Update Course 2021: MAGNET THERAPY FOR ESOPHAGEAL ATRESIA

The Flourish device is an FDA-approved commercially available device under humanitarian device exception from Cook Medical.

The Flourish device uses compression anastomosis by causing ischemia of tissue between two magnets, which then sloughs off to create the anastomosis.

The Flourish device tapers down to a 10 French coupling surface.

In a retrospective study of 13 patients over 17 years using Flourish magnets, all patients achieved anastomosis but all developed strictures post-operatively.

Two of 13 patients in the retrospective Flourish series required surgery for recalcitrant strictures after magnet placement.

Flourish device eligibility requires gap length less than 4 centimeters; if lengths are greater, magnets will not attract one another.

Flourish device requires either absent fistula (pure EA) or previously repaired fistula.

Flourish device requires gastrostomy that can accommodate 18 French catheter (diameter of gastric portion).

In the presented case, a full-term male with pure EA had gap study at 3 months showing 2.6 cm gap, and Flourish device was placed.

The patient was heavily sedated for 12 days during magnet treatment.

Four days after esophageal ends came together, patient had acute decompensation and was transferred to another hospital where large fistula between esophagus and left main stem bronchus was identified.

At emergency surgery, the surgeon found severe inflammation, divided the fistula, and divided the esophagus again, resulting in a 5 cm gap.

Subsequent workup revealed an upper pouch fistula that had not been previously diagnosed, which is a contraindication to using the Flourish device.

By International group classification, a gap of 4 centimeters or more is required to be considered long gap esophageal atresia.

Dr. Rothenberg's opinion: a patient with less than 4 cm gap should be amenable to primary anastomosis, which he would do thoracoscopically with maybe 20% stricture rate.

Dr. Slater agrees that not everyone with 2 cm gap should get a magnet; it can be used in select patients with cardiac disease or previous operations that increase anesthetic risk.

Magnets have been used as staged procedure: surgically approximate ends, then use magnet just for anastomosis portion rather than internal traction sutures.

Dr. Ponsky's experience: used magnets post-operatively in patient with complex airway reconstruction and median sternotomy where suture brought ends together but anastomosis was too tight, avoiding difficult reoperation.

Dr. Von Allmen's single magnet case worked but resulted in dense stricture requiring lots of dilation and G-tube feeds for long time, though avoided reoperation.

Dr. Rothenberg describes potential magnet candidate: 23-week premature infant, 340 grams at birth, pure atresia, who decompensates for two weeks after each thoracoscopic attempt to approximate ends.

Dr. Rothenberg's opinion: if a surgeon cannot sew together a 2-3 cm gap, the patient should be sent to a center that can, as that is the best outcome for the child.