thoracoscopic repair of esophageal atresia with tracheoesophageal fistula n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula PowerPoint Presentation
Download Presentation
Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

Loading in 2 Seconds...

play fullscreen
1 / 44

Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula - PowerPoint PPT Presentation


  • 354 Views
  • Uploaded on

Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula. George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri. EA/TEF History. Before 1670 Pre-recognition Era 1670 - 1939 Pre-survival Era 1939 Survival Era 1970 Salvage Era.

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula' - Ava


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
thoracoscopic repair of esophageal atresia with tracheoesophageal fistula

Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

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

Children’s Mercy Hospital

Kansas City, Missouri

ea tef history
EA/TEFHistory

Before 1670 Pre-recognition Era

1670 - 1939 Pre-survival Era

1939 Survival Era

1970 Salvage Era

ea tef history 1941
EA/TEFHistory1941

Haight, Ann Arbor: March 15

Left extrapleural approach

Single layer anastomosis

Leak/stricture/single dilation

neonatal fistula tract expresses a respiratory lineage molecule
Neonatal fistula tract expresses a respiratory lineage molecule

E13 TEF whole mount for TTF1

TTF1 in e19 TEF

J Pediatr Surg 37:1065-1067, 2002

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
ea tef1
EA/TEF

WaterstonSpitz

113 cases (1951-59) 357 Cases (1980-1992)

Grp A > 5-1/2 lb., healthy

(95% survival) (99% survival)

Grp B – 4-5 ½ lb., well, or

wt, moderate pneumonia

or congenital anomaly

(68% survival) (95% survival)

Grp C - < 4 lb., well, or

wt, several pneumonia, or

severe anomaly

(6% survival) (71% survival)

ea tef2
EA/TEF

New Risk Classification

(1994)

Spitz

Grp I – Wt > 1500 gm, no major cardiac anomaly

(97% survival)

Grp II – Wt < 1500 gm or major cardiac anomaly

(59% survival)

Grp III – Wt < 1500 gm plus major cardiac anomaly (22% survival)

postoperative problems
Postoperative Problems
  • GER: 40% (20% require fundoplication)
    • Mgmt: treat aggressively postoperatively

partial vs complete fundoplication

  • Tracheomalacia: 10% symptomatic (<5% require aortopexy)
slide13
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 tef2
Thoracoscopic Repair EA/TEF
  • Retrospective study
  • Six international centers
  • 2000 – 2004
  • 104 Pts
thoracoscopic repair ea tef 104 patients
Thoracoscopic Repair EA/TEF104 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 Ventilation 3.6 (± 5.8)

Mean Hospitalization (days) 18.1 (± 18.6)

thoracoscopic repair ea tef results 104 patients1
Thoracoscopic Repair EA/TEFResults(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/TEFComplications(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/TEFRight 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/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

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 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 tef3
EA/TEF

Operative Approach

ThoracoscopyThoracotomy

ea tef4
EA/TEF

Why Thoracoscopy?

  • Evolution of technology?
  • Shorter operative time?
  • Reduced hospitalization?
  • Reduced short term morbidity?
  • Reduced long term morbidity?
ea tef5
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 concerns with thoracoscopy
Thoracoscopic Repair EA/TEFConcerns With Thoracoscopy
  • Clip ligation/migration recurrent TEF
  • Transpleural route
  • Anesthesia issues
thoracoscopic repair ea tef4
Thoracoscopic Repair EA/TEF
  • Surgisis placed b/w esophagus & tracheal suture line to help prevent recurrent TEF

J LAST 17:380-382, 2007

how to get started ideal case
How To Get StartedIdeal Case
  • Baby > 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