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What is the Foker process?

The Foker process is an innovative procedure that is used to treat some forms of esophageal atresia. In this rare birth defect, a baby is born without part of the esophagus (the tube that connects the mouth to the stomach).

Until recently, there were no satisfactory treatment options for long-gap esophageal atresia to save the esophagus. The approach to this condition usually involves surgery to connect the ends of the esophagus together without stretching them. For a child with the more challenging form of esophageal atresia known as long-gap esophageal atresia, however, the gap between the two "nubs" of the esophagus is too far apart to connect surgically.

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 esophageal atresia. This technique, known as 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.

Since 2009, Dr. Foker has worked exclusively with Boston Children's Hospital surgeon Russell Jennings, MD, and the Esophageal and Airway Treatment Center team to ensure that his surgical technique continues to help young patients with esophageal concerns. We have the most extensive experience in the world in performing the Foker process, with outcomes data to support its benefits. Our published results show a clear difference in outcomes between children treated initially at Boston Children's and those who come to us for repair after a surgical procedure performed elsewhere.

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

What is the minimally invasive Foker process?

For some children, a new minimally invasive version of the Foker process may be an option. As its name implies, the minimally invasive Foker process involves very small incisions on your child’s back and uses minimally invasive instruments and a camera. The surgeon places traction sutures on each end of the esophagus but creates the traction system inside your child’s body by securing the sutures around one of their ribs. Surgeons tighten these sutures every week until the two ends of the esophagus are close enough to attach to each other.

Because the risk of tearing or breaking the traction system is reduced, your child won’t need to be kept asleep and still. Preliminary results show that the minimally invasive approach is as safe and effective as the traditional Foker process, but requires less time spent in the ICU and fewer pain medications and sedatives. Your surgeon can tell you more about this possible option.

Foker Process | What to Expect

The Foker process works best when used as the initial treatment for long-gap esophageal atresia. It can sometimes be used after other treatments, such as colonic interposition or a gastric pull-up, have failed, but experience has shown that this is not ideal.

At Boston Children's Hospital, we can perform the Foker process on newborns and children who weigh as little as 7 pounds. The process takes anywhere from several weeks to several months to complete, depending on the severity of your child's condition. Because the process allows your child to grow their own esophagus, surgically transplanting other parts of the digestive tract (such as the colon or stomach) is not necessary. This approach may also reduce the risk of infection, eating difficulties and malnutrition.

What happens during the Foker process?

With your child fully sedated, the surgeon will make an incision on the back of their chest. Unlike traditional treatments, which require large incisions on the abdomen as well as the neck and chest, the Foker process results in fewer incisions and smaller scars.

The surgeon will then place four or five sutures (stiches) on the upper and lower ends of your child's esophagus. These are tiny stitches that connect the ends to the outside. The tension on the sutures will be increased bit by bit, causing each end of the esophagus to grow about one to two millimeters each day — just like a muscle grows when you exercise it. This will create just enough growth for the two ends to be attached. Depending on how much your baby's esophagus needs to grow, this typically may take between one and three weeks.

For the Foker process to be successful, your baby will need to be motionless during the time the esophagus is being stretched, because excessive motion might pull out the sutures. Medication will be provided to keep your child still. During this time, your child will stay in the intensive care unit on a ventilator (breathing machine). Once the esophagus has grown to the desired length, the surgeon will remove the sutures and sew together the ends of the esophagus. This extraordinary procedure often results in an esophagus that is indistinguishable from one that has developed normally on esophagrams.

Depending on your child's unique situation, we also offer minimally invasive versions of the Foker process that do not require full anesthesia.

What happens after the Foker process?

Typically your child will be able to eat normally fairly soon after the surgery. Your child may need to be monitored for strictures (places of narrowing) in the esophagus, but these are treatable and in general, the outlook is very good. Almost all of the patients treated with this method to date are able to eat and swallow. Our doctors will continue to evaluate your child every year or two throughout childhood to make sure that there are no problems or complications.

Foker Process | Programs & Services