A modified surgical strategy for complicated long-gap esophageal atresia: A case report

Introduction Long-gap esophageal atresia (LGEA) remains challenging, particularly after esophagostomy following failed repair. Case presentation An 11-month-old girl with type A esophageal atresia (EA) was referred after initial management at another institution. Based on a medical-record extract and clinical history, gastrostomy was performed on day 3. At 53 days, thoracoscopy identified a six-vertebral-body gap (T2-T8), and internal traction was initiated. Eight days later, the traction sutures cut through both segments, causing exudate and inflammation; a cervical esophagostomy was created and the distal segment was closed. Because the proximal segment had been exteriorized from the posterior mediastinum, fluoroscopy could not provide a meaningful two-segment gap measurement or three-dimensional (3D) distal pouch assessment. Two CT examinations using gastrostomy-administered enteral contrast, intravenous contrast, pediatric dose-reduction settings, and 3D reconstruction defined the distal pouch's cranial extent, caliber, course, and relationships to adjacent mediastinal structures. Three thoracoscopic distal-segment traction procedures were performed at 1.5 to 3-month intervals; the first two were combined with extra-thoracic Kimura elongation of the proximal segment. A tension-free anastomosis was created by right thoracotomy at 2.2 years. Four balloon dilatations treated an anastomotic stricture. Gastrostomy feeding ceased at 2.5 years, and the tube was removed six months later. At the last follow-up at 4.5 years of age, she tolerated a full oral diet without dysphagia. Conclusion Thoracoscopic serial internal traction of the distal esophagus in addition to extra-thoracic elongation of the proximal pouch may allow an eventual esophageal anastomosis in selected patients with type A esophageal atresia who underwent a previous esophagostomy.