long - gap esophageal atresia ( lgea ) presents a difficult challenge for pediatric surgeons . most often , when the gap is too long for a primary repair , other conduits are used to re - establish continuity . more recently , the atretic ends of the esophagus have been lengthened using axial tension ( the foker process ) that has made a true primary esophageal repair possible in patients with lgea . although colonic interpositions will establish continuity , they may fail for the following reasons : venous obstruction , inadequate function or development of intrinsic disease . these difficulties led us to recommend the foker process for restoring continuity in these patients . herein , we describe a unique case , utilizing the foker process , to attain esophageal continuity following a failed colonic interposition for lgea . this patient , moreover , may also provide information on the vigor of the lengthening response and on closing longer gaps found in young children . this patient had a colonic interposition that was technically satisfactory and allowed for normal eating for 2 years . poor emptying and later aspiration , due to a proximal stricture , became difficult to overcome ; thus , she underwent a resection of a colonic interposition stricture with creation of cervical esophagostomy and gastrostomy . at 4 years of age , she was referred to us for a second opinion . with the distal colon graft in place , as well as the distal esophageal segment , we recommended a combined procedure with graft removal and growth induction given the 8.2-cm gap ( fig . a thoracoabdominal incision was made and the colonic conduit was dissected away from the diaphragm ; extensively mobilized from the left lateral segment of the liver and lung ; and , transected from its anastomosis with the stomach . traction sutures , using 4.0 prolene sutures , were then placed in the muscular layer of the distal esophageal segment and brought out onto the chest wall . figure  1:(a ) lateral view during her initial fluoroscopic examination illustrating a small , distal ( lower ) esophageal remnant present in situ ( black arrows ) . ( b ) anterior  posterior ( ap ) view during initial fluoroscopic examination illustrating an aperistaltic , native colonic interposition in situ with significant dilatation . ( a ) lateral view during her initial fluoroscopic examination illustrating a small , distal ( lower ) esophageal remnant present in situ ( black arrows ) . ( b ) anterior  posterior ( ap ) view during initial fluoroscopic examination illustrating an aperistaltic , native colonic interposition in situ with significant dilatation . daily tightening of her traction sutures was performed until the distal esophageal segment reached the chest wall ( fig .  2 ) . three traction suture revisions and two proximal esophageal lengthening operations were performed before esophageal continuity was re - established ( 46 days ) . two subsequent anastomotic leaks occurred ; 1 anastomotic leak was repaired surgically , whereas one subsequent leak was managed nonoperatively with a chest tube . five dilations and , one , 13-day retrievable stent placement were needed for anastomotic narrowing . a comparative postoperative esophagram and intraoperative esophagram illustrated neither a stricture nor an anastomotic leak ( fig . figure  2:fluoroscopic examination illustrating incremental  growth of the distal ( lower ) esophageal segment while the patient was undergoing external traction ( foker stage 1 ) . the metal dot refers to her esophagostomy ; thus , can measure the distance between the ends of her esophageal segments . figure  3:an intraoperative esophagram following a routine esophagogastroduodenoscopy ( egd ) is pictured on the right , as compared with her postoperative esophagram on the left . the egd was performed on this patient following her anastomosis ( foker stage ii ) ; the native esophagus was now in continuity . contrast was injected above the level of the anastomosis , which demonstrated neither leak nor stricture . growth of the distal ( lower ) esophageal segment while the patient was undergoing external traction ( foker stage 1 ) . the metal dot refers to her esophagostomy ; thus , can measure the distance between the ends of her esophageal segments . an intraoperative esophagram following a routine esophagogastroduodenoscopy ( egd ) is pictured on the right , as compared with her postoperative esophagram on the left . the egd was performed on this patient following her anastomosis ( foker stage ii ) ; the native esophagus was now in continuity . contrast was injected above the level of the anastomosis , which demonstrated neither leak nor stricture . a fundoplication was performed during a subsequent hospital stay ( postoperative day 237 ) for reflux . there was also concern for metaplasia of her distal esophagus from stratified squamous epithelium to simple columnar epithelium with goblet cells consistent with barrett 's esophagus . her total follow - up to date has been 1377 days with her last endoscopy was performed on postoperative day 1159 from stage 1 of her foker procedure ( fig . , however , were the first to describe the utilization of external traction sutures to promote delayed primary repair ; potentially , avoiding the need for an interposition in neonates . the premise behind this technique is that the native esophagus is the best long - term conduit for patients with lgea . this case demonstrates that lgea may be treated even after a failed colonic interposition if the distal esophageal remnant is still present . the lower esophageal segment may often be removed because of its potential susceptibility to ulcer formation ; therefore , this rescue approach will not always be possible . this case , to our knowledge , may be one of the first descriptions of its use in that manner , as well as demonstrate that an active esophageal lengthening response may still present in patients 4 years or younger . colonic interpositions have long been used for both benign and malignant esophageal conditions ; associated short- and long - term morbidities are well documented . initial surgical technique and associated perioperative complications may predict overt , short - term graft failure . long - term morbidities include : dysphagia , regurgitation , aspiration , pneumonias and chest pain . the main causes of long - term graft failure in all patients are colonic redundancy and gastrocolonic reflux [ 4 , 5 ] . adults may have the reserve to temporize these insults over time ; however , our patient already had evidence of chronic aspiration with resulting chronic lung disease and evidence of failure to thrive . esophageal replacements in children , in general , are also further complicated by scoliosis ; 27% requiring further operations and , over one - third of the patients reporting mild - to - moderate lifestyle limitations . anastomotic leaks are also not uncommon ( 30% in existing literature ) that arise during the management of lgea patients requiring either prompt surgical repair and/or optimal medical management . our patient did have two that were treated accordingly , but extended her hospital course . postoperative dilations and/or fundoplication have proven to be useful adjunctive measures in patients with lgea [ 8 , 9 ] . narrowing at the anastomosis , strictures , persistent reflux and/or need for a fundoplication are not unusual in patients with lgea [ 810 ] . medical adjuncts and operations avoid surgical revisions of potentially refractory strictures and protect the esophageal mucosa from reflux and its associated metaplasia from squamous to columnar epithelium . given these changes seen in our patient and the rarity of the disease overall , we recommend continued long - term screening and multidisciplinary follow - up . in approaching these patients holistically , the risks and benefits must be weighed in keeping a patient in - hospital for both serial operations and dilations versus other esophageal replacement surgeries . alternatives have included gastric pull - ups , transpositions or colon interpositions ; however , each of these has their own respective limitations and long - term consequences . gastric pull - ups do not appear to have as many gastrointestinal complications as the colon ; however , greater long - term respiratory morbidity has been reported in meta - analyses of these patients . the jejunum also provides for a suitable substitute , but concerns around its use have included relatively small sample sizes , center inexperience and microvascular support in smaller children . despite several initial operations , our patient is currently eating by mouth and has not had revisions to her native esophageal conduit . lgea may be treated by this process even after a failed colonic interposition if the distal esophageal remnant is still present in children 4 years or younger . the authors have no financial relationships to disclose , as well as no other conflicts of interest to disclose .
the foker process is a method of esophageal lengthening through axial tension - induced growth , allowing for subsequent primary reconstruction of the esophagus in esophageal atresia ( ea ) . in this unique case , 
 the foker process was used to grow the remaining esophageal segment long enough to attain esophageal continuity following failed colonic interpositions for long - gap esophageal atresia ( lgea ) . 
 initially developed for the treatment of lgea in neonates , this case demonstrates that ( i ) an active esophageal lengthening response may still be present beyond the neonate time - period ; and , ( ii ) the foker process can be used to restore esophageal continuity following a failed colonic interposition if the lower esophageal segment is still present .