Esophageal Atresia Treatment Program

The Foker Process

About the procedure

The EAT Program at Boston Children's is the only center in the world dedicated to using a highly advanced surgical technique, known as the Foker process, to treat cases of long-gap esophageal atresia (EA), and related problems such as extensive strictures in the esophagus or esophageal leaks following prior surgery.

Using the Foker process, our surgeons place small sutures in the disconnected or damaged ends of the esophagus and add small amounts of tension to those sutures daily. Over time, the tension stimulates the esophageal ends to grow longer and the two ends eventually grow closer together. The ends are then surgically connected to restore esophageal continuity. Though the esophageal muscle may not contract normally, the native esophagus may serve a child better long term than other organs or parts of organs that are sometimes used to replace the esophagus, such as the stomach, intestine or colon.

For the Foker process to be successful, patients need to be motionless during the time the esophagus is being stretched, because excessive motion might pull out the sutures. This requires the infants or children be given medications to keep them still. During this time, they stay in the intensive care unit on a ventilator (breathing machine). Repeat cases, in which the esophageal ends may take much longer to stretch, can require children to be sedated and motionless for weeks or months, giving the esophagus ends time to grow. It is not fully understood at this time whether such prolonged sedation has any long-term adverse impact on the infants and children. We know that decreased motion does make the bones weaker and more susceptible to fractures.

The Foker process can be performed on children as small as 7 pounds (3.5 kg), and it takes anywhere from several weeks to several months to complete, depending on the severity of the condition. Because the process allows the patient to grow his/her own esophagus, surgically transplanting other parts of the digestive tract, like the colon, is unneeded. This approach may also reduce the risk of infection, eating difficulties and malnutrition.

Unlike traditional treatments, which require large incisions on the abdomen as well as the neck and chest, the Foker process is done through an opening on the right side of the chest, which means that patients end up with fewer and smaller scars. Although repeated entries into the chest may increase the risk of scoliosis (curvature of the spine) in some children as they grow.

Finding the proper treatment to address your child's long-gap EA will depend on many factors. As is the case with all surgeries, many variables must be taken into consideration before a treatment plan is finalized; and as a parent, you will play a vital role in making those decisions. If you are weighing treatment options for your child with long-gap EA we encourage you to speak with a medical professional who can clearly explain all the options to you. For further details about how long-gap EA is treated at Boston Children's, we invite you to call 617-355-3529 and speak with one of our experts.

Outcomes

The Foker process works best when used as the initial treatment. It can sometimes be used after other long-gap EA treatments, such as colonic interposition or a gastric pull-up have failed, but experience has shown that this is not ideal. To further understand the benefits of having the Foker process before other treatments, see the outcomes chart below.

Our clinical results demonstrate the stark difference between the outcomes for children who have their first procedure for long-gap EA at our institution and those who have had initial surgery for long-gap EA elsewhere. Patients also often have other congenital abnormalities, such as heart and kidney problems, that may further complicate their care.

	Foker process as initial treatment	Repeat procedure cases
Average duration of hospitalization (days) Longest hospitalization (days) Average interval between placing the traction sutures and first attempt at joining the two ends (days) “Intact esophagus” Children eating by mouth Eating entirely by mouth Average number of surgical procedures (thoracotomy ) Average number of esophageal dilatations (Performed under anesthesia)	110 246 16 (range 6–34) 18/19 18/19 14/19 2.9 (range 2–7) 4.4 (range 1–17)	196 685 31 (range 8–57) 17/22 16/22 5/22 5.8 (range 2–15) 4.3 (range 0–17)
Mortality	0/19	2/22*

*no patients died in hospital, but two patients with complex anatomy who failed attempts at repair, died after discharge. (One had multiple additional complex medical problems.)

These groups have also encountered complications including fractures of their bones resulting from long periods of motionlessness. (Two in the primary group and 11 in the reoperative group.) Patients also have experienced hearing loss (from medications now rarely used) and pulmonary embolus (blood clot going to the lung). Three of the primary cases and 13 of the reoperative patients experienced leaks from the connected esophagus, which in some cases healed and in others required additional procedures, which accounts for the high number of thoracotomies in some patients.

Esophageal Atresia Treatment Program

The Foker Process

Foker process as initial treatment

Repeat procedure cases