Thoracic gastrostomy - a new technique for feeding gastrostomy in wide-gap esophageal atresia and tracheo-esophageal fistula

Introduction. Initial management of wide-gap esophageal atresia and tracheo-esophageal fistula, especially in developing countries, often involves ligation of the fistula, proximal esophagostomy and a gastrostomy. The conventional gastrostomy requires an abdominal incision and has several complications. The authors present an alternative technique of 'gastrostomy' that does not require an abdominal incision. Method. Through a standard right thoracotomy, the fistula is divided and tracheal end closed. If primary anastomosis is not possible due to wide gap, the lower esophageal pouch is mobilised and brought out as a stoma on the left posterior chest wall, lateral to the paraspinal muscles in the 7th or 8th intercostal space. A feeding tube is passed through the stoma into the stomach. The thorax is closed with a drain. Proximal esophagostomy is performed in the neck. The thoracic stoma is intermittently intubated for feeding until the child is ready for gastric transposition. Results. The technique was successfully used in 5 patients. Feeding through the stoma could be established in 4. One patient had stomal retraction and died of resultant sepsis. One patient has subsequently undergone gastric transposition and one more is waiting for it. Two patients died of unrelated causes before esophageal replacement could be carried out. Discussion. This is an alternative technique for feeding 'gastrostomy'. We have named the procedure as "Thoracic Gastrostomy" because the stoma is located on the chest but functions as a gastrostomy. The advantages include avoidance of a laparotomy and its complications, easy feeding by intermittent intubation, and availability of a virgin stomach for future gastric transposition.