First one with correct answer with justification win.

 

[size=20px]A full term infant weighing 3.2 kgs is born with esophageal atresia (EA) with a proximal pouch and distal fistula. A right thoracotomy is performed. The fistula is divided. However, the two ends of the esophagus are separated by over five cm.

 

The next step best step in management of this patient with long gap EA is

 

A esophageal myotomy.

 

B cervical esophagostomy.

 

C gastrostomy.

 

D reverse gastric tube.

 

E colon interposition.[/size]

(Untitled)

 

A

think again my friend

(Untitled)

 

C

C

correct

 

The definition of long gap is imprecise but generally means that the two ends of the esophagus are too far apart to permit primary anastomosis. A separation length of more than three vertebral bodies has been used in an effort to standardize this term. Historically, cervical esophagostomy was often performed in anticipation of subsequent enteric interposition. Although the optimal treatment remains open to debate, there is increasing recognition that the native esophagus has advantages over any of the other available conduits.

 

A number of innovative techniques have been employed to lengthen the native esophagus including dilatation, myotomy and electromagnetic bougienage. Myotomy alone in this patient is not likely to achieve the added length needed to obtain a primary anastomosis. Usually each myotomy will gain approximately one centimeter of length. A gastrostomy is typically placed at the outset to permit enteral feeding. Depending on the gap length, delayed primary repair under tension may be possible after one to three months because of spontaneous growth of the esophagus - perhaps fostered by luminal pressure from swallowing and gastroesophageal reflux. If the gap is still too long, esophageal reconstruction may require replacement with an autologous interposition graft derived from stomach, colon or jejunum. While primary gastric pull up has been described in newborns, reverse gastric tubes are delayed until the child is older and the stomach is larger. Over the last decade a technique for esophageal growth induction using continuous external traction has been advocated by Dr. John Foker to successfully address such very long gaps.