Conditions + Treatments

The Foker Process

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You may have heard that esophageal atresia (EA) can be challenging to treat. Unfortunately, that's true. However, the dedicated, compassionate esophageal disorders team at Boston Children's is world-renowned for innovative treatments that offer very successful, life-long solutions to EA and long-gap EA.

Until recently, EA was a condition with no truly satisfactory treatment options. For a child with the more difficult form of EA known as long-gap esophageal atresia, the gap between the two “nubs” of the esophagus is too far apart to connect surgically.

Boston Children’s is the only hospital in the world to offer the Foker process to treat long-gap EA and related problems. To date, almost all of the patients treated with this method are able to eat and swallow like other children.

Treating Long-Gap Esophageal Atresia with the Foker Process

The best treatment for esophageal atresia is usually surgery to connect the ends of the esophagus together without stretching them. But in long-gap esophageal atresia, the ends are often too far apart to be easily connected.

Traditionally, babies with long-gap atresia are treated in ways that require life-long care and monitoring, such as:

  • Gastric pull-ups: Pulling up the stomach to connect directly to the end of the esophagus. Various forms including gastric tubes and gastric transposition.
  • Colon transposition: Creating more “esophagus” from a piece of the child's large intestine

These procedures can cause complications and increase various risks, such as aspiration (food and liquids entering the lungs) and pneumonia.

John Foker, MD, PhD, a pediatric, general and cardiac surgeon from the University of Minnesota, developed a technique to stimulate growth of the upper and lower ends of the esophagus to treat cases of long-gap EA.  The Foker process is a revolutionary procedure that encourages natural growth and strengthening of a child’s existing esophagus, resulting in an esophagus that works so well that it is often nearly indistinguishable from one that developed normally on esophagram

Since 2009, Dr. Foker has worked exclusively with Boston Children’s surgeon Russell Jennings, MD and the EAT Center team to ensure that his surgical technique continues to help young patients with esophageal concerns.

Foker Process at Boston Children’s: Excellent outcomes

Surgical repair of esophageal atresia is an extremely rare and complex surgery and should be performed by a surgeon specializing in this area. Our published results show a clear difference in outcomes between children treated initially at Boston Children’s Hospital and those who come to us for repair after a surgical procedure performed elsewhere.

Foker process as initial treatment 


Repeat procedure cases


Average duration of hospitalization (days)



Longest hospitalization (days)



Average interval between placing the traction 
sutures and first attempt at joining the two ends (days)

14 (range 11–17)

35 (range 24–40)

Average number of days requiring mechanical ventilation

24 (range 15-173)

46 (range 9-236)

"Intact Esophagus"






Eating entirely by mouth



Average number of surgical procedures  (thoracotomy )

2 (range 2–10)

5 (range 2–15)

Average number of esophageal dilatations (Performed under anesthesia)

3 (range 0–18)

5 (range 0–20)



2/25 *

Statistically different outcomes between the two groups.

*no patients died in hospital, but two patients with complex anatomy who failed attempts at repair, died after discharge. (One had additional, multiple complex medical problems.)

These groups have also encountered complications including fractures of their bones resulting from long periods of motionlessness (Five [19%] in the primary group and 15 [60%] in the reoperative group).  Patients also have experienced hearing loss (from medications now rarely used) and pulmonary embolus (blood clot going to the lung usually from an intravenous catheter in a large vein in the chest); three (11%) of the primary cases and 12 (48%) of the reoperative patients. Leaks have also occurred from where the esophagus is connected in 7 patients (26%) in the primary and 17 (68%) in the secondary patients.  The leaks have healed in some cases and in others they have required additional procedures which accounts for the high number of thoracotomies in some patients.

Data shows that children who undergo the Foker process at Boston Children’s experience:

  • Fewer hospitalization days
  • Less time on mechanical ventilation
  • More success eating entirely by mouth
  • Fewer required surgical procedures

Contact us for more information about a preliminary screening.

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To make an appointment or speak with a member of our team, please call 617-355-3038.

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For families residing outside of the United States, please call Boston Children's International Health Services at +01-617-355-5209.

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- Sandra L. Fenwick, President and CEO

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