Initial surgical correction of EA

Esophageal atresia (EA)  is usually diagnosed shortly after birth, because of some combination of the newborn being unable to feed, has trouble breathing, chokes during feeding, and/or a nasogastric tube cannot be passed from the nose into the stomach. Normally, the baby will be stabilized in a Neonatal Intensive Care Unit, and surgery is carried out as soon as the baby is stable.

Surgery usually involves cutting the connection between the trachea and esophagus, drawing the two ends of the esophagus together, and then sewing the esophagus back together. Increasingly, the surgery is done by endoscopy, which means that rather than making a large cut in the chest to reach the tissues, tiny cuts are made and a number of small telescopes are used to locate the tissues; tiny instruments can be passed through these telescopes to carry out the surgery. When endoscopic surgery is feasible, the scars are smaller, there is less pain, and there may be fewer problems with the chest wall. The surgeon may place another telescope inside the trachea to check its condition; this is called a bronchoscopy.

The most difficult surgical cases occur when there is a Long-gap EA. A number of approaches can be used when the ends of the esophagus are too far apart to initially put them back together. Sometimes, a feeding tube is placed in the stomach (called a gastrostomy tube or G-tube) for feeding, a suction device is used to suction saliva from the proximal esophageal pouch, and the surgeon waits some weeks for the ends of the esophagus to grow so it’s easier to connect them. Some surgeons use metal probes or stitches in both ends of the esophagus to stimulate them to grow and lengthen faster. Another approach is to make some spiral cuts in the muscle in the walls of the esophagus. This allows the esophagus to be stretched more easily.

In the most severe cases, when none of these approaches work, an “artificial esophagus” is created from some tissue taken from the wall of the stomach or the large intestine (or colon), and this is connected to the proximal and distal ends of the esophagus.

This is called a gastric interposition, or gastric “pull up” in case of complete gastric transposition at the cervical esophagus, or a colonic interposition, respectively. A jejunal tube could give better functional results than a colonic interposition. An interposition doesn’t have normal peristalsis, and patients with this are at high risk of swallowing problems and gastroesophageal reflux.

Tom Kovesi MD, Pediatric Respirologist, Children’s Hospital of Eastern Ontario, Ottawa, OntarioCanada
06/10/2013

Bibliography: