Surgical Methods to Increase Esophageal Length in Long (Wide)-Gap Esophageal Atresia with and Without Tracheoesophageal Fistula

  • Sigmund H. EinEmail author


The long (wide)-gap esophageal atresia (EA) has been a problem for pediatric surgeons but only affects 10–20 % of newborns with EA who are not immediately suitable for primary anastomosis. Between the 1950s and the 2000s, several methods to eventually bring both esophageal segments together have been employed with limited success; their ultimate aim is to return the patient’s original esophagus to full and normal use, thus avoiding the inevitable replacement.

Most lengthening procedures focused on the usually bigger and better developed upper esophageal pouch, some on both esophageal segments, and a few on the always small and poorly developed lower esophagus. In spite of the above trials and tribulations, the end results are fairly similar to the common esophageal repair, that is, a fairly reasonable, but not perfect, swallowing tube.


Esophageal atresia Tracheoesophageal fistula Myotomies Flaps And partial pull-ups Types Classification 


  1. 1.
    Bax KMA. Jejunum for bridging long-gap esophageal atresia. Semin Pediatr Surg. 2009;18:34–9.CrossRefPubMedGoogle Scholar
  2. 2.
    Buonuomo V, Nanni L, Canali R, et al. Esophageal atresia. Personal experience and review of the literature. Ann Ital Chir. 2007;78:385–8.PubMedGoogle Scholar
  3. 3.
    Burrington JD, Stephens CA. Esophageal replacement with a gastric tube in infants and children. J Pediatr Surg. 1968;3:246–52.CrossRefGoogle Scholar
  4. 4.
    Cameron BH, Cochran WJ, McGill CW. The uncut Collis-Nissen fundoplication: results for 79 consecutively treated high-risk children. J Pediatr Surg. 1997;32:887–91.CrossRefPubMedGoogle Scholar
  5. 5.
    Davenport M, Bianchi A. Early experience with oesophageal flap oesophagoplasty for repair of esophageal atresia. Pediatr Surg Int. 1990;5:332–5.CrossRefGoogle Scholar
  6. 6.
    deLorimier AA, Harrison MR. Long gap esophageal atresia: primary anastomosis after esophageal elongation by bougienage and esophagomyotomy. J Thorac Cardiovasc Surg. 1980;79:138–41.Google Scholar
  7. 7.
    Eraklis AJ, Rossello PJ, Ballantine TVN. Circular esophagomyotomy of upper pouch in primary repair of long-segment esophageal atresia. J Pediatr Surg. 1976;11:709–12.CrossRefPubMedGoogle Scholar
  8. 8.
    Evans M. Application of Collis gastroplasty to the management of esophageal atresia. J Pediatr Surg. 1995;30:1232–5.CrossRefPubMedGoogle Scholar
  9. 9.
    Farkash U, Lazar L, Erez I, et al. The distal pouch in esophageal atresia – to dissect or not to dissect, that is the question. Eur J Pediatr Surg. 2002;12:19–23.CrossRefPubMedGoogle Scholar
  10. 10.
    Fernández MS, Gutiérrez C, Ibáñez V, et al. Long-gap esophageal atresia: reconstruction preserving all portions of the esophagus by Schärli’s technique. Pediatr Surg Int. 1998;14:17–20.CrossRefPubMedGoogle Scholar
  11. 11.
    Foker JE, Linden BC, Boyle Jr EM, et al. Development of a true primary repair for the full spectrum of esophageal atresia. Ann Surg. 1997;226:544–3.CrossRefGoogle Scholar
  12. 12.
    Foker JE, Kendall TC, Catton K, et al. A flexible approach to achieve a true primary repair for all infants with esophageal atresia. Semin Pediatr Surg. 2005;14:8–15.CrossRefPubMedGoogle Scholar
  13. 13.
    Foker JE, Kendall Krosch TC, Catton K, et al. Long-gap esophageal atresia treated by growth induction: the biological potential and early follow-up results. Semin Pediatr Surg. 2009;18:2329.CrossRefGoogle Scholar
  14. 14.
    Giacomoni MA, Tresoldi M, Zamana C, et al. Circular myotomy of the distal esophageal stump for long gap esophageal atresia. J Pediatr Surg. 2001;36:855–7.CrossRefPubMedGoogle Scholar
  15. 15.
    Gough MH. Esophageal atresia–use of an anterior flap in the difficult anastomosis. J Pediatr Surg. 1980;15:310–1.CrossRefPubMedGoogle Scholar
  16. 16.
    Harrison MR, Estefan-Ventaura D, Fechter R, et al. Magnetic mini-mover procedure for pectus excavatum I. Development, design, and simulations for feasibility and safety. J Pediatr Surg. 2007;42:811–6.CrossRefGoogle Scholar
  17. 17.
    Harrison MR, Curran PF, Fechter RJ, et al. Magnetic mini-mover procedure for pectus excavatum II: an FDA-sponsored trial (IDE # G050196). Presented at American Pediatric Surgical Association, Puerto Rico, May 2009.Google Scholar
  18. 18.
    Hendren WH, Hale JR. Electro-magnetic bougienage to lengthen esophageal segments in congenital esophageal atresia. NEJM. 1975;293:428–32.CrossRefPubMedGoogle Scholar
  19. 19.
    Hendren WH, Hale RJ. Esophageal atresia treated by electromagnetic bougienage and subsequent repair. J Pediatr Surg. 1976;11:713–22.CrossRefPubMedGoogle Scholar
  20. 20.
    Hikida S, Tanaka Y, Tsuru T, et al. The elongation of distal esophageal pouch by mechanical bougienage for a year resulted in a tension-free anastomosis in a patient with long gap esophageal atresia: a case report. Kurume Med J. 2003;50:139–42.CrossRefPubMedGoogle Scholar
  21. 21.
    Howard R, Myers NA. Esophageal atresia: a technique for elongating the upper pouch. Surgery. 1965;58:725–7.Google Scholar
  22. 22.
    Janek JS, Filler RM, Ein SH, et al. Long-term follow-up of circular myotomy for esophageal atresia. J Pediatr Surg. 1980;6:835–41.CrossRefGoogle Scholar
  23. 23.
    Johnson PW. Elongation of the upper segment in esophageal atresia. Report of a case. Surgery. 1965;58:741–4.Google Scholar
  24. 24.
    Kawahara H, Imurak, Yagi M, et al. Collis-Nissen procedure in patients with esophageal atresia: long-term evaluation. World J Surg. 2002;26:1222–7.CrossRefPubMedGoogle Scholar
  25. 25.
    Kimura K, Soper RT. Multistaged extrathoracic esophageal elongation for long gap esophageal atresia. J Pediatr Surg. 1994;29:566–8.CrossRefPubMedGoogle Scholar
  26. 26.
    Kimura K, Nishijima E, Tsugawa C, et al. A new approach for the salvage of unsuccessful esophageal atresia repair: a spiral myotomy and delayed definitive operation. J Pediatr Surg. 1987;22:981–3.CrossRefPubMedGoogle Scholar
  27. 27.
    Kimura K, Nishijimi E, Tsugawa C, et al. Multistaged extrathoracic esophageal elongation procedure for long gap esophageal atresia: experience with 12 patients. J Pediatr Surg. 2001;36:1725–7.CrossRefPubMedGoogle Scholar
  28. 28.
    Kleinman PK, Waite RJ, Cohen IT, et al. Atretic esophagus: transgastric balloon-assisted hydrostatic dilation. Radiology. 1989;171:831–3.CrossRefPubMedGoogle Scholar
  29. 29.
    Lafer DJ, Boley SJ. Primary repair in esophageal atresia with elongation of the lower segment. J Pediatr Surg. 1966;1:585–7.CrossRefPubMedGoogle Scholar
  30. 30.
    Lai JY, Sheu JC, Chang PY, et al. Experience with distal circular myotomy for long-gap esophageal atresia. J Pediatr Surg. 1996;31:1503–8.CrossRefPubMedGoogle Scholar
  31. 31.
    Lindahl H, Rintala R, Sariola H, et al. Cervical Barrett’s esophagus: a common complication of gastric tube reconstruction. J Pediatr Surg. 1990;25:446–8.CrossRefPubMedGoogle Scholar
  32. 32.
    Livaditis A, Björck G, Fängstroöm LG. Esophageal myectomy. Scand J Thorac Cardiovasc Surg. 1969;3:181–5.CrossRefPubMedGoogle Scholar
  33. 33.
    Livaditis A, Radberg L, Jonsson L, et al. Experimental evaluation of esophageal muscular cuffs in repair of esophageal defects. Scand J Thorac Cardiovasc Surg. 1975;9:155–61.CrossRefPubMedGoogle Scholar
  34. 34.
    Lopes MF, Reis A, Coutinito S, et al. Very long gap esophageal atresia successfully treated by esophageal lengthening using external traction sutures. J Pediatr Surg. 2004;39:1286–7.CrossRefPubMedGoogle Scholar
  35. 35.
    Nasr A, Ein SH, Gerstle JT. Infants with repaired esophageal atresia and distal tracheoesophageal fistula with severe respiratory distress: is it tracheomalacia, reflux or both? J Pediatr Surg. 2005;40:901–3.CrossRefPubMedGoogle Scholar
  36. 36.
    Pichakron KO, Grant D, Jelin EB, et al. Magnagosis II: magnetic compression anastomosis for gastrojejunostomy and jejunojejunostomy. Presented at The Meeting of the Section of Surgery, American Academy of Pediatric Surgeons, Washington, DC, October 2009.Google Scholar
  37. 37.
    Pompeo E, Coosemans W, De Leyn P, et al. Esophageal replacement with colon in children using either the intrathoracic or retrosternal route: an analysis of both surgical and long-term results. Surg Today. 1997;27:729–34.CrossRefPubMedGoogle Scholar
  38. 38.
    Rehbein F, Schweder N. Reconstruction of the esophagus without colon transplantation in cases of atresia. J Pediatr Surg. 1971;6:746–52.CrossRefPubMedGoogle Scholar
  39. 39.
    Ron O, DeCoppi P, Pierro A. The surgical approach to esophageal atresia repair and the management of long-gap atresia: results of a survey. Semin Pediatr Surg. 2009;18:44–9.CrossRefPubMedGoogle Scholar
  40. 40.
    Saeki M, Tsuchida Y, Ogata T, et al. Long-term results of jejunal replacement of the esophagus. J Pediatr Surg. 1988;23:483–9.CrossRefPubMedGoogle Scholar
  41. 41.
    Schärli AF. Elongation reconstruction in very long atresias by elongation of the lesser curvature. Pediatr Surg Int. 1992;7:101–5.CrossRefGoogle Scholar
  42. 42.
    Schwartz MZ. An improved technique for circular myotomy in long-gap esophageal atresia. J Pediatr Surg. 1983;18:833–4.CrossRefPubMedGoogle Scholar
  43. 43.
    Shafer AD, David TE. Suture fistula as a means of connecting upper and lower segments in esophageal atresia. J Pediatr Surg. 1974;9:669–73.CrossRefPubMedGoogle Scholar
  44. 44.
    Shamberger RC, Eraklis AJ, Kozakewich HP, et al. Fate of the distal esophageal remnant following esophageal replacement. J Pediatr Surg. 1988;23:1210–4.CrossRefPubMedGoogle Scholar
  45. 45.
    Sharma AK, Wakhlu A. Simple technique for proximal pouch mobilization and circular myotomy in cases of esophageal atresia with tracheoesophageal fistula. J Pediatr Surg. 1994;29:1402–3.CrossRefPubMedGoogle Scholar
  46. 46.
    Siegel MJ, Shackelford GD, McAlister WH, et al. Circular esophageal myotomy simulating a pulmonary or mediastinal pseudocyst. Radiology. 1980;136:365–8.CrossRefPubMedGoogle Scholar
  47. 47.
    Slim MS. Circular myotomy of the esophagus: clinical application in esophageal atresia. Ann Thorac Surg. 1977;23:62–6.CrossRefPubMedGoogle Scholar
  48. 48.
    Tamburri N, Laje P, Boglione M, et al. Extrathoracic esophageal elongation (Kimura’s technique): a feasible option for the treatment of patients with complex esophageal atresia. J Pediatr Surg. 2009;44:2420–5.CrossRefPubMedGoogle Scholar
  49. 49.
    Ten Kate J. A method of suturing in operations for congenital oesophageal atresia. Arch Chir Neder. 1952;4:43–7.Google Scholar
  50. 50.
    Till H, Muensterer OJ, Rolle O, et al. Staged esophageal lengthening with internal and subsequent external traction sutures leads to primary repair of an ultralong gap esophageal atresia with upper pouch tracheoesophageal fistula. J Pediatr Surg. 2008;43:E33–5.CrossRefPubMedGoogle Scholar
  51. 51.
    Till H, Rolle U, Siekmeyer W, et al. Combination of spit fistula advancement and external traction for primary repair of long-gap esophageal atresia. Ann Thorac Surg. 2008;86:1969–71.CrossRefPubMedGoogle Scholar
  52. 52.
    Todd DW, Shoemaker CT, Agarwal I, et al. Temporary banding of the gastroesophageal juncture in a very small neonate with esophageal atresia and tracheo-esophageal fistula. Minn Med. 1990;73:30–2.PubMedGoogle Scholar
  53. 53.
    van der Zee DC, Vieirra-Travassos D, Kramer WL, et al. Thoracoscopic elongation of the esophagus in long gap esophageal atresia. J Pediatr Surg. 2007;42:1785–8.CrossRefPubMedGoogle Scholar
  54. 54.
    Varjavandi V, Shi E. Early primary repair of long gap esophageal atresia: the Vater operation. J Pediatr Surg. 2000;12:1830–2.CrossRefGoogle Scholar
  55. 55.
    Vizas D, Ein SH, Simpson JS. The value of circular myotomy for esophageal atresia. J Pediatr Surg. 1978;13:357–9.CrossRefPubMedGoogle Scholar
  56. 56.
    Vogel AM, Yang EY, Fishman SJ. Hydrostatic stretch-induced growth facilitating primary anastomosis in long-gap esophageal atresia. J Pediatr Surg. 2006;41:1170–2.CrossRefPubMedGoogle Scholar
  57. 57.
    Worthington P. Francis was the only honest man. Toronto Sun: Saturday, May 15; 2010.Google Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2017

Authors and Affiliations

  1. 1.Adjunct Clinical Faculty, Department of SurgeryUniversity of Toronto Faculty of MedicineTorontoCanada
  2. 2.Division of General and Thoracic SurgeryHospital for Sick ChildrenTorontoCanada
  3. 3.Department of SurgeryLakeridge Health CorporationOshawaCanada

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