Background: Long gap esophageal atresia presents a challenge to pediatric surgeons due to the variability in surgical management when primary anastomosis is not feasible. Mechanical traction procedures enhance tissue growth that allows early anastomosis, before delayed primary closure (DPC) would be attempted to allow for rapid oral feeding, or when operative discoveries require flexibility of the surgical plan. The Suture Fistula procedure, first published by Alan Shafer and Tirone David in 1974, is a simple, effective, but underutilized single-stage procedure which results in spontaneous fistulization of approximated, non-anastomosed esophageal segments using tension sutures.
Methods: A retrospective chart review was performed of patients who underwent the Suture Fistula procedure at a single institution since 1992. A literature review of all published case series of patients who underwent this procedure was also performed.
Results: There were 5 case series found with a total of 24 patients, and three new cases presented. Patients were noted to have spontaneous fistulization with gastrostomy tube feed reflux noted in the upper esophagus or mouth on average of post-operative day 14, which occurred in over 85% of patients. While nearly all patients required esophageal dilation and anti-reflux procedures, the morbidity of the procedure, including esophageal leak, is very low, and similar to the Foker or Kimura procedures, which have been more popular despite their surgical complexity.
Conclusion: We propose the Suture Fistula technique to be a simpler, more effective, and safe alternative to other mechanical traction suture procedures in cases where primary anastomosis is not feasible.
Level of evidence: Level IV.
Keywords: Long-gap esophageal atresia; Mechanical traction procedure; Suture fistula.
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