University of Minnesota
June 14, 2013
An esophageal repair by Dr. John Foker helped young Donovan Bohn grow and thrive.
How Dr. John Foker's procedure helps babies grow an esophagus
Staring at an x-ray, a radiologist told a surgeon he'd never fix what ailed the infant patient: Most of his esophagus was missing.
The surgeon—Dr. John Foker, a University of Minnesota professor—began the operation anyway, intending to connect the upper and lower pieces of esophagus tissue.
But when he saw them, he realized they were much too far apart.
"I said to myself, 'You've got about one and a half minutes to think of something,'" Foker recalls. "So I thought, 'If I put sutures in the blind ends and apply tension, they should grow.'"
He knew that the esophagus develops in response to biomechanical tension generated by growth of the spinal column. So he placed sutures in both ends and passed the free ends of the sutures out through the incision, in the baby's right side. Then, making sure they were taut enough to apply tension, he attached the sutures to separate buttons that could not slip back through the incision.
Foker tightened the sutures daily. In response, the two ends grew, and in three weeks they were long enough to join into a new esophagus for the baby, Devin.
Eighteen years later, Devin is one of more than 100 children born with an incomplete esophagus—a condition known as esophageal atresia, or EA—who have benefited from what is now called the Foker procedure. Its use began at the University and continued there for more than 10 years, although now it is mostly done at Boston Children's Hospital, where Foker has trained a team headed by Dr. Russell Jennings.
Esophageal atresia affects about one in 3,000 babies. It is generally caused by an error in development, not genetics, says Foker.
In EA, the upper esophagus is usually a closed pouch that must be constantly suctioned to remove saliva. Feeding is done through a stomach tube. The severity runs from virtually the entire organ missing to a gap of only an inch or less between the upper and lower parts.
EA can be treated by grafting a section of colon or small intestine (jejunum) to complete the esophagus, or by pulling the stomach up into the chest. Those methods haven't worked as well as the Foker procedure, however.
But despite its success, the procedure isn't yet "textbook."
My goal is to not have this procedure die with Dr. Foker. I want to see more surgeons learn it and pass it on to their peers and the next generation.—Mara Lee Ebert
"Every patient came because of their parents' insistence," Foker stresses. "[They] researched the EA problem and the U of M solution and then became their child's advocate and pushed to come here. They are the heroes."
Here are some of their stories:
• In 1996 Mara Lee Ebert, then living in Colorado, sought help for her son Logan. Doctors in Colorado wanted to use the colon or stomach procedure, but Ebert found an article about Foker and called him. Having had success with Devin, he was willing to try the operation again.
"Five or six other opinions told us it would never work," says Ebert. "It was a 5.5-centimeter gap, which is like eight vertebral spaces—very big."
Today Logan, who had the surgery at age 2 months, lives a normal life, playing basketball and running track. "My goal is to not have this procedure die with Dr. Foker," says Ebert. "I want to see more surgeons learn it and pass it on to their peers and the next generation."
• In North Carolina, Jo Bishop's son Jack also was born with "an exceedingly long" gap.
"Our research showed the other techniques had more long-term adverse effects on a child's eating and growth development," Bishop says. "[But] within six weeks, our son was eating food and drinking by mouth for the first time ever. Today Jack is a normal, soon-to-be-13-year-old boy."
About 10 years ago, 27 of 28 former patients of Dr. John Foker who were at least three years post-surgery and replied to a survey said they could eat normally.
• In Minnesota, Kelley Bohn found a leading Twin Cities pediatrician, Dr. Leonard Snellman, who knew about Foker and recommended him for her son, Donovan's, EA. Foker "allowed our child the ability to eat his favorite foods— all-you-can-eat crab legs, popcorn at the movies, hotdogs at the ballpark— food most people take for granted," Bohn says. "We got the best of the best— Dr. John Foker." Without him, Donovan, now 13, may have had to live "with a feeding tube or on pureed foods."
Putting natural signals to work
The Foker procedure works so well because it enlists nature to do the work.
"We all grow at least 30 times our birth weight by adulthood," Foker explains. "The organs, tissues and cells of the body respond to their signals to grow. For the esophagus, the growth of the spinal column slowly provides an axial tension that signals the esophagus to grow. This procedure provides a much greater axial tension and speeds up esophageal growth many fold."
Similarly, other organs respond to specific growth signals. For example, Foker has mended hearts with an undersized left or right ventricle (the pumping chambers). For ventricles the growth signal is blood flowing through the valves that separate them from the atria. He has designed operations to increase flow across these valves, and the ventricles have grown to normal size.
Foker sees many potential applications for this kind of approach.
"When a child is born with an under-developed organ, supplying the growth signal could possibly speed up growth and correct the problem," he says. "This makes use of a general biological principle: Find the growth signal and use it to fill in the defect or make up for the under-development."
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