Esophagus

https://doi.org/10.1007/s10388-018-0636-6

ORIGINAL ARTICLE

A new esophageal elongation technique for long‑gap esophageal

atresia: in vitro comparison of myotomy techniques
Burhan Beger1 · Orhan Beger2

Received: 9 June 2018 / Accepted: 7 August 2018

© The Japan Esophageal Society and Springer Japan KK, part of Springer Nature 2018

Abstract
Background  Complications such as stricture, leakage, recurrent tracheoesophageal fistula and mucosal pouch are commonly
seen in myotomy techniques used for long-gap esophageal atresia (LGEA) treatments. Therefore, we think that there is a clear
need for other techniques which would enable us to create more robust and longer esophagus in such cases. In this study, we
reviewed multiple V-myotomy (VM) technique and the differences of the said technique with Livaditis circular myotomy
(LM) and Kimura spiral myotomy (KM) techniques using literature as an aid.
Methods  21 esophagus samples from 21 male lambs aged 12 months were used in vitro for the study. All esophageal sam-
ples were matched to have a length of 120 mm. Samples were divided into 3 groups of 7 and VM, LM and KM techniques
were used in each group, respectively. Post-op esophagus lengths, elongation amount with each incision and perforation
pressures were measured.
Results  Post-op esophageal lengths were measured as 227, 210 and 200 mm for VM, LM and KM, respectively. Elongation
amount per incision was measured as 5.1, 4 and 3.34 mm, again in previous order of VM, LM, and KM. Finally, perforation
pressure following VM, LM, and KM was measured as 460, 400, and 410 mmHg.
Conclusion  VM was found to significantly increase total esophagus length and elongation per incision over LM and KM. In
addition, VM was also shown to have a higher perforation pressure. Although in vivo live animal studies are required, we
can say that VM can be used to create longer and robust esophagus.

Keywords  Esophagus atresia · Kimura technique · Livaditis technique · Long-gap esophagus atresia · Newborn

Introduction
Congenital esophagus atresia (EA) is a rare anomaly seen as
1 in every 4500 live births [1]. Planned surgical treatment for
this anomaly is to separate tracheoesophageal fistula (TEF)
and primary end-to-end anastomosis of upper-lower esopha-
gus segments [1]. Although it is relatively easier to create
primary anastomoses in short-gap EA cases, this becomes
quite challenging in long-gap EA (LGEA) primary repara-
tion cases. Some authors define the cut-off point for this
anomaly as 2 cm for classifying the gap as short or long, yet
others define a short gap as 1 cm or less, an intermediate
* Orhan Beger
obeger@gmail.com
1
Department of Pediatric Surgery, Van Yüzüncü Yıl
University Faculty of Medicine, Van, Turkey
2
Department of Anatomy, Mersin University Faculty
of Medicine, Ciftlikkoy Campus, 33343 Mersin, Turkey
gap as 1–2.5 cm and long gap as more than 2.5 cm distance
between two esophagus segments [1, 2]. In gaps shorter than
2.5 cm, the primary anastomosis is reported to be sufficient
without any additional intervention. The main challenge lies
in the approach of gaps that are greater than 2.5 cm [3–7].
After defining LGEA, there are two different approaches
which are esophagus replacement or esophagus elongation
procedures which allows conservation of the native organ
[6, 8–10].
LGEA treatments still pose a serious challenge for pediat-
ric surgeons and there is no clear consensus on the preferred
treatment method [1, 3–5, 7]. Even though different tech-
niques such as Livaditis circular myotomy (LM) and Kimura
spiral myotomy (KM) were defined in the literature, there
is no ideal treatment method yet [2, 6, 8, 10]. This situation
is linked to the limited number of patients in LGEA studies
[6]. However, a common theme amongst authors is that there
is a clear need for the development of new techniques in
those cases [11, 12]. For this reason, we would like to define

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 Esophagus

multiple—V-myotomy technique which allows LM and KM

techniques with a single incision.
According to our hypothesis, the main advantage of VM
as a new synthesis which takes best parts of LM and KM can
be obtained with a single incision. In this study, we would
like to elaborate the VM technique we developed and to
compare this technique results with LM and KM techniques
under in vitro conditions.

Fig. 2  The illustration shows the techniques of VM, LM and KM

Materials and methods
Esophagus specimens
As esophagus samples were collected from a slaughter-
house, no ethics committee approval was required due to
legal procedures. Esophagus samples from 21 male lambs
aged 12 months which were born on the same day in the
same farm were collected by the attending veterinary sur-
geon of the slaughterhouse (Fig. 1a). To eliminate environ-
mental factors’ effect, the samples were placed in a saline
solution (0.85% NaCl) and were brought to Pediatric Surgery
Department.
Measurements
All esophagus samples were matched to have a length of
150 mm (Fig. 1b). Esophagus samples collected in an hour
following slaughter were separated into 3 groups of 7. Each
group was assigned to LM, KM and VM methods. Using
the mentioned techniques, muscle layer was incised in the
same amount with 1 cm distances in between. After all, sam-
ples were identified from one endpoint; they were hanged
for 10 min with 50 mg weight attached. Total elongation
amounts following myotomy were measured (Fig. 3). Elon-
gation amount per incision was measured by subtracting
the old esophagus length from new esophagus length and

VM technique

Esophagus surface is incised with a continuous “V” shape.

Incision degree is placed to be approximately 60°. Myot-
omy procedure can be repeated for elongation requirements
within certain periods. In this technique, preservation of
maximum distance between two VM is crucial in protect-
ing the flap circulation. For this reason, end-points of “V”
shape should be parallel in the vertical plane. LM and KM
techniques were performed according to previous studies [2,
8, 12, 13]. A descriptive scheme for VM, LM and KM was
created (Fig. 2).

Fig. 1  Esophagus samples obtained from the slaughterhouse (a) and

matching them in a length of 150 mm (b) Fig. 3  Techniques used in samples and their final lengths

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Esophagus

199.42 ± 2.87 mm and elongation per incision was cal-

culated as 3.31 ± 0.14  mm and mean perforation pres-
sure was calculated as 410.10 ± 22.80  mmHg in KM
group. Finally, mean post-op length was measured as
226.85 ± 2.91 mm and elongation per incision was calcu-
lated as 5.07 ± 0.11 mm, and mean perforation pressure
was calculated as 459.28 ± 22.80 mmHg in VM group.
Highest scores for total length (Fig. 5a) and elongation
per incision (Fig. 5b) were obtained by VM technique,
whereas KM had the lowest scores (p < 0.001). Most
robust technique against perforation was found to be VM
and weakest was LM (Fig. 5c) (p < 0.001).
Fig. 4  Perforation test in esophagus samples

dividing this difference by the incision number on one side

in millimeters.
One end of the esophagus was sutured shut. A blood pres-
sure cuff catheter was placed on the other end of the esopha-
gus and inflated in each sample (Fig. 4). Perforation pressure
for each esophagus was recorded.

Statistical analysis

Length measurements were done using digital calipers

(0.01  mm precision). Measurements were done by two
researchers (B.B. and O.B.) under same environmental
conditions. Measurements were taken 3 times and arithme-
tic mean was calculated from those values. Intra-observer
repeatability was assessed using ANOVA with repeated
measures and post hoc RIR Tukey tests, whereas inter-
observer repeatability was assessed using intra-class cor-
relation coefficients (ICC). Normality was checked using
Shapiro–Wilk test. Levene test was used to assess variance
homogeneity. Myotomy groups were compared using one-
way ANOVA and Bonferroni tests. The statistical signifi-
cance level was set at p < 0.05.

Results

ICC score measured as ICC = 0.998–0.996 (p < 0.001) shows

an excellent inter-observer repeatability for lengths obtained
in each technique. Similarly, the fact that there are no statis-
tically significant differences in measurements done by the
same researcher also shows the success of intra-observer
repeatability (p > 0.05).
All esophagus samples were fixed at 150 mm at the
beginning of the study. Mean post-op length was meas-
ured as 209.71 ± 2.69 mm and elongation per incision was
calculated as 4.01 ± 0.14 mm in LM and mean perfora-
Fig. 5  Total increase in length (a), elongation amount per incision (b)
tion pressure was calculated as 400.10 ± 13.22 mmHg. and perforation pressure values (c) according to techniques used in
Similarly, mean post-op length was measured as the graphic

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 Esophagus
Discussion
Initial treatment of LGEA is reported to be cervical
esophagostomy and esophagus replacement [6, 8, 9]. How-
ever, high complication rates were reported in esophagus
replacements using intestinal organs such as colon, jeju-
num or stomach [6, 9, 10]. For this reason, we also support
the thesis that natural esophagus is the best there is [13,
14]. Although there are a number of esophageal elongation
methods defined in the literature; there is no consensus
about the ideal elongation method. An ideal esophageal
elongation method should be simple to apply, practical,
can be finished within a single surgical intervention, is
related to shorter hospitalization periods and have a mini-
mal morbidity and mortality rates. Myotomy techniques
should provide enough esophageal elongation without dis-
rupting vascularization with a minimum number of inci-
sions. In addition, it should also distribute intraluminal
pressure towards wider incision line. It should withstand
both acute and chronic pressure, should not cause balloon-
ing on myotomy line and decrease the tension on anasto-
mosis line. It should not cause long-term complications or
motility disorders. Unfortunately, a single technique which
has all those qualities mentioned above is still not defined.
Myotomy neutralizes esophageal muscle structure
tonus, whereas it has no effect on submucosa, which is
made of elastic connective tissues [11, 12]. Previously,
mobilization of distal esophagus was especially limited
due to vascular damage risk, yet today it can be mobilized
with a lower risk due to vascularization support [15, 16].
Myotomy does not risk vascularization of the esophageal
stump and does not affect physiological peristalsis thanks
to mucosal and submucosal vascularization [15]. No sig-
nificant difference was seen in esophageal motility and
swallowing in primary anastomosis EA cases with or with-
out myotomy [15] in long-term clinical controls. For that
reason, spontaneous esophagus elongation using myotomy
techniques is encouraged [13, 14].
LM causes elongation in the proximal esophageal pouch
by circular myotomy and is the most commonly used tech-
nique in decreasing anastomosis tension [11, 12, 15]. LM
decreases tension by 50% and provides about an additional
0.5 cm length [8, 9, 16]. In our study, we measured this
elongation as 0.4 mm. In a canine study, LM was not able
to prevent anastomosis leakage [11]. Mucosal out-pouch-
ing is the most common complication seen in esophago-
gram and Lai et al. [17] reported seeing this complication
in every case in their study. In another animal model study
showed that LM did not decrease anastomosis-related
complications and even causes harmful changes in anas-
tomosis suture lines [11]. Livaditis et al. reported in his
piglet study that bulging occurred at 300 mm ­H2O with the
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LM procedure [18]. KM is reported to reduce pseudodiver-
ticulitis and leakage rates [9]. This can be explained due
to decreased pressure with a spiral incision. However, it
is not used as much as LM due to difficulties of technique
and unable to provide sufficient elongation.
We think that we can take the best parts of each technique
(esophagus elongation of LM and pseudodiverticulitis preven-
tion of KM) using VM in a single incision. Frequently reported
complications following LM and KM such as stricture, leak-
age, recurrent TEF and mucosal pouch formations can be low-
ered in VM due to increased durability of the esophagus. As
this study was performed on dead sheep esophagus samples
under in vitro conditions; we were not able to assess long-term
myotomy- and anastomosis-related complications related with
VM. However, we were able to obtain longer and more durable
esophagus samples in comparison with LM and KM.
Possible cause of a longer esophagus in the VM method; V
incisions made in addition to circular myotomy further reduce
the tension on the mucosa. In addition, contrary to LM and
KM, the VM prevents the press from being in the same direc-
tion and bulging mucosal area. The elongation in the incision
line can be spread over a wider area of the intraluminal press,
thus providing a more robust esophagus.
Conclusion
VM is an effective method in both esophagus elongation and
increasing pressure resistance. It is a new synthesis which
takes best parts of LM and KM and its results should be inves-
tigated in live animal studies prior to clinical trials and usage.
Acknowledgements  We thank Atilla Bayram for the illustration.
Author contributions  BB project development, data collection, data
analysis, manuscript writing, and manuscript editing. OB data collec-
tion, data analysis, and manuscript writing.
Funding None.
Compliance with ethical standards 
Ethical Statement  As esophagus samples were collected from a slaugh-
terhouse, no ethics committee approval was required due to legal pro-
cedures in our country.
Conflict of interest  B.B and O.B have no conflict of interest or finan-
cial ties to disclose.
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