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

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

  • Deficiency of tracheal cartilage

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


Postoperative Problems

  • GER:40% (20% require fundoplication)

    • Mgmt:treat aggressively postoperatively

      partial vs complete fundoplication

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


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 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/TEF


Thoracoscopic Repair EA/TEF

  • Retrospective study

  • Six international centers

  • 2000 – 2004

  • 104 Pts


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 Patients)

  • Fistula Ligation

    • 37 pts: suture ligation

    • 67 pts: clip ligation


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/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/TEFAssociated Anomalies(104 Patients)


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/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/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/TEFStaged Operation

  • 1 pt: long gap – thoracoscopic ligation

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


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/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/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


Patient Position


Port/Instrument Positions


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 MaterialCMH

AAP, 2006


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/TEF

Operative Approach

ThoracoscopyThoracotomy


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

  • 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/TEFAdvantages of Thoracoscopy

  • Avoidance of musculoskeletal sequelae

  • Superior visualization of anatomy

  • Easy to identify fistula for ligation


Thoracoscopic Repair EA/TEFFistula Ligation

  • Metal clip

  • Weck clip

  • Tie (x2 ?)

  • Suture ligature (x2 ?)

  • Suture closure – tracheal side


Second TE Fistula


Tips/Tricks

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

J LAST 17:380-382, 2007


Tips/Tricks

  • Oscillating ventilator

  • U-clips anterior anastomosis


How To Get StartedNot The Ideal Case

  • 2 - 2.5 kg

  • Very high upper pouch

  • Complex single ventricle physiology

  • Prostaglandin dependent


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/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


QUESTIONS

www.cmhcenterforminimallyinvasivesurgery.com


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