ESOPHAGEAL RECONSTRUCTION IN VERY LONG ATRESIAS BY ELONGATION OF THE LESSER CURVATURE

The treatment of long esophageal atresias is associated with numerous risks and complications. Bouginage and circular (Livaditis) or spiral myotomy permits the proximal blind pouch to be lengthened by a maximum of 2-3 cm. For longer atresias interposition of a loop of colon or stomach or intrathoracic displacement of the stomach becomes necessary. These measures make actual reconstruction of the esophagus impossible; new means for total preservation of the available esophagus and cardia must be sought. Experimental studies on cadavers have shown that mobilization of the distal esophagus is possible only to a limited extent due to the fixation of the lesser curvature and left gastric artery and that tension on the esophagus affects primarily this curvature. Ligation of the left gastric artery and transverse/diagonal division of the lesser curvature permits mobilization of 6-8 cm of distal esophagus with preservation of the cardia, ensuring that primary anastomosis of the esophageal ends is always possible. We have performed mobilization and transverse division of the lesser curvature using a stapler in five children with an esophageal gap of 4-8 cm. The esophageal anastomoses were tension-free and either intrathoracic or cervical. In one case of atresia without a tracheoesophageal fistula the esophagus was drawn retrosternally to the neck, making a thoracotomy unnecessary. In all patients a semifundoplication was performed as an anti-reflux measure and a pyloroplasty was done to improve gastric emptying. Complications were few after these procedures: one leaking anastomosis in the neck closed spontaneously, two stenoses required bouginage of the anastomosis. In most cases of esophageal atresia, even those with very long gaps, primary anastomosis of the esophagus is possible by elongating the lesser curvature. Substitution plasty can always be avoided. Our results in five children with this procedure have been encouraging.