Leah’s surgery is in 15 days.

Our little Bug was full of spitballs today. At one point this evening she even hacked up the water that had been used to flush her tube some 15 minutes earlier. She also had a bunch of pretty rough feeds – I don’t remember whether or not I’ve already mentioned this, but for the past few weeks, Leah has been having coughing and gagging episodes at nearly every meal (except sometimes when she is asleep during the feed). She is also hacking spitballs more frequently now that she has discovered nommable fingers; I think the holes are getting stuck to her throat more frequently (although someone once claimed erroneously that this was impossible…). I’m dreading Leah’s surgery day, but at the same time, it cannot come quickly enough. In the mean time, I am grateful for awesome [with an exception] nurses. (Yeah, every once in a while I reread that entry and my blood boils all over again.)

I’ve found myself explaining Leah’s procedure pretty frequently lately, so I want to take a minute to let you know what it is that they’re planning to do – at least, according to my untrained understanding of what will happen.

As you likely know, Leah has esophageal atresia (EA), which means that her esophagus and her stomach do not connect. In most cases of EA, there is also a tracheoesophageal fistula, which means that a part of the esophagus is growing into the trachea. From what I understand, this is typically a more urgent repair since it involves the trachea. Usually these repairs are done shortly after birth – like, within a few days, if that. From the drawings and diagrams that I’ve seen, though, most often what happens is that the proximal esophagus (the top part) ends in a pouch, and the distal esophagus (the part that connects to the stomach) grows into the trachea, which means that it’s long enough to connect to the proximal pouch, but it’s connected to the wrong structure.

Here is a diagram:

(from this website.)

What I just described is illustrated in the first drawing. Leah has the condition illustrated in the second drawing – a far more uncommon form of the condition. Although this drawing is second in the above diagram, it is referred to as “Type A” or “pure” esophageal atresia. It says 9% of cases, but 7-8% is the figure I usually see. In this condition, the proximal and distal portions of the esophagus each end in a pouch, without any fistula into the trachea, and there is a gap between the two pouches. Sometimes the gap is just past the point where it just could be connected on the spot, and sometimes it is very, very long. My understanding is that a gap larger than 3 vertebral bodies is considered a long gap. Leah’s first study showed a gap of 4 to 5 vertebral bodies, and the second study showed a gap of 5-6 vertebral bodies.

So here’s how it will work:

On November 1 they will take our sweet BabyBug into the OR and take a look at the gap, live and in-person, for the first time. From her surgeon’s description it sounded like they might be doing this laparoscopically, but I wouldn’t swear to it. I know he said they’d be using a scope to examine the pouches but I don’t know if that’s in addition to more substantial cutting. The surgeons will assess the actual distance of the gap and see whether they think it’s possible to do a primary anastomosis, which means they just connect the two ends directly. The odds are pretty small that this will be possible, but the surgeon seemed to think Leah would gain some esophagus length once they actually get in there and see how far the ends will reach.

In the more likely event that the surgeons cannot connect the two ends directly, they will perform the Foker procedure. The surgeons will place sutures and a clip at the end of each pouch. The sutures will be brought out of the chest at a slant, with the distal esophagus sutures pointing diagonally upward and the proximal esophagus sutures pointing diagonally downward. Leah will be completely immobilized (sedated and paralyzed) for a period of three to twelve days while the surgeons gradually put tension on the sutures to stretch the pouches but also stimulate them to grow. I think the clips allow the surgeons to take x-rays to see whether the ends are growing toward one another and if so, by how much. Leah must be paralyzed and sedated throughout the entire procedure, because if she moves even a tiny bit it could jeopardize the repair.

If the procedure works, ultimately the surgeons will go back into the OR and connect the two ends of the esophagus, which should be long enough to overlap slightly. At that point, Leah will begin her recovery, during which time she will be monitored vigilantly to watch for leaks and strictures (where the surgical site narrows), and will receive therapy to teach her how to swallow and feed by mouth. She will come home with the g-tube and continue her therapies and keep learning how to feed by mouth, albeit with vigilant monitoring since she is at constant risk of stricture and choking.

If the procedure does not work or if they have to abandon it for some other reason, the surgeons will perform an esophagostomy (also known as a “spit fistula”), in which they bring the proximal esophagus through the neck so that Leah’s saliva (and whatever else she swallows) drains externally into a gauze pad. After a short recovery period they will send Leah home until she is about a year old, at which point we will revisit some of the more traditional approaches to repairing long-gap esophageal atresia, each of which comes along with its own complications. The reason they don’t do the esophagostomy in the first place is that the Foker procedure generally doesn’t work once there has been any other surgical intervention, and that includes the esophagostomy. Since the Foker procedure is the only one that uses the child’s actual esophagus to repair the gap, that is the ideal procedure in many cases. But sometimes it doesn’t work.

I wish I could tell you what percentage of these procedures wind up being successful, but the fact is this just doesn’t really happen very often. I think I posted my little number-crunching exercise on Facebook but not on the blog, so take a look to put things in perspective:

On a completely different note… I’ve been thinking a lot lately about how much things are going to change once Leah’s surgery begins. I’ve mentioned that Leah’s room is like a brightly-colored bubble compared to the rest of the PICU. That changes when Leah’s surgery starts. The wall-o-mermaids stays, but her toys and books (and probably most of her clothes) will likely need to go back to Ronald McDonald House to make room for the ventilator and whatever other machines they will have supporting our little sweetheart.

We’ve gotten spoiled these past two months with our deceptively healthy-looking Bug, and will have to dig down and remember how things were when Leah was first born. I was talking with Leah’s nurse today about what we can expect in the days following her surgery, if they do proceed with the Foker procedure. She said that we need to minimize stimulation as much as possible because the more Leah gets stimulated, the more she will try to wake up from her sedation and the more likely she will be to try to move, which could cause the procedure to fail. Basically… this is the ICU and Leah will be receiving intensive care and needs to be regarded as such. We are going to double-check everything with the surgeons, but I think the general idea is that we are not just hanging out in this room all day visiting with friends and family during that time. To the extent that visitors are allowed at all, they will need to spend most of their time in the waiting room, with brief visits to see the baby, as was the case when she was first born. I doubt they will allow more than two people in the room at a time with the extra equipment that will be in here. I asked if we could read to her during her procedure, but it sounded like that would likely be too much stimulation and could cause her to try to wake up. It’s going to be a quiet week. :-/ In the time leading up to Leah’s surgery, Mandy and I plan to make sure that at least one of us is here every night, largely because she has been hacking up spitballs so frequently and you can’t always hear those from the nurses’ station. I’m not sure yet whether we should sleep in the room while Leah is sedated. It may cause too much commotion.

Argh. Okay. I think I’ve said what I needed to say so that I can try going to sleep without my mind running on its hamster wheel. I started this post at midnight, so technically today is the 17th – our anniversary. Mandy and I are celebrating eleven years together. Whew.

I leave you with this face: