Staged thoracoscopic internal traction approach for early repair of long-gap esophageal atresia (LGEA) with distal tracheoesophageal fistula (TEF)

Abstract Background Long-gap esophageal atresia (LGEA) can complicate the management of esophageal atresia (EA) with or without a tracheoesophageal fistula (TEF). This series describes a short interval, staged, thoracoscopic internal traction approach for LGEA with distal TEF to manage complex anastomotic tension or an anatomically impossible esophageal anastomosis. Methods A retrospective review (2018–2024) was performed across four tertiary centers to identify patients with LGEA and distal TEF, managed with a staged, thoracoscopic internal traction approach. In the first stage, the TEF was ligated and internal traction sutures were placed between esophageal pouches. In the second stage, patients underwent primary anastomosis. Short and long-term complications and outcomes were measured. Results In total, seven patients were treated with this approach. Gestational ages ranged from 33 to 39 weeks. The average age at the initial surgery was 2.3 days, and the average age at definitive anastomosis was 15.9 days. There were no cases of leak or esophageal dehiscence. Gastroesophageal reflux was a common post-operative complication, occurring in 85.7% of patients. Conclusions Temporary internal traction sutures allow for a minimally invasive, safe repair of LGEA with distal TEF, under decreased tension. This technique reduces operative time, and potential complications associated with other long-gap anastomotic techniques. Level of evidence IV.