Surgeons at the Boston Children’s Hospital Esophageal and Airway Treatment Center are pioneers in the development and improvement of innovative surgical approaches to long-gap esophageal atresia. In this condition, the child’s esophagus occurs in two separate segments and is not easily associated with surgery. ..
Among these techniques are the jejunal intervention and the focuser process. In the former, the surgeon replaces the missing part of the esophagus with the part of the small intestine, especially the jejunum. It is primarily used to treat children who have failed to repair long-gap esophageal atresia, or who have difficulty relieving the esophagus due to factors such as caustic alkali intake or esophageal perforation. It is also used in children where the focuser process, a technique that relies on the child’s existing esophageal tension growth, is infeasible.
Based on the relatively large amount of these procedures performed at the Boston Children, our surgeons have the expertise to continually improve the management of patients with esophageal atresia. They explain these advances in two recent studies.
Supercharging with jejunal intervention
About the first paper published in the April 2021 issue Surgery, Benjamin Zendejas-Mummert, MD, MSc, and his colleagues reviewed Medical record From 55 children who underwent jejunal intervention at the Boston Children between 2010-2015 (historical cohort) or 2016-2019 (modern cohort). Specifically, we investigated the effect of “supercharging” (a type of enhancement of blood flow or microvessels) on the risk of anastomotic leakage (disorder of anastomosis).
They found that 41 patients in the modern cohort had significantly shorter duration of drug-induced paralysis, intubation, ICU stay, and hospital stay than 14 children in the past cohort. Also, the operation time was short. The anastomotic leak rate was very low and similar between the two groups, but patients who received supercharged jejunal intervention did not experience such leaks.
“This is a big step forward, as this type of anastomosis has historically been associated with significant leakage rates,” explains Zendejas-Mummert. “We found that the extra blood flow generated by supercharging allowed us to reduce the leakage rate of the anastomotic site to zero. Jejunal intervention is still our preferred type of esophageal replacement.”
Evolution of the focuser process
A second study by Zendejas-Mummert and his colleagues examined the results of the Foker process in children with long-gap EA. In the traditional Focuser process, the surgeon connects the sutures at both ends of the esophagus to an external traction system, increasing the tension of the sutures over time. This allows both ends to grow sufficiently to perform anastomosis or gradual repair. Due to the external traction system, children undergoing the focuser process must remain sedated, medically paralyzed, and ventilated during this time. Recently, a Boston pediatric surgeon has developed a minimally invasive approach to the Focuser process. This reduces the time spent in the ICU, reduces painkillers and sedatives, and eliminates the need for paralysis because the traction system is inside or inside the patient’s chest. However, not all patients are candidates for this approach.
The team received medical records of 65 patients with long-gap esophageal atresia (modern cohort) who underwent a focuser process at the Boston Children between 2014 and 2020, and underwent surgery between 2005 and 2014. Compared with medical records of 41 patients (historical cohort).
They found that patients in the modern group had significantly less traction leaks, fractures, anastomotic leaks, and focuser failures than patients in past cohorts. Children who underwent a minimally invasive focuser process were paralyzed and intubated in the ICU and hospital for fewer days with comparable anastomotic results. The survey results were published in the February 2021 issue. Journal of Pediatric Surgery..
There is no one-size-fits-all approach
“These results show that children with long-gap esophageal atresia do not have a universal approach and need to develop custom controls for each child,” said Zendejas-Mummert. “We continue to show that the best option for these children is to try to maintain their original esophagus. We have a classic open external traction and a new minimally invasive approach. Both have improved and continue to improve the results of the focuser process, which are the results of these complexes. Children Most well cared for in the center of expertise. The amount and interdisciplinary approach to their care is really important there. ”
Kyle Thompson et al., Evolution, lessons learned, and the modern consequences of jejunal esophageal replacement for children, Surgery (2021). DOI: 10.1016 / j.surg.2021.01.036
Wendy Jo Svetanoff et al, modern achievements of the Foker process and evolution of long-gap treatment algorithms for esophageal atresia, Journal of Pediatric Surgery (2021). DOI: 10.1016 / j.jpedsurg.2021.02.054
Boston Childrens Hospital
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