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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 George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital
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 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 • 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 Ventilation 3.6 (± 5.8) Mean Hospitalization (days) 18.1 (± 18.6)
Thoracoscopic Repair EA/TEFAssociated Anomalies(104 Patients)
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/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/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/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
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
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
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