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

Abstract

Introduction?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). Materials and Methods?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. Results?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. Conclusion?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.

Foker process for the correction of long gap esophageal atresia: Primary treatment versus secondary treatment after prior esophageal surgery

“…The overall incidence of esophageal atresia, a rare congenital anomaly, occurs in 1:4500 live births [6]. The exact incidence of LGEA is not known; however, several studies have employed the FP for LGEA but many of these studies have been on a smaller scale and even fewer have included revision cases [7][8][9]. This may be one of the largest reports of secondary LGEA cases treated at a single institution; however, despite being successful in repairing infants with primary LGEA, our success rate with achieving a native esophageal conduit in secondary LGEA/FP patients has not been as high (96% versus 68%).…”

Difficult esophageal atresia: Trick and treat

“…Referred LGEA patients, showed a higher rate of CE (44% vs 3%). 39 In 2013, Sroka et al 58 reported their comparable experience on 15 LGEA cases (5-14 cm), 9 of which with a previous CE fashioned. Only 2 referred patients with CE required esophageal substitution due to postoperative complications.…”

“…58 Lengthening of the neck by traction is an ancient practice for cosmetic reasons; just think of the giraffe women of the Kenyan tribes who wear rings to lengthen it. Other examples of stretching and growth procedures are surgical techniques of limb traction, such as the Ilizarov procedure, 59 or the use of skin expanders, causing the skin and soft tissue growth, as well as autologous bowel-lengthening procedures.…”

“…Major disruption and failure of conservative management with need for drainage or reoperation was reported in up to 15% of dated series and in 1-13% of the most recent reports. 39,58,73,75,76 Lastly, esophageal replacement for unsatisfactory results after delayed anastomosis was required in 14%.…”

“…78 Since then, ETEE has been widely used as a "traction" procedure, either as a technique of choice in patients who had been electively treated with CE for a variety of reasons (primary esophagostomy) or as an esophagus "rescue" procedure for those babies in which an esophagostomy had been performed because of a previous failed attempt (secondary esophagostomy). 39,58 Advantages of the ETEE are to maintain the native esophagus, to allow early oral alimentation, and to shorten hospital stay while waiting for the final esophago-esophagostomy. Preferably, the esophagostomy is created on the right side of the neck.…”