**2.11 Manoeuvres for managing long-gap OA to achieve primary repair**

Various manoeuvres are used to narrow the gap between the upper and lower oesophageal segments [50]. These manoeuvres are classified as preoperative manoeuvres and intraoperative manoeuvres (**Table 8**).

Preoperative manoeuvres are those that are done before the surgery for primary repair is attempted; and they may be achieved thoracoscopically [45, 51]. These include external traction technique by Foker [50, 52, 53]; multistage, extrathoracic elongation technique by Kimura [52, 54]; bougienage of the upper oesophageal pouch, sometimes including the lower pouch; placement of magnets in the two ends of the oesophageal segments with patient placed in an electromagnetic field and delaying of surgery for some months to allow growth of the oesophagus.

In the Kimura technique, the upper part of the oesophagus is mobilised and brought out as an end-cervical oesophagostomy. The oesophagus and its cutaneous stoma are surgically mobilised and translocated down the anterior chest wall every 2–3 weeks. This is continued until enough length is achieved to perform an end-to-end oesophageal anastomosis. The Foker technique involves open or thoracoscopic placement of traction sutures on both the proximal and distal oesophageal pouches with the sutures exiting through the chest wall. These sutures are serially pulled in opposite directions until the pouches approximate. This external traction technique of Foker is reported to induce oesophageal growth and expedite approximation of the pouches.

Internal traction techniques have also been used to bridge long gaps [45, 55]. These include open or thoracoscopic suturing of the oesophageal segments to the prevertebral fascia or costal bone under tension.

Intra-operative manoeuvres include full mobilisation of the upper segment of the oesophagus; mobilisation of the distal segment; circular myotomy (Levaditis technique) or spiral myotomy, usually of the upper pouch and mobilisation of the stomach into the chest.

Other intraoperative techniques include full-thickness anterior flap of the upper pouch [56] and injection of Botox into the upper segment.

**Figure 3** shows an algorithm for the management of patients with oesophageal atresia.


**61**

*Oesophageal Atresia: Drowning a Child in His/Her Own Saliva*

*DOI: http://dx.doi.org/10.5772/intechopen.84525*

**2.12 Complications after repair of OA**

*Algorithm for the management of patients with oesophageal atresia.*

ciplinary approach.

**Figure 3.**

*2.12.1 Early complications*

*2.12.1.1 Anastomotic leak*

Complications [57–59] resulting from repair of OA are generally grouped into two: early and late complications (**Table 9**). Early complications include anastomotic leak, anastomotic stricture, and recurrent tracheo-oesophageal fistula. Tracheomalacia, gastro-oesophageal reflux and oesophageal dysmotility are the late complications. Factors that promote postoperative complications include preoperative intubation, birth weight less than 2.5 kg, long-gap OA [60], post-operative intubation for more than 4 days, anastomotic leak and inability to feed orally for more than 1 month [61]. Management of the complications may involve a multidis-

Anastomotic leak at the oesophago-oesophagostomy is found in about 14–16% of patients after primary repair of OA. Most often, the leaks are clinically insignificant and can be managed with adequate drainage and nutritional support. Up to 95% of the leaks close spontaneously when a retropleural approach is undertaken and a patent mediastinal drain is in place [62]. Even in transpleural repair with leakage, spontaneous closure occurs with adequate drainage. Anastomotic breakdown

#### **Table 8.**

*Pre-operative and intraoperative oesophageal elongation manoeuvres for long-gap oesophageal atresia.*

*Oesophageal Atresia: Drowning a Child in His/Her Own Saliva DOI: http://dx.doi.org/10.5772/intechopen.84525*

*Pediatric Surgery, Flowcharts and Clinical Algorithms*

compared with open surgery (thoracotomy).

manoeuvres and intraoperative manoeuvres (**Table 8**).

prevertebral fascia or costal bone under tension.

pouch [56] and injection of Botox into the upper segment.

stomach into the chest.

atresia.

oesophagus during the placement of the feeding gastrostomy [27]. This helps to avoid the stress of thoracotomy that may negatively affect patient outcome. Patients who undergo staged repair are later offered oesophageal replacement surgery.

**2.11 Manoeuvres for managing long-gap OA to achieve primary repair**

oesophageal segments [50]. These manoeuvres are classified as preoperative

delaying of surgery for some months to allow growth of the oesophagus.

In the Kimura technique, the upper part of the oesophagus is mobilised and brought out as an end-cervical oesophagostomy. The oesophagus and its cutaneous stoma are surgically mobilised and translocated down the anterior chest wall every 2–3 weeks. This is continued until enough length is achieved to perform an end-to-end oesophageal anastomosis. The Foker technique involves open or thoracoscopic placement of traction sutures on both the proximal and distal oesophageal pouches with the sutures exiting through the chest wall. These sutures are serially pulled in opposite directions until the pouches approximate. This external traction technique of Foker is reported to induce oesophageal growth and expedite approximation of the pouches. Internal traction techniques have also been used to bridge long gaps [45, 55]. These include open or thoracoscopic suturing of the oesophageal segments to the

Intra-operative manoeuvres include full mobilisation of the upper segment of the oesophagus; mobilisation of the distal segment; circular myotomy (Levaditis technique) or spiral myotomy, usually of the upper pouch and mobilisation of the

Other intraoperative techniques include full-thickness anterior flap of the upper

**Figure 3** shows an algorithm for the management of patients with oesophageal

*Pre-operative and intraoperative oesophageal elongation manoeuvres for long-gap oesophageal atresia.*

It should be noted that the surgical management of OA has been advanced into the realm of minimally invasive surgery (thoracoscopy) due to recent advances in surgical techniques. [40–49]. Thoracoscopic approach to the repair of OA is associated with early recovery and minimal chest wall musculoskeletal morbidity as

Various manoeuvres are used to narrow the gap between the upper and lower

Preoperative manoeuvres are those that are done before the surgery for primary repair is attempted; and they may be achieved thoracoscopically [45, 51]. These include external traction technique by Foker [50, 52, 53]; multistage, extrathoracic elongation technique by Kimura [52, 54]; bougienage of the upper oesophageal pouch, sometimes including the lower pouch; placement of magnets in the two ends of the oesophageal segments with patient placed in an electromagnetic field and

**60**

**Table 8.**

**Figure 3.** *Algorithm for the management of patients with oesophageal atresia.*
