Passive Lengthening of the Esophageal Pouches in Long-Gap Esophageal Atresia: A Technical Innovation

Abstract

There are many surgical procedures for the treatment of long-gap esophageal atresia, which are associated with different complications. In the passive lenghening of the esophageal pouch technique, one metallic or radio-opaque rubber ring is fixed to the blind end of each pouch, then a non-absorbable thread is fixed to the ring of the lower pouch, passed through the ring of the upper pouch, and finally fixed to the tip of a calibrated nasogastric tube (NGT) in the lower pouch. The NGT is anchored on the abdominal wall by a safety pin, and by gradual pulling of the NGT, lengthening of both pouches occurs. Determination of the degree of lengthening is easy and helps decide the time for the definitive repair. Saliva accumulation in the upper pouch can be managed at home by continuous Reblogle tube suction by keeping the patient in a prone head-down position, or by a combination of continuous Reblogle tube suction and oral suction dummy. MethodUnder general endotracheal anesthesia, with the patient in the left lateral position, right lateral extrapleural thoracotomy through the fourth intercostal space is performed. The azygos vein and posterior mediastinum should be exposed, so that both esophageal pouches and fistula are seen. The azygos vein is ligated and divided. The upper pouch is identified and dissected as much as possible to gain maximum length. The lower pouch is identified, and if a fistula is present, it has to be divided. Meticulous dissection of the lower pouch has to be done to gain the maximum length. Metallic or radiopaque rubber ring (stainless steel or titanium) is fixed, one to the end of each pouch with non-absorbable stitch. The ring is about 3 mm in diameter (Figures 1 and 2).Gastrostomy is to be done, one for feeding gastrostomy tube and one for calibrating the NGT, which is passed up the lower pouch up to its opened end, in the presence of a fistula or up to its blind end, where there is no fistula. In this case, it has to be opened to allow the NGT to come through its tip. The two pouches are anchored together by non-absorbable stitch with good tension. Using non-absorbable thread which is fixed to the ring attached to the lower pouch, it is passed through the ring fixed to the upper pouch and finally fixed to the tip of the NGT by the shortest length, which keeps the NGT pushing against the tip of the lower pouch. This will now be closed with a purse-string suture using non-absorbable thread. The gap between the ends of the two pouches can easily be measured intraoperatively.The calibrated NGT is anchored on the abdominal wall with a safety pin and the point of exit, for example, at the 10 cm mark on the NGT. The thoracotomy incision is then closed in layers without intercostal tube drainage.Passive stretching has to be done soon after surgery to avoid fibrous tissue formation around the pouches by pulling on the NGT, which will pull the lower pouch up and the upper pouch down, decreasing the gap. This maneuver has to be done twice weekly. After each setting, the NGT is anchored on the abdo...