Minimally Invasive Surgery for Esophageal Atresia with Tracheoesophageal Fistula After Low Esophageal Banding in a Low-Birth Weight Infant

Abstract

Background: Birth body weight has been recognized as a remarkable prognostic factor in esophageal atresia with tracheoesophageal fistula (EA/TEF). Surgical repair, either open or thoracoscopic, leads to inevitable lung manipulation and adversely affects lung functions. Low esophageal banding (LEB) has been recommended in high-risk patients as the initial operation, which temporarily occludes the esophagocardiac junction (ECJ) and prevents the communication between airway and stomach.1,2 The definitive surgical repair can be conducted in stable conditions of adequate body weight and better lung functions. We present a low-birth weight infant with EA/TEF who received minimally invasive surgery after LEB. Materials and Methods: A premature infant was born with birth weight of 1389 g. Nasal respirator support was required for respiratory distress soon after birth. Contrast study showed EA/TEF. The abdomen was progressively distended because of constant air pumping into the stomach. A decision was made to perform LEB on day 2 of life. Through an upper midline incision, a 12F G-tube was initially placed to decompress the pumping air from TEF and have a better surgical exposure. The ECJ was identified. A retroesophageal window was made. The low esophagus was wrapped doubly circumferentially with a vessel loop. Two clips were put on the vessel loop to tighten up the banding. Enteral feeding through the G-tube was initiated on postoperative day 3 after the contrast study confirmed no gastroesophageal reflux. At 45 days of age with the body weight of 2569 g, thoracoscopic repair was arranged. The patient was placed in the left semiprone position. Three ports of 5, 5, and 3 mm were made at 1 cm below the scapular tip, fourth, and sixth intercostal spaces along midaxillary line, respectively. Lung was collapsed with CO2 insufflation at pressure of 3 mm Hg. The azygos vein was cauterized and divided. TEF was clipped with a hemolock and left undivided at this time point. The proximal esophageal pouch was mobilized. After confirmation that the proximal esophagus has appropriate length, TEF was divided. An 8F feeding tube was inserted into the distal esophagus until resistance was encountered. Esophagoesophagostomy was accomplished with 5-0 polydioxanone interruptedly. A chest tube was placed. The patient was changed to supine position for laparoscopic banding removal. Severe adhesions were noted particularly between the anterior stomach wall and the liver. A loose space was found between pylorus and liver. Continuing dissection upward along the lesser curvature of the stomach, the vessel loop was discovered and removed. Under the direct vision of transgastrostomy endoscope, the nasogastric tube was placed into the stomach smoothly. Results and Conclusions: There was no leakage shown in the esophagogram on postoperative day 10. Oral feeding was restored. Minimally invasive EA/TEF repair is technically feasible after LEB. A long vessel loop should be left along the lesser curvature of the stomach to facilitate banding removal. No competing financial interests exist. Runtime of video: 6 mins 9 secs