Growth Induction, or the Foker Procedure for Esophageal Atresia

9 May 2014

Dr. John Foker, at the Boston Children’s Hospital (Boston, USA) describes an innovative technique for stimulating the growth of the esophagus in patients with long-segment esophageal atresia by placing sutures in the ends of the esophagus, to give growth signals to the tissues. You can watch 2 videos – one by Dr. Foker describing the importance of parents being aware of various surgical treatment options, and a second video, by Dr. Russel Jennings, describing the surgical technique.

Although people generally consider birth defects as genetic in origin, we believe EA is a developmental problem and, therefore, if one provides the correct signal, catch up developmental growth of the esophageal segments will occur. This has proven to be the case and in well over 100 cases at the University of Minnesota and, more recently, at Boston’s Children’s Hospital, we have shown that the signal we provide will reliably and effectively produce catch up growth. The EA growth procedure requires two operations; the first to initiate the growth response, followed by time for it to occur and then the second operation to put the esophageal ends together (the anastomosis).

The growth signal is produced at the first operation by placing fine sutures into the small esophageal segments which are, sometimes, only little nubbins of tissue. These sutures are brought to the outside where tension can be applied producing the growth esophageal signal. The applied tension mimics the much slower signal provided by the growth of the spinal column which normally stimulates esophageal growth in the child.

The first operation is carried out through a small incision on the right side of the baby’s back. Fine sutures are placed in both the upper and lower segments and brought out to the skin surface and threaded through “buttons”. Each day the tension is increased by putting short pieces of tubing under the suture loops from the esophagus to make up for the growth that occurs. If the sutures were not tightened up, they would no longer provide the tension triggering growth signal. Also, in order to move the growth process along as quickly as possible and to minimize the chance of the sutures pulling out and having to be redone, the babies are kept on a ventilator and sedated. Each day the babies are partially awakened for a short period of time to allow movement and give them a brief “holiday” from the sedation.

We have found this technique, when carefully applied over 1-3 weeks will induce a considerable amount of growth, mostly in the lower esophageal segment. When enough growth has been achieved, the baby is returned to the operating room and the two ends of the esophagus are joined together. Although the growth process itself (Foker procedure) typically requires 2 or more weeks, in the end a very desirable goal is reached. Pediatric surgeons have long believed that “one’s own esophagus is best” and the growth procedure allows this goal to be reached, even in the most difficult EA cases.

Following the growth procedure and joining the two ends of the esophagus together, these babies also need to be evaluated for gastro-esophageal reflux (GE reflux) in which stomach acid and bile flow backwards up into the esophagus. (GE reflux is also very common in normal adults and is what causes “heartburn”). Reflux will be detrimental over time producing inflammation of the esophagus and worse. In addition, a stricture (fibrous scarring) often occurs at the anastomotic site where the 2 ends are joined together. This is usually treated by dilating the narrowed area with a balloon tipped catheter which is passed down through the baby’s mouth for a few minutes.

The GE Reflux can be treated with both medications and anti reflux surgery. When surgery is indicated a wrap procedure  (usually a Nissen fundoplication) in which the upper part of the stomach is brought around the esophagus much like a shawl. Carefully done, this will be a barrier to the acid and bile reflux while still allowing the passage of food down into the stomach.

Although the Foker Procedure may seem like a lot, and it is, once everything is accomplished the children can lead normal lives and eat anything they wish. Very importantly, they have an esophagus in the normal location, connecting their mouth and stomach in the normal location and to date (up to 15+ years as of now) there is no sign of late failure. Our expectations are that this will continue to be the case and they will enjoy 70+ good years from their newly grown and repaired esophagus.

 

John E. Foker, M.D., Ph.D

Advice to parents: compare the alternatives

 

Russel Jennings, MD, Director Esophageal Atresia Treatment Program at Children’s Hospital Boston, presenting the Foker procedure