The newly formed Esophageal Advanced Treatment (EAT) Center at Children’s Hospital Boston is the only center offering the most advanced surgical treatment for esophageal atresia (EA) and the commonly associated condition tracheoesophageal fistula (TEF).
A partnership between Russell W. Jennings, MD, associate in Surgery, and the University of Minnesota’s John E. Foker, MD, PhD, is responsible for bringing this innovation to Children’s.
One out of every 3,000 to 4,500 babies is born with a segment of his esophagus missing. This condition, known as EA, presents in multiple types. The most common (“type C”) involves a fistula that connects the lower esophageal segment with the trachea. Problems associated with these malformations are easy to discern: without a working esophagus, nutrition by mouth is impossible. The baby is also at risk for aspiration and pneumonia, both of which are also common hazards of the two most common surgical treatments.
Removing the fistula between the lower esophageal segment and trachea often leaves the lower segment too short to allow for connection with the upper one. In other cases, including cases of EA unaccompanied by TEF, the incomplete esophageal segments are simply too far apart to join. Surgeons may overcome the gap by performing a gastric pull-up, linking the stomach to the upper esophageal segment. However, crowding the throat this way decreases functional lung volume and intensifies the risks associated with acid reflux. Alternatively, surgeons can reposition a segment of colon to function as a replacement esophagus. But the colon, with its bumpy contour, is inefficient as a passageway for food prior to digestion in the stomach. Also, repeated operations are required to straighten the colon segment as it grows.
For more than a decade prior to his retirement this year, Dr. Foker achieved one clinical success after another by treating EA with a technique he devised. He knew that the normal esophagus develops in fetuses due to the tension placed on it by growing bones. To encourage this same tension-induced elongation for children with EA following birth, he surgically attached traction sutures to the tiny esophageal ends and increased the tension on these sutures intermittently. After two to three days of tension—or in the case of long gaps, two to three weeks—the elongated esophageal ends were close enough to be sewn together. Dr. Foker’s first patient responded well to the treatment, a success he’s duplicated in dozens of cases since.
Since inventing his technique, Dr. Foker has met with skepticism from his peers. Fortunately, Dr. Jennings emerged as one believer. This August, Dr. Jennings visited Dr. Foker in Minnesota to assist him in operations employing the “Foker technique.” Dr. Jennings is now putting his education to use at Children’s. Together with Bradley C. Linden, MD, director of Minimally Invasive and Computer-Assisted Pediatric Surgery at Children’s, he’s established the world’s only center offering the Foker technique.
For many, care at the new center will provide something unthinkable to most surgeons: a resolution to EA. Gastric pull-ups and colonic transpositions entail a long, if not lifelong, dependence on the medical system. The Foker technique, on the other hand, offers what appears to be a one-time, 70-year solution. At least two operations are required: one to apply the traction sutures and another to remove the sutures and join the esophageal ends. In the interim, the patient is sedated while a ventilator provides respiratory assistance. Although the stimulus to induce growth may take up to three weeks, the result is an esophagus virtually indistinguishable from one that has developed normally. Practice with oral feeding—and for older kids, socialization—is usually sufficient to overcome any oral aversion.
To provide the full spectrum of pre- and post-surgical care, doctors Jennings and Linden will collaborate with specialists from many disciplines, including Critical Care, Gastroenterology, Endocrinology, Otolaryngology and Interventional Radiology. “Dr. Foker’s ideas never reached worldwide acceptance because implementing them is so difficult,” says Dr. Jennings. “It takes a robust system to support an approach this innovative. This is where Children’s can help.”
More information, including video interviews with doctors Foker, Jennings and Linden: childrenshospital.org/eatc
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