title: Foker process for the correction of long gap esophageal atresia: Primary treatment versus secondary treatment after prior esophageal surgery.
abstract: OBJECTIVE
  The Foker process (FP) uses tension-induced growth for primary esophageal reconstruction in patients with long gap esophageal atresia (LGEA). It has been less well described in LGEA patients who have undergone prior esophageal reconstruction attempts.
  
  
  METHODS
  All cases of LGEA treated at our institution from January 2005 to April 2014 were retrospectively reviewed. Patients who initially had esophageal surgery elsewhere were considered secondary FP cases. Demographics, esophageal evaluations, and complications were collected. Median time to esophageal anastomosis and full oral nutrition was estimated using the Kaplan-Meier method. Multivariate Cox-proportional hazards regression identified potential risk factors.
  
  
  RESULTS
  Fifty-two patients were identified, including 27 primary versus 25 secondary FP patients. Median time to anastomosis was 14 days for primary and 35 days for secondary cases (p<0.001). Secondary cases (p=0.013) and number of thoracotomies (p<0.001) were identified as significant predictors for achieving anastomosis and the development of a leak. Predictors of progression to full oral feeding were primary FP cases (O.R.=17.0, 95% CI: 2.8-102, p<0.001) and patients with longer follow-up (O.R.=1.06/month, 95% CI: 1.01-1.11, p=0.005).
  
  
  CONCLUSIONS
  The FP has been successful in repairing infants with primary LGEA, but the secondary LGEA patients proved to be more challenging to achieve a primary esophageal anastomosis. Early referral to a multidisciplinary esophageal center and a flexible approach to establish continuity in secondary patients is recommended. Given their complexity, larger studies are needed to evaluate long-term outcomes and discern optimal strategies for reconstruction.
authors.affiliation: Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Sigrid
authors.initials: S
authors.lastname: Bairdain
authors.affiliation: Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Thomas E
authors.initials: TE
authors.lastname: Hamilton
authors.affiliation: Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Charles Jason
authors.initials: CJ
authors.lastname: Smithers
authors.affiliation: Division of Gastroenterology & Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Michael
authors.initials: M
authors.lastname: Manfredi
authors.affiliation: Division of Gastroenterology & Nutrition, Boston Children's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Peter
authors.initials: P
authors.lastname: Ngo
authors.affiliation: Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA.
authors.forename: Dorothy
authors.initials: D
authors.lastname: Gallagher
authors.affiliation: Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA; Department of Anesthesiology, Perioperative & Pain Medicine, Boston Children's Hospital, Boston, MA.
authors.forename: David
authors.initials: D
authors.lastname: Zurakowski
authors.affiliation: University of Minnesota, Minneapolis, MA.
authors.forename: John E
authors.initials: JE
authors.lastname: Foker
authors.affiliation: Department of Pediatric Surgery, Boston Children's Hospital, Harvard Medical School, Boston, MA. Electronic address: Russell.jennings@childrens.harvard.edu.
authors.forename: Russell W
authors.initials: RW
authors.lastname: Jennings
mesh_terms: D000714:Anastomosis, Surgical / Q000379:methods; D004933:Esophageal Atresia / Q000601:surgery*; D004944:Esophagoplasty / Q000379:methods*; D004947:Esophagus / Q000601:surgery*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D007223:Infant; D008297:Male; D012086:Reoperation; D012189:Retrospective Studies; D013314:Stress, Mechanical; D016896:Treatment Outcome
keywords: Esophageal atresia; Foker process; Secondary long-gap esophageal atresia patients