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

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 Tracheoesophageal Fistula


Ea tef
EA/TEF Tracheoesophageal Fistula

  • 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 Tracheoesophageal Fistula

  • GER: 40% (20% require fundoplication)

    • Mgmt: treat aggressively postoperatively

      partial vs complete fundoplication

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


Ea tef preoperative evaluation
EA/TEF Tracheoesophageal FistulaPreoperative 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 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 Tracheoesophageal Fistula: A Multi-Institutional Analysis


Thoracoscopic repair ea tef2
Thoracoscopic Repair EA/TEF Tracheoesophageal Fistula: A Multi-Institutional Analysis

  • Retrospective study

  • Six international centers

  • 2000 – 2004

  • 104 Pts


Thoracoscopic repair ea tef 104 patients
Thoracoscopic Repair EA/TEF Tracheoesophageal Fistula: A Multi-Institutional Analysis(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 Tracheoesophageal Fistula: A Multi-Institutional Analysis(104 Patients)

  • Fistula Ligation

    • 37 pts: suture ligation

    • 67 pts: clip ligation


Thoracoscopic repair ea tef 104 patients2
Thoracoscopic Repair EA/TEF Tracheoesophageal Fistula: A Multi-Institutional Analysis(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/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisResults(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 Ventilation 3.6 (± 5.8)

Mean Hospitalization (days) 18.1 (± 18.6)


Thoracoscopic repair ea tef associated anomalies 104 patients
Thoracoscopic Repair EA/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisAssociated Anomalies(104 Patients)


Thoracoscopic repair ea tef results 104 patients1
Thoracoscopic Repair EA/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisResults(104 Patients)

  • Fundoplication 26

    (22 Nissen, 4 Thal)

  • Aortopexy 7

    ( 6 thoracoscopic)

  • Duodenal atresia 4

    (4 laparoscopic)

  • Imperforate anus 10

    (7 high, 3 low)

  • Cardiac operations 5

    ( other than VSD/ASD)


Thoracoscopic repair ea tef complications 104 patients
Thoracoscopic Repair EA/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisComplications(104 Patients)

  • Recurrent fistula 2

    ( 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/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisRight Aortic Arch6 Pts

  • Conversion from R thoracoscopy 3 to L thoracoscopy

  • Conversion from R thoracoscopy 1 to L open

  • Left thoracoscopy 2


Thoracoscopic repair ea tef staged operation
Thoracoscopic Repair EA/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisStaged 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/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisConversion 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/TEF Tracheoesophageal Fistula: A Multi-Institutional Analysis104 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 Tracheoesophageal Fistula: A Multi-Institutional Analysis

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 Tracheoesophageal Fistula: A Multi-Institutional Analysis


Patient position
Patient Position Tracheoesophageal Fistula: A Multi-Institutional Analysis


Port instrument positions
Port/Instrument Positions Tracheoesophageal Fistula: A Multi-Institutional Analysis


Impact of suture material cmh
Impact Of Suture Material Tracheoesophageal Fistula: A Multi-Institutional AnalysisCMH

  • 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 Material Tracheoesophageal Fistula: A Multi-Institutional AnalysisCMH

AAP, 2006


Impact of suture material cmh2
Impact Of Suture Material Tracheoesophageal Fistula: A Multi-Institutional AnalysisCMH

  • 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 Tracheoesophageal Fistula: A Multi-Institutional Analysis

Operative Approach

ThoracoscopyThoracotomy


Ea tef2
EA/TEF Tracheoesophageal Fistula: A Multi-Institutional Analysis

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 Tracheoesophageal Fistula: A Multi-Institutional Analysis

  • 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/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisAdvantages 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/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisFistula Ligation

  • Metal clip

  • Weck clip

  • Tie (x2 ?)

  • Suture ligature (x2 ?)

  • Suture closure – tracheal side


Second te fistula
Second TE Fistula Tracheoesophageal Fistula: A Multi-Institutional Analysis


Tips tricks
Tips/Tricks Tracheoesophageal Fistula: A Multi-Institutional Analysis

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

J LAST 17:380-382, 2007


Tips tricks1
Tips/Tricks Tracheoesophageal Fistula: A Multi-Institutional Analysis

  • Oscillating ventilator

  • U-clips anterior anastomosis


How to get started not the ideal case
How To Get Started Tracheoesophageal Fistula: A Multi-Institutional AnalysisNot 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 Started Tracheoesophageal Fistula: A Multi-Institutional AnalysisIdeal 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/TEF Tracheoesophageal Fistula: A Multi-Institutional AnalysisSummary

  • 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 Tracheoesophageal Fistula: A Multi-Institutional Analysis

www.cmhcenterforminimallyinvasivesurgery.com


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