Primary anastomosis in difficult cases of type "C" esophageal atresia: The atraumatic microvascular clamp technique of minimal tension with good outcome.

• Techniques to bridge the gap in difficult cases of type "C" esophageal atresia are challenging. The most important objective is to use the native esophagus. It may require multiple stages with morbidities at each stage. When done in a single stage, a primary anastomosis may only be possible under tension and at the cost of compromised vascularity with chances of leak later. • Multiple techniques have been proposed to bridge this gap to enable an anastomosis under minimal tension. But these have their own drawbacks and are often debated. Our method of partially severing the lower esophagus after ligation of fistula followed by anastomosis using a microvascular atraumatic clamp avoids unnecessary traction and judicious tissue handling without violating principles of healing. • This technique is simple and reproducible. It satisfies principles of tissue healing by keeping the trauma at esophageal ends minimum. It enables bridging of relatively longer gaps with outcome comparable to standard methods of esophageal atresia repair. It may be considered a suitable technique in cases where the anastomosis initially looks to be difficult and assures satisfactory outcome. Surgical maneuvers for esophageal anastomosis in difficult cases of Gross type "C" esophageal atresia (EA) are challenging. The methods of early primary anastomosis are technically difficult and staged surgeries expose the child to repeated general anesthesia with problems of nursing care. We describe a simple method of partial disconnection of the lower esophagus from the fistula followed by approximation by an atraumatic microvascular clamp. The suitability of this method and its outcomes are discussed. It was a prospective observational study that included 32 patients of type "C" EA between January 2014 and December 2016. Babies with birth weight more than 2 kg without cyanotic heart defects and requirement of intensive care were included. An early primary anastomosis using this technique was tried in all. A cervical esophagostomy with feeding gastrostomy was done where it was not possible. Analysis of the gap and post operative outcomes i.e. gastroesophageal reflux (GER), stricture, tracheomalacia, dysmotility, recurrence and survival were analyzed. The mean gap between esophageal ends was 4.3 cm. Primary anastomosis was possible in 26 (81.25%). Minor and major leak occurred in 3 (11.54%) and 1 (3.85%) patients respectively. Survival was 84.62% (22/26). All mortalities were early post operative. During mean follow up of 23.73 months (till December 2019), GER decreased from 63.64% (14/22) to 13.64% (3/22), partial stricture was seen in 18.18% (4/22), tracheomalacia in 36.36% (8/22) and dysmotility in 77.27% (17/22). There was no recurrence of fistula. Complications with this method did not show any significant difference as mentioned with other methods. This technique seems to be physiologically suitable as it enables anastomosis with minimal trauma to the esophageal ends. It is easy, reproducible and produces favorable outcomes comparable with other methods for difficult cases of type "C" esophageal atresia (EA). [ABSTRACT FROM AUTHOR]