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Afridi F G, Vaughan

Afridi F G, Vaughan

West Virginia University Hospital Program, USA

Title: Successful primary repair of long-gap esophageal atresia in a neonate employing circular myotomy on upper pouch and hemi-circular myotomy of the distal esophageal pouch: A novel approach

Biography

Biography: Afridi F G, Vaughan

Abstract

Introduction: Pure esophageal atresia (EA) with a long gap between the pouches remains a challenge for a primary repair.
Several techniques to facilitate primary repair of this defect have been described: complete mobilization of distal esophageal
pouch, single or double circular myotomies or spiral myotomy of upper pouch, circular myotomy of both upper and lower
pouches, flaps raised from the upper pouch to bridge the gap and external traction sutures. Complete mobilization of upper
pouch with circular myotomy is standard and often favored approach. It is feasible due to the anatomical advantage of blood
supply of the upper pouch. Although complete mobilization of lower pouch with or without circular myotomy is described, it
has a risk of impairing blood supply to the lower pouch due to segmental nature of its blood supply. We present a novel case
of primary repair of long gap esophageal atresia using a circular myotomy on the upper esophageal pouch along with a hemi
circular myotomy of the lower pouch, the latter is done without complete circumferential mobilization of the lower esophageal
pouch.
Case Report: We report the case of a 38 4/7 weeks IUGR term infant with tetralogy of Fallot (TOF) with a long 4.5 cm gap pure
esophageal atresia who was repaired aged 16 weeks. Per-operatively, gap assessment was done on the operating table and the
gap was almost five vertebral bodies. The upper pouch was mobilized completely up to neck. Upon reassessment, a further 2.5
cms gap was found. The upper esophageal pouch was small and narrow, hence unsuitable to facilitate flap reconstruction and
only a single circular myotomy was performed approximately 1 cm proximal to its blind end. The lower pouch was mobilized
taking care that its blood supply was not compromised. This still left a one cm gap that was overcome by performing a hemicircular
(180 degree) myotomy on the lower esophageal pouch approximately 1 cm away from the blind end. A tension free
primary esophageal anastomosis was then performed. The anastomosis did not leak albeit developing a stricture, which is
amenable to balloon dilation. The infant had three esophageal dilations and the last one dilated the stricture successfully to 10
mm.
Conclusion: Hemi-circular myotomy of the lower esophageal pouch can help to achieve adequate lengthening of the pouch
without compromising its blood supply and can help in facilitating a tension-free primary repair of long gap esophageal
atresia. This technique has lesser risk of compromising blood supply to the distal esophageal pouch as it does not require full
circumferential mobilization of the lower pouch as required with full circular myotomy.