Interventional procedures consultation document - foker technique for long gap oesophageal atresia

NATIONAL INSTITUTE FOR CLINICAL EXCELLENCE

Interventional Procedure Consultation Document

Foker technique for long-gap oesophageal atresia

The National Institute for Health and Clinical Excellence is examining the Foker technique for long-gap oesophageal atresia and will publish guidance on its safety and efficacy to the NHS in England, Wales and Scotland. The Institute's Interventional Procedures Advisory Committee has considered the available evidence and the views of Specialist Advisors, who are consultants with knowledge of the procedure. The Advisory Committee has made provisional recommendations about the Foker technique for long-gap oesophageal atresia.This document summarises the procedure and sets out the provisional recommendations made by the Advisory Committee. It has been prepared for public consultation. The Advisory Committee particularly welcomes:

  • comments on the preliminary recommendations
  • the identification of factual inaccuracies
  • additional relevant evidence.

Note that this document is not the Institute's formal guidance on this procedure. The recommendations are provisional and may change after consultation.

The process that the Institute will follow after the consultation period ends is as follows.

  • The Advisory Committee will meet again to consider the original evidence and its provisional recommendations in the light of the comments received during consultation.
  • The Advisory Committee will then prepare draft guidance which will be the basis for the Institute's guidance on the use of the procedure in the NHS in England, Wales and Scotland.

For further details, see the Interventional Procedures Programme manual, which is available from the Institute's website (www.nice.org.uk/ipprogrammemanual).

Closing date for comments: 23 August 2005
Target date for publication of guidance: November 2005


Note that this document is not the Institute's guidance on this procedure. The recommendations are provisional and may change after consultation.


1 Provisional recommendations
1.1

Current evidence on the safety and efficacy of the Foker technique for long- gap oesophageal atresia is limited but appears adequate to support the use of the procedure in the context of this rare and serious condition, provided that normal arrangements are in place for consent, audit and clinical governance.

1.2 Clinicians wishing to undertake the Foker technique should ensure that parents understand the implications of the condition and know that secondary interventions may be necessary. In addition, use of the Institute's Information for the public is recommended.
1.3 This procedure should be undertaken only in specialist paediatric surgical units.
1.4

Clinicians should audit and review their results. Publication of further information about the Foker technique and its outcomes may be useful.



2 The procedure
2.1 Indications
2.1.1 Oesophageal atresia is a congenital condition in which there is a break in the continuity of the oesophagus between the mouth and stomach. In some patients, both the proximal and the distal ends of the oesophagus end in pouches; more commonly, one or both ends of the oesophagus are attached to the trachea forming tracheo-oesophageal fistulae. Saliva and milk enter the lungs after pooling in the upper oesophagus or pass though the tracheo-oesophageal fistula, resulting in episodes of choking, coughing and cyanosis. If untreated, oesophageal atresia leads to death from aspiration pneumonia or malnutrition. The definition of long-gap atresia varies but generally it means the gap is greater than 3 or 3.5 cm.
2.1.2 The vast majority of patients are treated by surgical division of the fistula and primary anastomosis of the oesophagus, to allow normal swallowing.
2.1.3

With long-gap atresia, any direct anastomosis is placed under significant tension. Usually, therefore, the fistula is divided, and a gastrostomy is sited to enable enteral feeding. Repair is delayed for up to 3 months to allow the upper and lower pouches to elongate and hypertrophy, with the intention that anastomosis will then be possible. If it is not possible, alternative surgical approaches include pulling the stomach partially up into the thorax, or using a length of colon to join the oesophageal ends.

2.2 Outline of the procedure
2.2.1

Using a transthoracic extrapleural approach, the fistula or fistulae are divided and oversewn. The oesophageal pouches are opened and traction sutures are placed in the ends, brought out through the skin and fixed with silastic buttons. Traction is applied to the sutures, which stimulates elongation of the oesophagus by 1-2 mm per day. Once the ends of the oesophagus have come together, or are in close proximity, a primary anastomosis is performed. After the repair, the patient may be kept sedated and ventilated for a few days to allow the anastomosis to heal. Oesophageal balloon dilatation may be performed if required.

2.3 Efficacy
2.3.1

Reported clinical outcomes varied considerably between studies, and were often qualitative only. One case series reported 70 infants with oesophageal atresia treated by primary repair: ten of the patients had long-gap atresia and four of these were treated with the Foker technique. All four patients were eating excellently or satisfactorily at a mean follow-up of 8.8 years. After treatment, all ten of the infants with long-gap atresia had gastro-oesophageal reflux requiring fundoplication.

2.3.2

One case series reported that 67% (2/3) of patients achieved full oral feeding at up to 4 months after treatment with the Foker technique. Another found that 50% (1/2) of patients were eating solids normally at 1 year, and 50% (1/2) still required a gastric tube for feeding. The rate of successful anastomosis varied between studies from 100% (4/4 and 2/2) to 33% (1/3). For more details, refer to the sources of evidence (see Appendix).

 

2.4 Safety
2.4.1

Disruption of sutures during the traction stage of the procedure occurred in 25% (3/12) of patients with long-gap atresia across all the studies identified, usually requiring the anastomosis to be performed under greater tension than intended. No deaths were reported that were directly related to repair of the oesophageal atresia.

2.4.2 The Specialist Advisors noted adverse events including stricture formation and gastro-oesophageal reflux. They also noted other possible adverse events including anastomotic leak, suture disruption during the period of traction, fistulae, gastric emptying problems and difficulties in swallowing.
2.5 Other comments
2.5.1 Long-gap oesophageal atresia is often associated with multiple abnormalities, and mortality after the Foker technique is often related to these conditions rather than to the operation.

Bruce Campbell
Chairman, Interventional Procedures Advisory Committee
August 2005

Appendix: Sources of evidence

The following document, which summarises the evidence, was considered by the Interventional Procedures Advisory Committee when making its provisional recommendations.

  • Interventional procedure overview of the Foker technique for long-gap oesophageal atresia, May 2005.

Available from: www.nice.org.uk/ip255overview

This page was last updated: 04 February 2011