Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula
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Thoracoscopic Repair of Esophageal Atresia With Tracheoesophageal Fistula. George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital. Esophageal Atresia. EA/TEF. 1 per 2500 – 3500 live births Sporadic, non-syndromal Dysmotile distal esophagus

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Thoracoscopic Repair of Esophageal Atresia With Tracheoesophageal Fistula

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Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula

Thoracoscopic Repair of Esophageal Atresia With Tracheoesophageal Fistula

George W. Holcomb, III, M.D., MBA

Surgeon-in-Chief

Children’s Mercy Hospital


Esophageal atresia

Esophageal Atresia


Ea tef

EA/TEF

  • 1 per 2500 – 3500 live births

  • Sporadic, non-syndromal

  • Dysmotile distal esophagus

  • Deficiency of tracheal cartilage

  • 50% have 1 or more associated anomalies: cardiac, anorectal, GU, vertebral/skeletal, others


Postoperative problems

Postoperative Problems

  • GER:40% (20% require fundoplication)

    • Mgmt:treat aggressively postoperatively

      partial vs complete fundoplication

  • Tracheomalacia: 10% symptomatic (<5% require aortopexy)


Ea tef preoperative evaluation

EA/TEFPreoperative Evaluation

  • Echocardiogram – assess cardiac anomalies

  • Renal US – assess kidneys

  • CXR/spine films – assess vertebral anomalies

  • PE – assess limb, anorectal anomalies

  • US great vessels – assess location of aortic arch


Thoracoscopic repair ea tef

Thoracoscopic Repair EA/TEF


Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula

Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula: A Multi-Institutional Analysis

George W. Holcomb III, Steven S. Rothenberg, Klaas MA Bax, Marcelo Martinez-Ferro, Craig T. Albanese, Daniel J. Ostlie, David C. van der Zee, C K Yeung

American Surgical Association, 2005

Ann Surg 242:422-430, 2005


Thoracoscopic repair ea tef1

Thoracoscopic Repair EA/TEF


Thoracoscopic repair ea tef2

Thoracoscopic Repair EA/TEF

  • Retrospective study

  • Six international centers

  • 2000 – 2004

  • 104 Pts


Thoracoscopic repair ea tef 104 patients

Thoracoscopic Repair EA/TEF(104 Patients)

  • Tracheal intubation

  • 30 - 45º prone position

  • 3 ports (99 pts)

  • 4 ports (5 pts)

  • CO2 insufflation used


Thoracoscopic repair ea tef 104 patients1

Thoracoscopic Repair EA/TEF(104 Patients)

  • Fistula Ligation

    • 37 pts: suture ligation

    • 67 pts: clip ligation


Thoracoscopic repair ea tef 104 patients2

Thoracoscopic Repair EA/TEF (104 Patients)

  • Anastomosis – Suture

    • 46 pts: Vicryl

    • 40 pts: PDS

    • 11 pts: Silk

    • 7 pts: “Other”

  • Anastomosis – Technique

    • 42 pts: extracorporeal

    • 62 pts: intracorporeal


Thoracoscopic repair ea tef results 104 patients

Thoracoscopic Repair EA/TEFResults(104 Patients)

Mean Age (days)1.2 (± 1.1)

Mean Wt (kg)2.6 (± 0.5)

Mean Operative Time (min)129.9 (± 55.5)

Mean Days Ventilation3.6 (± 5.8)

Mean Hospitalization (days) 18.1 (± 18.6)


Thoracoscopic repair ea tef associated anomalies 104 patients

Thoracoscopic Repair EA/TEFAssociated Anomalies(104 Patients)


Thoracoscopic repair ea tef results 104 patients1

Thoracoscopic Repair EA/TEFResults(104 Patients)

  • Fundoplication26

    (22 Nissen, 4 Thal)

  • Aortopexy7

    ( 6 thoracoscopic)

  • Duodenal atresia4

    (4 laparoscopic)

  • Imperforate anus10

    (7 high, 3 low)

  • Cardiac operations5

    ( other than VSD/ASD)


Thoracoscopic repair ea tef complications 104 patients

Thoracoscopic Repair EA/TEFComplications(104 Patients)

  • Recurrent fistula2

    ( 3 mos, 8 mos)

  • Mortality 3

    • 7 mo old - NEC

    • 10 day old – CHD

    • 21 day old with esophageal disruption at intubation


Thoracoscopic repair ea tef right aortic arch 6 pts

Thoracoscopic Repair EA/TEFRight Aortic Arch6 Pts

  • Conversion from R thoracoscopy 3 to L thoracoscopy

  • Conversion from R thoracoscopy 1 to L open

  • Left thoracoscopy2


Thoracoscopic repair ea tef staged operation

Thoracoscopic Repair EA/TEFStaged Operation

  • 1 pt: long gap – thoracoscopic ligation

    3 mos later – repair via thoracotomy (2 myotomies needed)


Thoracoscopic repair ea tef conversion to open 5 pts

Thoracoscopic Repair EA/TEFConversion to Open5 Pts

  • 1 Pt:R aortic arch

    (despite negative ECHO)

  • 3 Pts:Intraoperative desaturation, relatively long gap

  • 1 Pt:1.2 kg baby – only 1 port placed – too small


Thoracoscopic repair ea tef 104 patients3

Thoracoscopic Repair EA/TEF104 Patients

Waterston A: > 5.5 lb with no significant associated problems

Waterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomaly

Waterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly


Thoracoscopic repair ea tef3

Thoracoscopic Repair EA/TEF

N.R.:Not reported

A:87% are Gross Type C

B:Stricture is defined as a significant narrowing on the initial esophagram

C:Stricture in this paper is defined as requiring > 4 dilations

D:Stricture in this paper is defined as requiring > 2 dilations


Preoperative bronchoscopy

Preoperative Bronchoscopy


Patient position

Patient Position


Port instrument positions

Port/Instrument Positions


Impact of suture material cmh

Impact Of Suture MaterialCMH

  • 99 patients

    • Absorbable suture used in 32 patients

    • Permanent suture in 62 patients

    • Combination used in 5 patients

  • No difference in weight at operation, EGA, age at repair, or mean number of associated anomalies between the groups.

AAP, 2006


Impact of suture material cmh1

Impact Of Suture MaterialCMH

AAP, 2006


Impact of suture material cmh2

Impact Of Suture MaterialCMH

  • There is no difference in leak rates based on suture material or size

  • Suture material or type has no effect on stricture formation

AAP, 2006


Ea tef1

EA/TEF

Operative Approach

ThoracoscopyThoracotomy


Ea tef2

EA/TEF

Why Thoracoscopy?

89 pts/16 yrs

  • shoulder elevation: 24%

  • chest deformity: 20%

  • abduction limited:100%

  • spine deformities: 18%

  • breast deformities: 27% (3/11)

Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985


Musculoskeletal morbidity following thoracotomy for ea tef

Musculoskeletal Morbidity Following Thoracotomy for EA/TEF

  • Durning RP, et al: J Bone Joint Surg AM 62:1156, 1980

  • Gilsanz V, et al: Am J Roentgenol 141:457, 1983

  • Chetcuti P, et al: J Pediatr Surg 24: 244, 1989

  • Goodman P, et al: J Comput Assist Tomogr 17:63, 1993

  • Frola C, et al: Am J Roentgenol 164: 599, 1995

  • Bianchi A, et al: J Pediatr Surg 33: 1798, 1998


Thoracoscopic repair ea tef advantages of thoracoscopy

Thoracoscopic Repair EA/TEFAdvantages of Thoracoscopy

  • Avoidance of musculoskeletal sequelae

  • Superior visualization of anatomy

  • Easy to identify fistula for ligation


Thoracoscopic repair ea tef fistula ligation

Thoracoscopic Repair EA/TEFFistula Ligation

  • Metal clip

  • Weck clip

  • Tie (x2 ?)

  • Suture ligature (x2 ?)

  • Suture closure – tracheal side


Second te fistula

Second TE Fistula


Tips tricks

Tips/Tricks

  • Surgisis placed b/w esophagus & tracheal suture line to help prevent recurrent TEF

J LAST 17:380-382, 2007


Tips tricks1

Tips/Tricks

  • Oscillating ventilator

  • U-clips anterior anastomosis


How to get started not the ideal case

How To Get StartedNot The Ideal Case

  • 2 - 2.5 kg

  • Very high upper pouch

  • Complex single ventricle physiology

  • Prostaglandin dependent


How to get started ideal case

How To Get StartedIdeal Case

  • Baby – 2.5-3 kg; no other anomalies

  • Esophageal segments close together (CXR, Bronchoscopy)

  • Start thoracoscopically – Go as far as comfortable

  • Try it again


Thoracoscopic repair ea tef summary

Thoracoscopic Repair EA/TEFSummary

  • Thoracoscopic repair of EA/TEF can be performed safely and effectively

  • The thoracoscopic approach may be advantageous by reducing the musculoskeletal sequelae seen following thoracotomy


Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula

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