A flexible approach to achieve a true primary repair for all infants with esophageal atresia.

Our purpose is to present our results using a flexible surgical approach to achieve a true primary repair for all infants with esophageal atresia (EA). The proposed methods are designed to reach this goal, even when most of the intrathoracic esophagus is missing. What has made this goal attainable is the ability to rapidly induce esophageal growth. We reviewed the results of 63 consecutive patients who presented between 1984 and 2004 with an esophageal gap of greater than 2.5 cm, a distance where increasingly difficult repairs begin. Gaps of 4 cm or longer (46), 6.0 cm or longer (14), and over 10 cm (3) were included. Repairs begun elsewhere (20) included 17 spit fistulas. We present 3 surgical stages, designed to overcome tension and, for longer gaps, induce esophageal growth. For 25 infants, traction in the operating room was sufficient to dissipate tension and allow a primary repair. For the longest gaps, successful esophageal growth was induced over days in 38 patients by internal (5), external (23), and mixed internal/external traction (10). Growth quickly produced adequate esophagus for a primary repair. We conclude that adequate esophageal growth can be induced within days, even early in infancy, and this flexible approach allows the entire EA spectrum to be repaired primarily.