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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. 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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  1. Thoracoscopic Repair of Esophageal Atresia With Tracheoesophageal Fistula George W. Holcomb, III, M.D., MBA Surgeon-in-Chief Children’s Mercy Hospital

  2. Esophageal Atresia

  3. 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

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

  5. 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

  6. Thoracoscopic Repair EA/TEF

  7. 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

  8. Thoracoscopic Repair EA/TEF

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

  10. Thoracoscopic Repair EA/TEF(104 Patients) • Tracheal intubation • 30 - 45º prone position • 3 ports (99 pts) • 4 ports (5 pts) • CO2 insufflation used

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

  12. 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

  13. 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)

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

  15. 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)

  16. 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

  17. 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

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

  19. 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

  20. 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

  21. 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

  22. Preoperative Bronchoscopy

  23. Patient Position

  24. Port/Instrument Positions

  25. 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

  26. Impact Of Suture MaterialCMH AAP, 2006

  27. 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

  28. EA/TEF Operative Approach ThoracoscopyThoracotomy

  29. 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

  30. 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

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

  32. Thoracoscopic Repair EA/TEFFistula Ligation • Metal clip • Weck clip • Tie (x2 ?) • Suture ligature (x2 ?) • Suture closure – tracheal side

  33. Second TE Fistula

  34. Tips/Tricks • Surgisis placed b/w esophagus & tracheal suture line to help prevent recurrent TEF J LAST 17:380-382, 2007

  35. Tips/Tricks • Oscillating ventilator • U-clips anterior anastomosis

  36. How To Get StartedNot The Ideal Case • 2 - 2.5 kg • Very high upper pouch • Complex single ventricle physiology • Prostaglandin dependent

  37. 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

  38. 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

  39. QUESTIONS www.cmhcenterforminimallyinvasivesurgery.com

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