The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia

•What is currently known about this topic?.•Magnetic compression anastomoses can be created for endoscopic primary repair of esophageal atresia (EA) with favorable outcomes.•What new information is contained in this article?.•An esophageal magnetic compression anastomosis device is used for salvage of primary repair in 2 surgically and medically complex EA patients. Two operative approaches are reported: totally endoscopic and a novel hybrid approach. Preservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions. Two approaches using the Connect-EA are described – a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device. Salvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy. The Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.