Long-gap esophageal atresia (LGEA) usually occurs as Gross type A, which constitutes only 4% of all EA patients [1]. The rarity of these patients may partially contribute to the lack of evidence establishing definite LGEA correction procedures. Serial esophageal elongation, colon or intestinal interposition, gastric pull-up (GPU), and gastric tube formation have been attempted to correct LGEA. Since the first successful thoracoscopic repair (TR) in EA without tracheoesophageal fistula (TEF) in 1999, TR became a standard procedure in many institutions [23]. TR was applied in the operation of EA with TEF in 2000 and became widely performed for patients with relatively stable conditions [3]. However, minimally invasive surgery (MIS) is hard to apply in LGEA due to the complexity of procedures.

We introduce a case of LGEA, corrected by esophageal replacement with gastric tube through totally laparoscopic and thoracoscopic surgery.

A male baby weighing 3,000 g, with prenatal suspicion of EA was born at gestational age of 37+6 weeks. Initial infantogram at birth revealed no bowel gas and a feeding tube in the proximal esophageal pouch, suggesting EA Gross type A, specifically LGEA. Further evaluations including brain, spinal, abdominal ultrasonography and echocardiography did not show any other major anomalies. Gastrostomy was made 2 days after birth. He was admitted once to hospital for viral pneumonia (pathogen: respiratory syncytial virus) at 4 months, and otherwise healthy before definite operation.

Seven months later, his body weight was 11.2 kg, and definite operation was planned. Since the distance measured via fluoroscopy between the upper and lower esophageal stumps was more than 6 vertebrae (i.e. too long to achieve primary end-to-end anastomosis), esophageal replacement with gastric tube (Fig. 1) was performed.

The definition of LGEA has no global consensus. Some centers use a definite distance [1] while others define LGEA functionally as the inability to perform a primary anastomosis because of the long gap [4]. Thus, comparison between studies is difficult and ideal management remains unclear. Although primary anastomosis with native esophagus demonstrates better management than GPU [5], tension-free anastomosis is not always possible. Anastomotic stricture, one of the most common complications after correction of EA, is closely related to anastomotic tension [6]. Esophageal replacement with colon, jejunum or stomach is a good option for tension-free anastomosis. GPU is generally accepted as the best replacement procedure among those previously mentioned. GPU does not need bowel preparation and has only one anastomosis compared to jejunal interposition or colon interposition. However, high respiratory complication and leakage rates are reported following GPU, likely due to the relatively large stomach occupying a narrow thoracic cavity and extensive gastric vessel ligation for obtaining gastric mobilization to perform GPU [5]. To overcome these drawbacks, one institution reported long-term results of partial gastric pull-up (PGP) [7]. The incidence of stenosis and gastro-esophageal reflux after PGP is considerably high, even compared with alternative surgical techniques for the treatment of LGEA and their high complication rates. Many disadvantages of open thoracotomy have been reported such as air leak, postoperative pain, significant mucoskeletal morbidity [3].

To overcome potential problems previously mentioned, we performed this minimally invasive procedure. Thoracoscopy is a comparable, even superior, operative modality than thoracotomy with respect to pain, stress, and musculoskeletal morbidities [8]. Without cervical esophagostomy, which may be accidentally detrimental to mediastinal structures, we performed gastric tube pull-up and anastomosis using both laparoscopy and thoracoscopy. Minimal dissection preserving left and right gastric and right gastroepiploic artery to the stomach maintains sufficient blood flow. We made a gastric tube for minimizing the volume effect of the stomach to avoid respiratory complications. Parilli et al. [9] reported laparoscopic transhiatal esophagectomy and GPU in LGEA, however those investigators included extracorporeal esophagectomy and anastomosis. As far as we know, this is the first reported case of this procedure.

Recently, Elfiky et al. [10] reported the results of 50 patients who underwent gastric tube for esophagoplasty. Long-term follow-up reports of weight gain, swallowing pattern, quality of life, and overall satisfaction were excellent. Yet, open laparotomy plus cervical esophagostomy was performed. This leaves the question of the long-term synergetic results of the previous study plus the MIS presented herein.

We presented a successful gastric tube replacement for the LGEA through minimally invasive procedure. A prospective comparison study is needed to evaluate the long-term outcomes of this procedure.