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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 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.

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Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula

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  1. Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri

  2. EA/TEFHistory Before 1670 Pre-recognition Era 1670 - 1939 Pre-survival Era 1939 Survival Era 1970 Salvage Era

  3. EA/TEFHistory1941 Haight, Ann Arbor: March 15 Left extrapleural approach Single layer anastomosis Leak/stricture/single dilation

  4. Esophageal Atresia

  5. Rat Model of Esophageal Atresia/ Tracheoesophageal Fistula E14 TEF-AP E14 TEF-Lateral

  6. Fistula originates as a bud from the lung as a trifurcation Fistula E12 Trifurcation

  7. 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

  8. 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

  9. 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)

  10. 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)

  11. Postoperative Problems • GER: 40% (20% require fundoplication) • Mgmt: treat aggressively postoperatively partial vs complete fundoplication • Tracheomalacia: 10% symptomatic (<5% require aortopexy)

  12. Thoracoscopic Repair EA/TEF

  13. 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

  14. Thoracoscopic Repair EA/TEF

  15. Thoracoscopic Repair EA/TEF • Retrospective study • Six international centers • 2000 – 2004 • 104 Pts

  16. Thoracoscopic Repair EA/TEF104 Patients • Tracheal intubation • 30 - 45º prone position • 3 ports (99 pts) • 4 ports (5 pts) • CO2 insufflation used

  17. Thoracoscopic Repair EA/TEF(104 Patients) • Fistula Ligation • 37 pts: suture ligation • 67 pts: clip ligation

  18. 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

  19. 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)

  20. Thoracoscopic Repair EA/TEFAssociated Anomalies(104 Patients)

  21. 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)

  22. 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

  23. 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

  24. Thoracoscopic Repair EA/TEFStaged Operation • 1 pt: long gap – thoracoscopic ligation 3 mos later – repair via thoracotomy (2 myotomies needed)

  25. 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

  26. 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

  27. 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

  28. Preoperative Bronchoscopy

  29. Preoperative Bronchoscopy

  30. Patient Position

  31. Port/Instrument Positions

  32. 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

  33. Impact Of Suture MaterialCMH AAP, 2006

  34. 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

  35. EA/TEF Operative Approach ThoracoscopyThoracotomy

  36. EA/TEF Why Thoracoscopy? • Evolution of technology? • Shorter operative time? • Reduced hospitalization? • Reduced short term morbidity? • Reduced long term morbidity?

  37. 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

  38. 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

  39. Thoracoscopic Repair EA/TEFAdvantages of Thoracoscopy • Avoidance of musculoskeletal sequelae • Superior visualization of anatomy • Easy to identify fistula for ligation

  40. Thoracoscopic Repair EA/TEFConcerns With Thoracoscopy • Clip ligation/migration recurrent TEF • Transpleural route • Anesthesia issues

  41. Thoracoscopic Repair EA/TEF • Surgisis placed b/w esophagus & tracheal suture line to help prevent recurrent TEF J LAST 17:380-382, 2007

  42. 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

  43. 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

  44. www.cmhcenterforminimallyinvasivesurgery.com

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