[Lessons we've learned in the treatment of long gap esophageal atresias]

A gap greater than 3 cm between both esophageal pouches is observed in 1 of 20 cases of esophageal atresia. Our goal was to critically review our experience in the management of these patients.

During 1995-2004, 15 patients were treated for a long gap esophageal atresia (LEA). Gaps ranged from 3 to 8 cm. Ten patients presented a pure esophageal atresia. They were managed with a gastrostomy and delayed repair: 8 Schärli interventions and 2 esophageal flaps. The other 5 patients had an esophageal atresia with distal fistula (LEA-DF), and primary repair was attempted: 3 end-to-end esophageal anastomosis were achieved under a strong tension; 1 a Schärli procedure; 1 ligation of the fistula, feeding gastrostomy and delayed esophageal flap. The use of esophageal flaps is a late event in our series. since its introduction we've performed 5 esophageal atresia repairs using 3 flaps (2 pure atresias and 1 LEA-DF).

From 9 Schärli we have to practice 2 reinterventions for anastomotic leak; there was 1 parahiatal hernia that needed surgery after 8 years. From 3 flaps 2 patients presented a persistent stricture that needed reintervention. All of the 3 E-E anastomosis had reintervention for persistent stricture and also anti-reflux procedures (Nissen). Eight patients showed a normal growth and development (4/9 Schärli, 3/3 flaps and 1/3 E-E). Seven patients are growth retarded (4/7 with associated malformations, 1/7 who developed an eosinophilic esophagitis and 2/7 preterm babies).

The esophageal flap is our first choice, because the own esophagic tissue fills in the gap. In LEA-DF, we prefer fistula ligation, gastrostomy and delayed rise of a flap (as we did in our last patient) better than a very tense primary anastomosis. As a second option, a Schärli procedure offers satisfying mid-term results. Keeping the patient paralyzed and mechanically ventilated for 5-7 days after surgery helps to avoid disrupting forces on the anastomosis.