Primary Anastomosis in Wide-Gap Esophageal Atresia after Upper and Lower Pouch Bougienage

Abstract

It is generally agreed that the ideal goal in esophageal atresia reconstruction is to establish continuity of the esophagus by end-to-end anastomosis. One of the most difficult problems is bridging a wide gap between the two ends of the esophagus, specially in Gross Type A mainly when the lower esophageal segment appears as a diverticulum of the gastric fundus which barely reaches above the diaphragm. Several approaches have been described to resolve this problem such as the colon interposition procedure of Waterson or the gastric tube method of Burrington and Stephens, which are not simple procedures, therefore, prone to have high mortality, complications and sequelae.The aim of this letter is to present a simple bougienage technique for the upper pouch and lower segment via gastrostomy in Type A esophageal atresia.A newborn male weighing 3.9 kg at five hours of age presented with excessive salivation. Attempts at passing nasogastric tube failed. X-ray of the chest and abdomen confirmed the diagnosis of esophageal atresia without distal tracheal fistula. On the same day gastrostomy was performed. The following day contrast study of the upper pouch and gastrography study of the lower pouch was done through gastrostomy tube. There was wide gap esophageal atresia. The distance was about five vertebral lengths (Figure 1). No fistula was seen in the upper pouch. We inserted a thin suction catheter into the upper pouch. Suction when required was done, and the baby was kept under strict supervision with gastrostomy feeding.After one week, we started the bougienage of the both segments with formed Hegar dilator 11 times for 25 days in the ward repeatedly by the same person. At intervals, the dilatation was done under fluoroscopy to assess the size of the gap. At no time was anesthesia employed. Once we were satisfied that the gap had narrowed considerably, the baby was taken to surgery and extrapleural end-to-end anastomosis in two layers was performed. The postoperative period was uneventful. The esophagogram showed slight stenosis in the anastomotic area (Figure 2). Oral feeding was started after eight days and was tolerated well. The patient was discharged to be followed-up in OPD. The baby was lost to follow-up. The patient returned to the hospital after two months with feeding difficulty. Esophagogram revealed severe stricture at the anastomotic site which did not improve with dilatation. Subsequent thoracotomy, resection of stricture, and end-to-end anastomosis was performed. The patient had done well for the last two months.