Esophageal reconstruction by elongation of the lesser gastric curvature

Long-gap esophageal atresias (EA) generally require surgical substitution using colon, jejunum, or a portion of the stomach. In these procedures, as in total gastric pull-up operations, the distal portion of the esophagus is sacrificed. Experimental studies on cadaver stomachs have shown that retrosternal transfer of the distal esophagus with preservation of all esophageal portions is possible when the lesser curvature is incised diagonally, provided the collateral circulation via the left gastric artery (LGA) is preserved. A tension-free esophageal anastomosis is then carried out intrathoracically or cervically. This technique was employed successfully in eight children. In two cases ligation of the LGA alone was sufficient; in six an additional incision in the lesser curvature was required to achieve adequate length. This procedure is advantageous in that all portions of the esophagus are preserved and, due to the retrosternal position, a thoracotomy is unnecessary. The morbidity is significantly lower than that associated with all the other substitution techniques. The main complications included cervical anastomotic leaks, which closed spontaneously, and stenoses that required bouginage. There was no mortality. From our experience to date, it can be concluded that esophageal anastomosis is possible in long-gap EA after incising the lesser gastric curvature, and that substitution plasties can be avoided.