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Suture fistula revisited for long gap esophageal atresia
Kevin Janek1, David Meagher2, Charles Goodwin2
1Department of Surgery, University of Wisconsin School of Medicine and Public Health, Madison, WI.
Insights
The Suture Fistula procedure offers a simpler, safer alternative for long gap esophageal atresia when primary anastomosis is not feasible. This technique promotes spontaneous fistulization, enabling early feeding and reducing surgical complexity.
Area of Science:
- Pediatric Surgery
- Gastroenterology
- Thoracic Surgery
Background:
- Long gap esophageal atresia poses surgical challenges, often requiring mechanical traction to promote tissue growth for delayed primary closure (DPC).
- The Suture Fistula procedure, a single-stage technique, facilitates spontaneous fistulization of esophageal segments without direct anastomosis.
- This method allows for early oral feeding and surgical plan flexibility.
Purpose of the Study:
- To evaluate the Suture Fistula procedure as a simpler and effective alternative for managing long gap esophageal atresia.
- To compare the Suture Fistula procedure with other mechanical traction methods like Foker and Kimura procedures.
Main Methods:
- Retrospective chart review of patients undergoing the Suture Fistula procedure since 1992.
- Comprehensive literature review of published case series on the Suture Fistula procedure.
- Level IV evidence study.
Main Results:
- Analysis of 5 case series (24 patients) plus 3 new cases.
- Over 85% of patients achieved spontaneous fistulization by postoperative day 14, evidenced by gastrostomy tube feed reflux.
- Low morbidity, including esophageal leak, comparable to more complex procedures; esophageal dilation and anti-reflux procedures were commonly required.
Conclusions:
- The Suture Fistula technique is a simpler, effective, and safe alternative for esophageal atresia when primary anastomosis is not feasible.
- This procedure demonstrates favorable outcomes and low morbidity, making it a viable option for pediatric surgeons.
- Further adoption of the Suture Fistula procedure is recommended for its efficacy and simplicity.
Background:
Long gap esophageal atresia presents a challenge to pediatric surgeons due to the variability in surgical management when primary anastomosis is not feasible. Mechanical traction procedures enhance tissue growth that allows early anastomosis, before delayed primary closure (DPC) would be attempted to allow for rapid oral feeding, or when operative discoveries require flexibility of the surgical plan. The Suture Fistula procedure, first published by Alan Shafer and Tirone David in 1974, is a simple, effective, but underutilized single-stage procedure which results in spontaneous fistulization of approximated, non-anastomosed esophageal segments using tension sutures.
Methods:
A retrospective chart review was performed of patients who underwent the Suture Fistula procedure at a single institution since 1992. A literature review of all published case series of patients who underwent this procedure was also performed.
Results:
There were 5 case series found with a total of 24 patients, and three new cases presented. Patients were noted to have spontaneous fistulization with gastrostomy tube feed reflux noted in the upper esophagus or mouth on average of post-operative day 14, which occurred in over 85% of patients. While nearly all patients required esophageal dilation and anti-reflux procedures, the morbidity of the procedure, including esophageal leak, is very low, and similar to the Foker or Kimura procedures, which have been more popular despite their surgical complexity.
Conclusion:
We propose the Suture Fistula technique to be a simpler, more effective, and safe alternative to other mechanical traction suture procedures in cases where primary anastomosis is not feasible.
Level Of Evidence:
Level IV.
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