L. A. McDuffie1, A. Jensen1, E. Groh1, F. Rescorla1 1Indiana University School Of Medicine,Pediatric Surgery,Indianapolis, IN, USA
Introduction:
Long-gap esophageal atresia (LGEA) precludes immediate primary anastomosis. Native esophagus is considered the ideal conduit for reconstruction. When delayed primary repair (DPR) is not possible, the optimal reconstructive approach is controversial. The study purpose is two-fold: 1) To evaluate short and long-term outcomes for DPR of long-gap esophageal atresia, and 2) To evaluate short and long-term outcomes of reverse gastric tube (RGT) as a salvage therapy when primary repair is infeasible.
Methods:
Billing records for years 1994-2016 were queried for the diagnosis of esophageal atresia. Medical records were retrospectively reviewed for patients with long-gap esophageal atresia, defined by the technical impossibility of an immediate primary repair. Mann-Whitney U and Chi-squared tests were used for data analysis.
Results:
218 patients with esophageal atresia were treated during this period; 37 were identified as having long-gap esophageal atresia. The mean gap length was 3.31 cm at time of repair. 33 patients underwent some form of repair, all of which were managed initially with a gastrostomy tube and bolus feeds. 25 patients underwent DPR. 22 of these (89%) never required revision, and 86% of these have excellent function on long-term follow-up. In eight patients, esophageal length was never adequate for primary repair. Six were reconstructed with RGT, and two underwent gastric transposition. One RGT failed immediately to ischemia requiring colon interposition. The remaining grafts are all functional: one has severe neurologic impairment precluding oral feeds; one requires supplemental gastrostomy feeds due to oral aversion; and three sustain their intake with oral feeding alone. There was no significant difference in complications, need for revisions, ventilator days, number of dilations, NICU stay, overall length of stay, weight percentiles, height percentiles, BMI, BMI percentiles, or conduit function between children undergoing RGT compared with DPR at a median follow-up of 62.8 and 68.3 years, respectively.
Conclusion:
Surgical treatment of LGEA is complex, and controversy exists regarding the optimal repair method when primary repair is not feasible. In this series, delayed anastomosis after gastrostomy tube feeds often allows for sufficient esophageal lengthening to permit primary esophagoesophagostomy. Long-term esophageal function is usually satisfactory following DPR and is accompanied by excellent growth outcomes. When adequate length for primary anastomosis is not attainable, these data suggest that RGT is a viable conduit with favorable short-term and long-term outcomes.
