Internal traction as an effective bridge to successful anastomosis in complex esophageal atresia

Internal traction is an evolving strategy for patients with long-gap esophageal atresia (LGEA) and esophageal atresia (EA) patients with a distal tracheo-esophageal fistula in whom primary anastomosis cannot be achieved. This study aimed to evaluate outcomes and complications following placement of internal traction sutures in EA.

A retrospective review was performed of consecutive patients with EA undergoing internal traction suture placement at a single center over an 11-year period (2014-2025). Data were collected from a prospectively maintained institutional EA database and supplemented with retrospective medical chart review. Endpoints were successful esophageal anastomosis, traction-related complications, and long-term complications.

Twenty-three patients underwent internal traction: 14 presented with a gasless abdomen and 9 with distal fistula. Traction sutures were placed thoracoscopically for 13 patients (56.5 %), all of whom presented with a gasless abdomen. Two (8.7 %) patients died from unrelated comorbidities, one prior to anastomosis. Eighteen patients (78.3 %) had successful delayed primary anastomosis, and 4 patients (21.1 %) had esophageal auto-anastomosis from fistulation post-internal traction. Traction-related complications occurred in 3 patients (13.0 %): two conservatively managed esophageal leaks and one air leak. Three patients (13.0 %) required thoracoscopic suture re-tensioning. Median follow-up duration was 3.7 years (IQR: 1.5-6.4 years). Twelve patients (57.1 %) developed anastomotic strictures. No patients have required fundoplication or esophageal replacement to date.

Internal traction is an effective primary management strategy in complex EA patients, with high rates of successful delayed primary esophageal anastomosis. There is also evidence that internal traction may infrequently precipitate esophageal auto-anastomosis.

Level IV.