WOFAPS 2025 8th World Congress of Pediatric Surgery

Mustafa Çağrı Savaş, Yeliz Kart, Emine Bilaloğlu, Levent Duman

Department of Pediatric Surgery, Süleyman Demirel University Medical School, Isparta, Turkey

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Primary Anastomosis Using Pledget-Reinforced Horizontal Mattress Sutures in “Long-Gap” Gross Type C Esophageal Atresia

Cagri Savas, Yeliz Kart, Emine Bilaloglu, Levent Duman

Introduction

The “long-gap” in proximal esophageal atresia and distal trachea-esophageal fistula (TEF) represents a gap of such length that primary anastomosis cannot be achieved under tension. We describe a technique using pledget-reinforced sutures to perform the primary anastomosis.

Patients and Methods

Pouchograms revealed proximal esophageal atresia and distal TEF, and echocardiograms were normal in 3 term neonates. Fistula ligation and mobilization of both atretic esophageal segments were done after a right posterolateral thoracotomy in all patients. Two full-thickness stay sutures are passed through on each side. Then, a horizontal mattress suture, reinforced with pledgets on the posterior wall of the anastomosis, is placed and tied. If the integrity of the posterior wall is established with this suture without tearing, the two stay sutures on each side are tied. The anterior wall of the anastomosis is then completed in the same manner, using a pledget-reinforced horizontal mattress suture.

Results

The first and third patients began oral feeding on the 10th and 9th days after esophagograms, and they were discharged home uneventfully on the 18th and 21st postoperative days, respectively. The second patient suddenly developed cardiac arrest and died unexpectedly on the 3rd postoperative day.

Discussion

Pledget-reinforced sutures help apply axial tension on both ends to induce esophageal elongation, eliminate the need for excessive mobilization of esophageal segments and esophagomyotomy, which jeopardizes the esophageal blood flow, and shear at the tissue-suture junction, thus preventing anastomotic breakdown.

Conclusion

This technique was successfully performed as a primary single-stage operation in three patients, and we recommend it as the first choice over various complex multi-staged procedures for any long-gap proximal esophageal atresia and distal TEF when the atretic ends can be approximated.