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A safer way of suturing in Foker's technique

A safer way of suturing in Foker's technique
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  A safer way of suturing in Foker  ’ s technique Mohan K. Abraham ⁎ , Bindu Sudarsanan, Naveen Viswanath,Ramakrishnan Puzhankara, Anup B. Palliwal, Aisha Naaz, Narasimha K. Nandakumar,Ashwin Prabhakaran, Divya Prakash  Department of Pediatric surgery, Amrita Institute Of Medical Sciences, Ponekkara, Kochi, 682041, Kerala, India Received 11 January 2013; revised 13 March 2013; accepted 13 March 2013 Key words: Esophageal atresia;Long gap atresia;Foker technique;Esophageal lengthening;Thoracoscopy AbstractBackground/Purpose:  Foker  ’ s technique allows esophageal lengthening facilitating end to endanastomosis in long gap esophageal atresia. The problem faced with this technique is that the tractionsutures cut through the tissues leading to re-operations. Our aim was to find a technique of suturing that will prevent the sutures from cutting through the esophagus. Methods:  After dissection of the upper and lower esophageal pouches, purse string sutures were placed,two each on both pouches. Clips were applied at the ends of both the pouches. Sutures were brought out on the posterior chest wall and traction applied. This was tried in a total of three cases. Case 1 was anewborn with pure esophageal atresia, Case 2 was an eighteen month old child with cervicalesophagostomy and gastrostomy, and Case 3 had esophageal atresia with distal fistula. Two cases weredone thoracoscopically and the third one by thoracotomy. Results:  In all three cases sutures held and lengthening could be obtained. In the first case it took twelvedays, in the second case six days, and in third case eight days for the ends to come together. Conclusion:  This modification of traction sutures is simple and reduces the risk of suture disruption.© 2013 Elsevier Inc. All rights reserved. Most pediatric surgeons believe that the native esophagusshould be preserved and used in the repair of long gapesophageal atresia. Esophageal substitution with stomach,colon or jejunum may lead to difficulty in swallowing, pulmonary and cardiac compression due to dilatation of theconduit in the mediastinum, necrosis of the conduit, severereflux leading to aspiration and development of malignancyin the pulled up stomach or colon. Foker designed theexternal traction technique for esophageal lengthening [1].This made end to end anastomosis of esophagus possibleeven in long gap esophageal atresia. Foker used multiplesutures on both esophageal ends. These sutures were brought out on the chest wall and were put on traction promotingesophageal growth. Once the esophageal ends came together an anastomosis was performed. The main problem with thistechnique was that sutures cut through the esophageal wallcausing esophageal leak and re-operations [2,3]. We haveused a modification of the suturing technique with goodoutcome in three cases. 1. Case 1 The first case was a baby girl born at 38 weeks gestationweighing 2.5 kg with pure esophageal atresia. Transpleural ⁎  Corresponding author. Tel.: +91 4842801234; fax: +91 4842802020.  E-mail addresses:, (M.K. Abraham)$  –  see front matter © 2013 Elsevier Inc. All rights reserved. of Pediatric Surgery (2013)  48 , 1819 – 1821  thoracoscopic placement of multiple seromuscular simplesutures was done as described by Foker and others [1,4,5]. A5 mm camera port was placed just anterior to the angle of scapula in the fourth right intercostal space. Two working ports, one 5 mm and one 3 mm port were placed oneintercostal space below the camera port, 5 mm being posterior and 3 mm anterior to the camera port. This formeda triangle with the base towards the diaphragm. The 5 mm port was used for clip application. A fourth 3 mm port for lung retraction was placed in the 6th space below the 5 mmworking port. Carbon dioxide was insufflated at a pressure of 5 mm Hg. Mediastinal pleura over the upper and lower  pouches was incised and dissected. The upper pouch wasmobilized extensively after ligating and the azygos veindivided. Dissection was made easy by keeping a 14 Fr. Foleycatheter in the upper pouch. There was a gap of 3 cm (4vertebral bodies) after mobilization and keeping the pouchesunder maximum stretch. 4  ‘ 0 ’  prolene suture with astraightened 16 mm needle was inserted into the pleuralspace through the chest wall. Multiple seromuscular simplesutures were placed on both the pouches and brought out onthe posterior chest wall. This was done by first inserting a No18 injection needle at the point of exit and then telescopingthe prolene needle into the lumen of the injection needle and pulling out both together. Upper pouch sutures were brought out in the lower chest and lower pouch sutures in the upper chest in such a way that they crossed each other. Gradualtraction was applied. But, on the 3rd day the sutures becameloose and were found to have cut through.The baby was taken back to the operating room (OR) andthoracoscopically, through the same port positions, pursestring sutures were applied on both ends [Figs. 1, 2]. Two purse string sutures were applied with the ends exiting at opposite sides of the pouch so that the pull will not produceexcessive traction only on one side. Mucosa was not included in the bite. Sutures were brought out on the chest wall and tied after threading it through a piece of No:8 feeding tube. Titanium clips were applied at the ends of the pouches and not on the traction sutures. This prevented afalse impression of pouches coming together on the chest radiograph in case the traction sutures became loose or cut through. Operating time was 130 min and blood loss wasminimal. Traction was applied by inserting gauze piecesunder the feeding tube daily; thickness of the gauze piecewas decided by the laxity of the traction suture. Withtraction, the initial 3 cm as measured on the radiograph wasreduced to 0.5 cm by day 12 progressively. At this point the baby was taken back to the OR and a thoracotomy was performed. There was only flimsy adhesion between the pouches and the chest wall probably because of the fact that the lungs are in constant movement breaking up and preventing adhesions. Adhesions formed between the pouchand the chest wall also stretch with the traction. End to endanastomosis of the esophagus was done with 6  ‘ 0 ’  prolene.The baby had uneventful recovery and is feeding well. 2. Case 2 An 18-month-old infant, with pure esophageal atresia wasreferred to our institute with window cervical esophagost-omy and gastrostomy done elsewhere. Esophagogram donethrough the cervical esophagostomy showed the upper pouchdescending to the T4 level. A thoracoscopic approach waschosen. The lower pouch was seen at T7 level just above thediaphragm. After mobilization and putting the pouches under maximum stretch, there was a gap of 3 cm (3 vertebral bodies). Circumferential purse string sutures were placed andtraction applied as in the first case. Operating time was110 min. Ends came together and anastomosis was done onsixth day of traction. Cervical esophagostomy was not closedat this time and was used for suction of the upper pouch inthe post operative period. The infant had an uneventfulrecovery. On follow up she was found to have severe gastro-esophageal reflux uncontrolled with medications. Feedsgiven through the gastrostomy were refluxing through the Fig. 1  Line drawing of purse string suture. Fig. 2  Picture of intra operative suturing. 1820 M.K. Abraham et al.  cervical esophagostomy. She underwent closure of cervicalesophagostomy and gastrostomy and a Nissen fundoplica-tion four months later. She is swallowing well now andgaining weight. 3. Case 3 A 35 week gestational age boy weighing 2.05 kg was brought with esophageal atresia and distal fistula. Thoracot-omy and division of distal fistula were performed. After extensive mobilization and stretching, the gap between the pouches was found to be 2 cm (3 vertebral bodies). Thedistal pouch was closed and both pouches were put ontraction as described earlier. The gap was reduced to 0.5 cmafter 8 days of traction, and a thoracotomy and end to endanastomosis were done. The baby recovered well from the procedure and is now thriving. 4. Discussion Foker and many others have described esophageallengthening by traction and subsequent anastomosis [1 – 6].The problem with multiple simple suture traction was thesuture cutting through the tissues [2,3,7]. This was one of the reasons preventing the widespread acceptance of the procedure. This problem was not encountered in our caseswhere we used the purse string suture. In the first case, inspite of the edema of the pouch as a result of suture cuttingthrough in the previous attempt the purse string sutures held.This is because the total amount of tissue included in the bite is much more than in the case of placing individualsutures which reduces the chance of tearing. The secondcase raises the question whether cervical esophagostomy, if at all needs to be done, should be done as a window or sideesophagostomy, so that at a later date Foker  ’ s technique andanastomosis of the native esophagus can be accomplished.Foker  ’ s technique helped us avoid esophageal replacement in the third case and is a useful procedure even after thoracotomy is done for esophageal atresia with distalfistula. Transpleural repair of esophageal atresia has beenshown to produce no increase in mortality or morbidity [8].A thoracoscopic approach was used in the first two cases toreduce the surgical trauma, since the baby needed more thanone operation in a short period of time. In the third case,since the chest was already opened in an attempt for primaryesophageal anastomosis, thoracoscopy was not used.Placement of circumferential purse string suture is easier and less time consuming. In our three cases it was shown to be stable with lesser chance of cutting through the tissues.The weakness of this study is that we present only 3 cases.We need a larger number of patients to confirm these preliminary findings. But long gap atresia is not verycommon and numbers may be small in any single center. Amulticenter study in the future may resolve this issue. References [1] Foker JE, Linden BC, Boyle EM, et al. Development of a true primaryrepair for the full spectrum of esophageal atresia. Ann Surg 1997;226:533-43.[2] AL-Qahtani A, Yazbeck S, Rosen N, et al. Lengthening technique for long gap esophageal atresia and early anastomosis. J Pediatr Surg2003;38:737-9.[3] Lopes MF, Reis A, Coutinho S, et al. Very long esophageal atresiasuccessfully treated by esophageal lengthening using external tractionsutures. J Pediatr Surg 2004;39:1286-7.[4] Van der Zee DC, Vieirra-Travassos D, Kramer WLM, et al. Thoraco-scopic elongation of the esophagus in long gap esophageal atresia. JPediatr Surg 2007;42:1785-8.[5] Van der Zee DC. Thoracoscopic elongation of the esophagus in long-gap esophageal atresia. J Pediatr Gastroenterol Nutr 2011;52(Suppl 1):S13-5.[6] Skarsgard ED. Dynamic esophageal lengthening for long gapesophageal atresia: experience with two cases. J Pediatr Surg2004;39:1712-4.[7] Paya K, Schlaff N, Pollak A. Isolated ultra-long gap esophageal atresia —  successful use of the Foker technique. Eur J Pediatr Surg 2007;17(4):278-81.[8] McKinnon LJ, Kosloske AM. Prediction and prevention of anastomoticcomplications of esophageal atresia and tracheoesophageal fistula. JPediatr Surg 1990;25:778-81. 1821A safer way of suturing in Foker  ’ s technique
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