Long Gap Esophageal Atresia:

Magnetic Compression Anastomotic Repair

Charles Wulf
Tufts Medical Student

Objectives
Overview of Esophageal Atresia
Current Treatments
What is Long Gap Atresia and how its repair
difers

MCA Repair- Background and Procedure

Esophageal Atresia
Epidemiology

1 in 2500 Live Births

Etiology:

No specific etiology

Some associations with mutations of the N-myc, Sox-2 and CHD7

genes

Embryology

Esophagus and Trachea share same embryonic origin

Multiple associated abnormalities (VACTERL Association)

~4 weeks GA, improper development at of trachebronchial

diverticulum and elongation of the esophagus results in atresia
and fistula formation

From: Specific Considerations

Schwartz's Principles of Surgery, 10e, 2014

Date of download: 2/19/2015

Copyright 2015 McGraw-Hill Education. All rights reserved.

Presentation
Very difficult to diagnose prenatally

US: polyhdramnios, dilated proximal pouch and absence of

gastric bubble

MRI: Non-visualization intra-thoracic esophagus

Postnatal presentation, if Type A, B, C,or D:

After initiating feeding: cough, apnea, cyanosis, tachypnea

Can also occur due to inability to swallow secretions

Abdominal distension if distal pouch has fistula to trachea

X-ray shows impassible orogastric catheter with air in
stomach

Type E- Presents with recurrent PNA and chemical

pneumonitis of lungs

Imaging: Classic CXR

Prognosis

Most important
predictors:
Birth weight
Severity of
pulmonary
dysfunction
Presence of
major
congenital
cardiac
disease

Montreal Childrens Hospital

Staging
Group Characteristics

Survival
Rate

-Weight > 1,500 g

-No major cardiac
anomalies

97%

II

-Weight < 1,500 g

OR
-Major cardiac
anomalies

59%

III

-Weight < 1,500 g

AND
-Major cardiac
anomalies

22%

Management
Before treatment, stabilize: Ventilate,

drainage for upper pouch, and possible

gastrostomy tube to alleviate abdominal
distension (which can compress lungs)

Contraindications for immediate surgery

Long Gap Atresia

Low BW
Congenital Heart Disease
Unstable airway status

Treatment Methods
Once patient is stable:

Primary repair- Either thoracotomy or thorocoscopy

Thoracotomy:

Right side incision, followed by mobilization of the

pleura

Ligation of azygous vein

End to end anastomosis between proximal and distal

esophagus with a single layer of interrupted sutures

Transection of any tracheoesophageal fistula, with repair

of the trachea with a single layer of interrupted sutures

Thorocoscopy-Same approach, but less invasive

Post Operative Complications

Leak : 10-15%
Stricture: 10-20%, serial balloon dilation or Tuck dilators
GERD:Common
Esophageal Dysmotility: Common
Thoracic Wall deformities (Winged Scapula,
Scoliosis):~20%

Recurrence of the atresia: Rare, but anastomosis can fail

Long Gap Atresia

Long gap atresia is defined as >2.5 Vertebral
bodies or >3cm

Initially, primary surgery is not usually

possible.

Repair has to be delayed for 1-3 months, though it can

be up to a year before final repair

Drainage placed in proximal pouch to drain swallowed

secretions

Gastrostomy tube placed in distal pouch for feeding

Some long gaps self resolve and can be repaired with

the primary surgical approach, most need lengthening

Long Gap Atresia Treatment

Often done as 2 step procedure:

Extension
Anastomosis

Current extension techniques include:

Foker Process:

Bakes Dilators: Repeated non-invasive

lengthening maneuvers

Replacement: Gastric pull up or gastric, jejunum,

or colon transplant to bridge gap

Long Gap complications

Complications

Same as with the standard repairs, however, leaks

are far more common, as well as a higher risk of
strictures

Many have long term GI issues years after treatment

More likely to fail completely, due to tension on the
anastomotic sutures

Magnetic Compression Anastomotic

Repair (MCA Repair)

Background

First suggested in the 1975, using electromagnetic

repair at MGH

Used external electromagnet to drive 2 metal bullets

Would then repair using standard surgical repair

Stretching the esophageal pouches stimulated tissue

growth

MCA Repair

Current methods:

Case study in 2001-2004

When magnets meet, they compress the tissue

Still relies on stretching to stimulate tissue growth

Uses rare earth magnets (Samrium-cobalt and Neodymiumiron-boron) that are catheter based & latex-free

Center of compression site becomes ischemic, causing tissue to

slough of, making the esophagus patent

The outer rim heals, uniting the pouches and creating an end to
end anastmosis

MCA Repair Technique

1st stage: Bakes dilators used to manually lengthen and

widen pouches, with full thickness sutures placed for
alignment

1 placed at the center, 1 on the lateral pouch end bilaterally

2nd Magnets placed using guide wires into each pouch, and
checked for magnetic tension

3-5 days for lengthening

3-5 days for anastomotic compression
Confirm with contrast patency and integrity of anastomosis, then
remove

Placement and removal takes ~20 minutes

New anastomosis often then protected by feeding tube to

allow feedings and prevent closure

Lovvorn, Harold N., Christopher M. Baron, Melissa E. Danko, Nathan M. Novotny, Brian T. Bucher, Krystal K. Johnston, and Mario F. Zaritzky. "Staged Repair of
Esophageal Atresia: Pouch Approximation And catheter-based Magnetic Anastomosis." Journal of Pediatric Surgery Case Reports (2014): n. pag. Web.

Outcomes
Sutureless anastomosis
Allows for anastomosis using only esophageal
tissue, versus transplant of gastric or other GI
tract tissue

Minimizes the invasiveness compared to

classic tension based approaches, which

require multiple thoracotomy/thorocoscopy

Limitations and
Complications

Limitations

Magnetic fields lose efectiveness over distance.

Most are efective at maximum distance of 3-5cm

Complications

Still encounter the same problems of most long gap

repairs

No reports of failures

Magnets can also theoretically become lost- Same

issues of magnetic ingestions (Fistulas, perforations)
and inability to use magnetic imaging

No such issues reported so far

Current Evidence

Most papers are limited to case studies

Trials limited by small number of long-gaps, plus novelty of treatment

Of those studies, most have shown success, though small sample

pool

Larger pool of MCA used for significant stricture or failure of anastomosis

Primary repair still remains best treatment when it is possible

Summary
Esophageal Atresia is a life threatening congenital
condition if not identified or repaired

Current surgical repair allows for approximation and

anastomosis of esophageal atresia

Long gap has additional complications for repair,

requiring delay of treatment and often a 2 step repair

MCA allows a less invasive, sutureless anastomosis of

the esophagus; however, limited use has limited
evaluation

Sources

Hackam, David J., et al."Pediatric Surgery."Schwartz's Principles of Surgery, 10e.Eds. F. Charles

Brunicardi, et al.New York, NY: McGraw-Hill, 2014. n. pag.AccessMedicine.Web.22
Feb.2015.<http://accessmedicine.mhmedical.com.ezproxy.library.tufts.edu/content.aspx?
bookid=980&Sectionid=59610881>.

Gonzales, Kelly D., and Hanmin Lee."Chapter 35. Congenital Disorders of the Trachea &
Esophagus."CURRENT Diagnosis & Treatment in OtolaryngologyHead & Neck Surgery, 3e.Ed. Anil K.
Lalwani.New York, NY: McGraw-Hill, 2012. n. pag.AccessMedicine.Web.22 Feb. 2015.

Stringer, Mark D., Kathleen M. Mckenna, Ruth B. Goldstein, Roy A. Filly, N.scott Adzick, and Michael R.
Harrison. "Prenatal Diagnosis of Esophageal Atresia."Journal of Pediatric Surgery30.9 (1995): 1258-263.
Web.

Zaritzky, Mario, Ricardo Ben, Gaston I. Zylberg, and Brian Yampolsky. "Magnetic Compression Anastomosis
as a Nonsurgical Treatment for Esophageal Atresia."Pediatric Radiology39.9 (2009): 945-49. Web.

Lovvorn, Harold N., Christopher M. Baron, Melissa E. Danko, Nathan M. Novotny, Brian T. Bucher, Krystal K.
Johnston, and Mario F. Zaritzky. "Staged Repair of Esophageal Atresia: Pouch Approximation Andcatheterbased Magnetic Anastomosis."Journal of Pediatric Surgery Case Reports(2014): n. pag. Web.

Takamizawa, Shigeru, Eigoro Yamanouchi, Toshihiro Muraji, Eiji Nishijima, Shiiki Satoh, and Jiro Tsugawa.
"MCRA of an Anastomotic Stenosis after Esophagoesophagostomy for Long Gap Esophageal Atresia: A
Case Report."Journal of Pediatric Surgery42.5 (2007): 769-72. Web.

Hendren, W. Hardy, and J. Richard Hale. "Electromagnetic Bougienage to Lengthen Esophageal Segments
in Congenital Esophageal Atresia."New England Journal of Medicine293.9 (1975): 428-32. Web.

Esophageal Atresia - Radiographic Features. Digital image.Pediatric Radiology. The University of Virginia,
2013. Web. <https://www.med-ed.virginia.edu/courses/rad/peds/abd_webpages/abdominal2b.html>.

Questions?