 6-21 dilations), and three of those patients underwent a thoracotomy for stricture resection (two patients) or stricturoplasty (one patient). On long-term follow-up, all patients in whom a primary anastomosis was achieved had their gastrostomy closed and were on full oral feeds. FT was successful in achieving a primary anastomosis in 80% of the patients with LGEA, with a significant morbidity but favorable long-term outcomes.

Bobanga ID ，Barksdale EM 《-》

Long gap esophageal atresia: an Australian experience.

Al-Shanafey S ，Harvey J 《-》

Early results of an objective feedback-directed system for the staged traction repair of long-gap esophageal atresia.

Treatment of long-gap esophageal atresia challenges pediatric surgeons. Dr. Foker described utilization of external traction sutures to promote in-vivo growth through tension-induced lengthening, but reproducibility of this technique is difficult. We describe a safe and reproducible traction system using transduction of hydrostatic pressure as a surrogate for tension. We conducted a multi-institutional review of patients treated with this system from 2005 to 2012. All children had sutures applied to both pouches with continuous measurement of associated hydrostatic pressures (tension). Main outcome measures were days to delayed primary repair and thoracotomies prior to primary repair. Seven children were included. Median time to delayed repair was 15 days (range: 6-47 days). Three patients required repeat thoracotomies owing to mechanical entrapment of a pouch, all identified early by this system. All required postoperative dilations. Three had self-limited postdilation leaks, and there was one operation-related leak. This system provides reproducible traction application, facilitating staged primary repair by preventing major failures through limiting excessive traction and guides re-exploration for trapped segments. Larger studies are needed to determine the optimal tension protocol, prevent postoperative leaks, while decreasing the need for dilations and time to enteral feeding.

Bairdain S ，Ricca R ，Riehle K ，Zurakowski D ，Saites CG ，Lien C ，Anderson GF ，Wahoff DC ，Linden BC ... -  《-》