Thoracoscopic Repair Of Esophageal Atresia Research Articles

Transthoracic Single Port with Peroral Assistance: An Animal Experiment to Assess a Less Invasive Technique for Human Esophageal Atresia Repair

Thoracoscopic repair of esophageal atresia has becoming the gold standard in many centers because it allows a better cosmetic result and avoids the musculoskeletal sequelae of a thoracotomy. Natural orifice translumenal endocopic surgery (NOTES) is a new surgical paradigm, and its human application has already been started in some procedures. In the present study, we explore the feasibility of performing an esophagoesophageal anastomosis using a single transthoracic single port combined with a peroral access in a rabbit model to simulate repair of esophageal atresia by hybrid NOTES in a human newborn. Adult male rabbits (Oryctolagus cuniculus, n=28) were used to perform the surgical protocol. We used a transthoracic telescope with a 3-mm working channel and a flexible endoscope with a 2.2-mm working channel by peroral access. We performed total esophagotomy with peroral scissors followed by an esophagoesophageal anastomosis achieved with a rigid transthoracic scope helped by the peroral operator. Extracorporeal transthoracic knots were performed to complete the anastomosis. The anastomoses were examined in loco and ex loco, after animal sacrifice. We successfully accomplished a complete esophageal anastomosis in all rabbits using a combination of transthoracic and peroral 3-mm instruments. This study provides important insights for a possible translation of hybrid NOTES to human newborns with esophageal atresia. Forward studies to accomplish their feasibility in human newborns will still be necessary.

Respiratory morbidity and growth after open thoracotomy or thoracoscopic repair of esophageal atresia

BackgroundRespiratory morbidity has been described in patients who underwent repair of esophageal atresia as a neonate. We compared the influence of open thoracotomy or thoracoscopy on lung function, respiratory symptoms, and growth. MethodsFunctional residual capacity (FRCp), indicative of lung volume, and maximal expiratory flow at functional residual capacity (V′maxFRC), indicative of airway patency, of 37 infants operated for esophageal atresia were measured with Masterscreen Babybody at 6 and 12 months. SD scores were calculated for V′maxFRC. ResultsRepair was by thoracotomy in 21 cases (57%) and by thoracoscopy in 16 cases (43%). Lung function parameters did not differ between the types of surgery (FRCp; P = .384 and V′maxFRC; P = .241). FRCp values were in the upper normal range and increased from 6 to 12 months (22.5 and 25.4 mL/kg respectively, P = .010). Mean (SD) V′maxFRC was below the norm without significant change in SD scores from 6 to 12 months (−1.9 and −2.3, respectively, P = .248).Neither lung function nor type of repair was associated with clinical evolution up to 2 years. ConclusionLung function during the first year was similar in EA infants repaired by thoracotomy or thoracoscopy. Ongoing follow-up including pulmonary function testing is needed to determine whether differences occur at a later age in this cohort.

Learning Curve of Thoracoscopic Repair of Esophageal Atresia

BackgroundThoracoscopic repair of esophageal atresia is considered to be one of the more advanced pediatric surgical procedures, and it undoubtedly has a learning curve. This is a single-center study that was designed to determine the learning curve of thoracoscopic repair of esophageal atresia.MethodsThe study involved comparison of the first and second five-year outcomes of thoracoscopic esophageal atresia repair.ResultsThe demographics of the two groups were comparable. There was a remarkable reduction of postoperative leakage or stenosis, and recurrence of fistulae, in spite of the fact that nowadays the procedure is mainly performed by young staff members and fellows.ConclusionsThere is a considerable learning curve for thoracoscopic repair of esophageal atresia. Centers with the ambition to start up a program for thoracoscopic repair of esophageal atresia should do so with the guidance of experienced centers.

Thoracoscopic Repair of Esophageal Atresia and Tracheo-Esophageal Fistula in Neonates: Evolution of a Technique

Advancements in minimally invasive surgical techniques and instruments for neonates have allowed even the most complex neonatal procedures to be endoscopically approached. In 1999, the first successful thoracoscopic repair of an esophageal atresia (EA) was performed in a 2-month-old infant. One year later, the first totally thoracoscopic repair of an atresia with distal fistula (tracheo-esophageal fistula [TEF]) was realized in a newborn. Over the ensuing 10 years, this technique was used and modified by a single surgeon in 49 consecutive patients. Overall, 43 patients with TEF and 6 with pure EA were repaired by using a thoracoscopic approach. An additional 3 patients with H-type TEF were also thoracoscopically treated. Weight ranged from 1.2 to 3.8 kg. Operative time ranged from 50 to 120 minutes. In fact, 48 out of 49 were successfully completed thoracoscopically. There were 2 patients with leaks that resolved with conservative management. Thirty percent of patients required at least one dilatation, but this number dropped to less than 10% in the second half of the series. There were no deaths and no recurrent fistula. Thoracoscopic TEF repair has proved to be an effective and safe technique. Evolution of the technique has resulted in fewer complications while avoiding the significant short- and long-term morbidity associated with thoracotomy in neonates.

Repair of esophageal atresia with tracheoesophageal fistula via thoracotomy: a contemporary series

BackgroundA recent series detailing thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (EA/TEF) reported lower complication rates compared with historic controls. This study provides a contemporary cohort of patients repaired via thoracotomy for comparison with the recent large multi-institutional thoracoscopic series. MethodsRecords of patients with EA/TEF between 1993 and 2008 were reviewed. Attention was focused on demographics and complications including anastomotic leak, recurrent fistulae, stricture formation, and need for fundoplication. ResultsSeventy-two patients underwent repair of EA/TEF via thoracotomy. Complication rates in the current series compared with the thoracoscopic series were anastomotic leak, 2.7% versus 7.6%; recurrent fistulae, 2.7% versus 1.9%; stricture, 5.5% versus 3.8%; and need for fundoplication, 12% versus 24%. Differences in complication rates did not reach statistical significance. Two children in this cohort developed mild scoliosis attributed to congenital vertebral anomalies, neither of whom required intervention. ConclusionsThoracoscopic repair of EA/TEF yielded complication rates similar to this contemporary series; however, trends toward increased anastomotic leaks and greater need for fundoplication were noted. No musculoskeletal sequelae were directly attributable to thoracotomy.

Perioperative Outcome of Patients with Esophageal Atresia and Tracheo-esophageal Fistula Undergoing Open Versus Thoracoscopic Surgery

Thoracoscopic approach for repair of esophageal atresia (EA) and tracheo-esophageal fistula (TEF) has become a standard procedure in many pediatric surgical centers. Thoracoscopic surgery in a newborn is demanding from both the surgeon and the patient. The potential benefits for the newborn are still discussed by neonatologists, pediatric intensive care physicians, and also parents. The aim of our investigation was to clearly define perioperative outcome and complication rates in children undergoing thoracoscopic versus open surgery for EA and TEF repair. We reviewed the records of 68 newborns undergoing surgery for EA and TEF between March 2002 and February 2010. Patient data of open versus thoracoscopic approach were compared regarding operating time, intraoperative as well as postoperative pCO(2)max values, postoperative ventilation time, and complications. Specific patient data are reported with the median and range. Data analysis was done with the JMP(®) 7.0.2 statistical software (SAS Institute, Cary, NC). For the 68 patients, the mean gestational age was 35 weeks (28-41), the median birth weight was 2720 g (1500-3510 g) in the thoracoscopic group and 2090 g (780-3340 g) in the open group. There were 36 girls and 32 boys. Thirty-two children had associated anomalies. Twenty-five children were undergoing a thoracoscopic procedure. In 8 cases, the operation was converted to open thoracotomy. Another 32 children received a thoracotomy. In 11 newborns, a cervical esophagostomy was performed because of long-gap EA and these patients were excluded from the study. Operating time was 141 minutes (77-201 minutes) in the thoracoscopic group and 106 minutes (48-264 minutes) in the thoracotomy group, with significant difference (P=.014). Values of pCO(2)max during operation were 62 mm Hg (34-101 mm Hg) in the thoracoscopic group and 48 mm Hg (28-89 mm Hg) in the open group, with significant difference (P=.014). Postoperative ventilation time was 3 days (1-51 days) in all groups, with no significant difference (P=.79). Early complications were noticed in 9 children undergoing thoracoscopy and in 8 patients of the thoracotomy group, again with no significant difference (P>.05). Thoracoscopic repair of EA with TEF is justified because of a comparable perioperative outcome to open surgery, competitive operating times, decreased trauma to the thoracic cavity, and improved cosmesis despite skeptical considerations. Complication rates are not higher than in children operated on through a thoracotomy. However, a learning curve has to be taken into account and large experience in minimal invasive surgery is mandatory for this procedure. Larger series have to be expected for a more objective evaluation of perioperative as well as long-term outcomes. To our opinion, the thoracoscopic approach appears to be favorable and could be a future standard.

Thoracoscopic Repair of Esophageal Atresia Through the Right Chest in Neonates with Right-Sided Aortic Arch

The management of neonates with esophageal atresia (EA) associated with right-sided aortic arch (RAA) is often difficult technically. Many surgeons would advise for repair through left-chest access. In this article, we report our experience of repairing 2 patients with EA associated with RAA thoracoscopically. We conclude that thoracoscopic repair is ideal for all patients with EA.

Influence of thoracoscopic esophageal atresia repair on esophageal motor function and gastroesophageal reflux

Background/Purpose Thoracoscopic repair has recently been attempted in newborns with esophageal atresia (EA), but it remains unclear whether thoracoscopic dissection reduces pathological gastroesophageal reflux. We investigated the influence of a thoracoscopic approach on esophageal motor function in patients with EA. Methods Clinical and gastrointestinal data of 10 patients with EA with open repair (group A) and 7 with thoracoscopic repair (group B) were analyzed retrospectively. Videomanometry was conducted to investigate esophageal motor patterns. Esophageal acid exposure was evaluated with 24-hour esophageal pH monitoring. Data are expressed as medians and ranges. Results Contractions in the distal esophagus were conspicuously absent in 1 and 3 patients in groups A and B, respectively ( P = .26). There were no significant differences in esophageal acid exposure (5.5% [0.7%-24.6%] vs 3.7% [0.3%-56.8%]; P = .71) or mean esophageal acid reflux time (0.5 minutes [0.1-1.4 minutes] vs 0.5 minutes [0.1-1.3 minutes]; P = .87) between the 2 groups. Fundoplication was conducted in 2 patients in each group ( P = .60), all of whom had conspicuously absent distal esophageal contractions. Those contractions were preserved in the remaining patients with the exception of 1 group B patient. Conclusion There are unlikely to be benefits from thoracoscopic repair of EA in terms of postoperative esophageal motor function.

Locking sliding knots in laboratory model of thoracoscopic repair of esophageal atresia

Aim The study aimed to assess feasibility and strength of locking sliding knots, in comparison to intracorporeal square knots, in a thoracoscopic model of esophageal atresia (EA). Methods A simple thoracoscopic model of EA was created, and inside this model, 26 sliding knots were used to suture a soft drain together. In all cases, ten 5-0 monofilament sutures were used for this “anastomosis.” The drain is then mounted on a motorized digital tensometer, and the knots with the best tension profile were retested 4 more times to obtain an average. The tensometer measured the knots' strength by producing a constant and increasing weight on the sutured EA model and continuous readings were taken by integrated computer software. The point, at which either the knot slipped, broke, or the drain disrupted, was taken as the maximum load tolerated by the sliding knots. Knot pushers were not required for any of these knots. Results Of the 26 sliding knots, only locking sliding knots tolerated reasonably high tensions. However, when comparing these knots to the standard square knot, only Giant and Field knots had similar tension readings. Field knot was found to be very complex and therefore impractical with 5-0 suture material, leaving Giant knot as the only knot with favorable results. Conclusions Locking sliding knots and particularly Giant knot could have an enormous impact in minimally invasive surgery of neonatal conditions and can potentially replace intracorporeal knots. Giant knot is faster to tie and thus could reduce surgeon's fatigue during complex procedures.

A Novel Technique for Risk Calculation of Anastomotic Leakage after Thoracoscopic Repair for Esophageal Atresia with Distal Fistula

A Novel Technique for Risk Calculation of Anastomotic Leakage after Thoracoscopic Repair for Esophageal Atresia with Distal Fistula

Thoracoscopic Repair of Tracheoesophageal Fistula and Esophageal Atresia

To evaluate the safety and efficacy of the thoracoscopic repair of esophageal atresia and tracheoesophageal fistula (EA/TEF). From August 2005 to March 2008, 23 consecutive patients (16 boys, 7 girls) weighing 1,070 to 3,390 g underwent thoracoscopic EA/TEF repair. Nine cases had associated malformations. Two 5-mm and one 2.5-mm trocars were placed. The 5-mm 25- to 30-degree telescope was preferred. A pneumothorax was maintained with 5 to 6 mm Hg. The azygos vein was never divided. The TEF was closed with 5-mm titanic clips mainly.The esophageal anastomosis was made over 6-French nasogastric tube by three to seven simple stitches of 5-0Vicryl. The 8-French chest tube was left without suction. The enteral feeding was usually started on postoperative day 3 or 4. Barium swallow was performed on postoperative day 5 or 6, then the chest tube was removed. All procedures were successfully completed without conversion. The average operative time was 131 minutes (range, 55-245 minutes) with significant improvement after gaining experience (mean, 171 minutes for first 10 cases and 98 minutes for last 13 cases). There were two cases of accidental tracheal opening. The anastomotic leak rate was 13% (three cases), and all were healed on conservative treatment. Four cases required one to three courses of anastomotic stricture dilatations. There were three deaths (13%) of causes not related with performed operation. The thoracoscopic repair of EA/TEF is effective method, and based on our experience, it is the procedure of choice if performed by an experienced endoscopic pediatric surgeon. The intraoperative complications observed if properly managed have a good prognosis.

A Novel Technique for Risk Calculation of Anastomotic Leakage after Thoracoscopic Repair for Esophageal Atresia with Distal Fistula

PurposeThis study was designed to determine the risk of anastomotic leakage after thoracoscopic repair for esophageal atresia by digitally measuring the length of the proximal esophagus and distance of carina to proximal esophagus.MethodsWith the use of Picture Archiving and Communication System (PACS), the length of the proximal esophagus from the top of the first thoracic vertebra was measured on the preoperative chest x-ray, as well as the distance from the carina to the proximal esophagus. The chest x-rays of 27 neonates, born with esophageal atresia with distal fistula, were examined. Furthermore, the tapes from the procedures were reviewed. Statistical analysis was performed with the t test for equality of means by using SPSS® 12.0.1 for Windows.ResultsBoth groups were comparable, and there was a statistical significant difference in both length of the proximal esophagus (p < 0.023) and distance of carina to proximal esophagus (p < 0.022) in patients who did and did not leak postoperatively. There seems to be a tendency toward a shorter proximal esophagus in recent years that was not obvious earlier.ConclusionsThe digital measurement of the length of the proximal esophagus (M < 7 mm) and distance of carina to proximal esophagus (M > 13.5 mm) with the use of PACS gives a good risk calculation for postoperative leakage.

Thoracoscopic treatment of esophageal atresia with distal fistula and of tracheomalacia

Single center experience with thoracoscopic repair of esophageal atresia with distal fistula and of tracheomalacia. Between May 2000 and December 2006, 51 neonates with an esophageal atresia were presented for thoracoscopic repair. Gestational age varied from 31 3/7 to 42 2/7 weeks (M = 37 2/7). Birth weight was between 1025 g and 4030 g (mean 2620 g). Concomitant anomalies or VACTERL association were encoutered in 31 patients (61%). Duration of the operation was from 90 minutes to 390 minutes (mean 178 minutes). All but 1 patient had an esophageal atresia with a distal fistula. Six patients had tracheomalacia requiring aortopexia, which was performed thoracoscopically. In 2 patients the thoracoscopic procedure had to be converted to a thoracotomy. All other patients underwent a successful thoracoscopic repair. One patient died in the postoperative period because of sepsis. A total of 22 patients (45%) developed a stenosis in the postoperative follow up (1 month-7y 7 month) requiring 1 to 18 dilatations (mean 1.5). Postoperative leakage occurred in 9 patients (18%). Recurrent fistula was encountered in 2 patients. A total of 11 patients (22%) underwent a laparoscopic antireflux procedure for either recurring stenosis (8) or ALTES (3). Six children (12%) underwent thoracoscopic aortopexy for tracheomalacia. In 2 children symptoms recurred for which a successful repeat thoracoscopic aortopexy was undertaken. The thoracoscopic approach to the treatment of esophageal atresia and tracheomalacia is becoming increasingly accepted. The cosmesis is undoubtedly better. The secundary effects like thoracic cage deformities, winged scapula, or scoliosis have not yet been described and are expected to be reduced in comparison to the open technique. Sequelae like leakage, stenosis, recurrent fistulae, and GERD and ALTES will probably remain the same. Whether thoracoscopic dissection has less detrimental effect on disturbed motility remains to be proven. Thoracoscopic aortopexy for severely symptomatic tracheomalacia is relatively simple. Even repeat thoracoscopic aortopexy is not that difficult. It was immediately effective in 2/3 of the patients.

Thoracoscopic elongation of the esophagus in long gap esophageal atresia

Long gap esophageal atresia in which a primary anastomosis cannot be achieved remains a challenge. Elongation of the esophagus by traction on the 2 ends has been previously described. With the advent of thoracoscopic repair of esophageal atresia, there have thus far been no reports of thoracoscopic repair of long gap esophageal atresia. This paper describes the first successful repair of long gap esophageal atresia by thoracoscopic traction of the 2 esophageal ends and delayed thoracoscopic anastomosis.

Thoracoscopic repair of a type D esophageal atresia in a newborn with complex congenital heart disease

This report describes a case of thoracoscopic repair of esophageal atresia with a rare type D tracheoesophageal fistula in a child with complex congenital heart disease. We demonstrate the feasibility of thoracoscopic repair and anesthetic management in a child with complex congenital heart disease.

The Use of Biosynthetic Mesh to Separate the Anastomoses During the Thoracoscopic Repair of Esophageal Atresia and Tracheoesophageal Fistula

Recurrent tracheoesophageal fistula following the repair of esophageal atresia and tracheoesophageal fistula (EA/TEF) is a difficult complication to manage, which makes prevention the dominant concern of surgeons performing the primary repair. To this end, the surrounding pleural tissues are usually brought over the tracheal closure to prevent the development of a recurrence during the open repair. This maneuver is not usually feasible when using the thoracoscopic approach. Therefore, in this paper, we describe a case in which we interposed a biosynthetic mesh between the esophageal and tracheal suture lines during the thoracoscopic repair of EA/TEF on a 2.9-kg newborn girl.

Minimal Access Surgery in the Neonate

After completing this article, readers should be able to: 1. Review physiologic, anatomic, and technical issues related to minimal access surgery in the neonate. 2. Describe conditions in which minimal access surgery can be used in neonates. Historically, pediatric surgeons were slow to adapt to minimal access surgery (MAS) techniques compared with the adult surgical community. However, MAS now is widely established in infants and children. Differences in size and physiology have necessitated a number of surgical and technological modifications to apply MAS techniques to this population. This review outlines the important differences between children and adults with respect to MAS and provides examples of the use of MAS for diseases seen in infants. ### Physiologic Issues The physiologic response to pneumoperitoneum in children is more pronounced than in adults. Peritoneal insufflation with carbon dioxide has been shown to cause hypercarbia, acidemia, and decreased oxygenation in the pediatric piglet model. (1) In infants, however, there is no detrimental effect on blood pressure, heart rate, or oxygen saturation during short periods of pneumoperitoneum, and elevations in end-tidal CO2 can be counteracted readily by increasing the minute ventilation. (2) Hypercarbia-induced pneumoperitoneum in infants is associated with changes in cerebral blood flow and cardiac output. Nevertheless, laparoscopic procedures have been performed safely with proper anesthetic management in children who have even severe congenital cardiac abnormalities such as hypoplastic left heart syndrome. (3) Hypothermia also can be a concern due to rapid insufflation of unwarmed CO2 gas, mandating the moderation of flow rates. (4) ### Anatomic Issues A number of anatomic factors set children apart from adults and must be accounted for when performing laparoscopic surgery in this age group. Young children and infants have thinner abdominal walls than adults, so extreme care must be exercised when placing trocars. Due to the small size of the abdomen, the working …

Successful Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula in a Newborn with Single Ventricle Physiology

A neonate with VACTERL association including tricuspid atresia was scheduled for thoracoscopic esophageal atresia with tracheoesophageal fistula (EA/TEF) repair and laparoscopic gastrostomy tube placement. In addition to standard noninvasive monitoring, arterial blood pressure, central venous pressure, and cerebral oxygen saturation were monitored. Gastric distension resulting from positive pressure ventilation prevented laparoscopic gastrostomy tube placement. Thoracoscopy with a CO2 insufflation pressure of 6 mm Hg at low flow (1 L/min) was well tolerated hemodynamically despite hypercarbia and cerebral oxygen saturation was maintained. Careful monitoring and good communication were critical to the safe management of this single ventricle patient during thoracoscopic EA/TEF repair. Esophageal and tracheoesophageal fistula in conjunction with single ventricle physiology carries a significant risk of mortality. We present the anesthetic management of a neonate with unpalliated tricuspid atresia who underwent thoracoscopic tracheoesophageal fistula repair.

Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: anesthetic and intensive care management of a series of eight neonates

Advances in minimally invasive techniques have made pediatric laparoscopic surgery commonplace. Thoracoscopic surgery in children however is still performed in only a few centers throughout the world. Between July 2001 and January 2004, the first eight esophageal atresia with tracheoesophageal fistula repairs were performed thoracoscopically at the Royal Hospital for Sick Children in Edinburgh. This article presents their anesthetic management, their postoperative management in the pediatric intensive care unit and reviews the complications seen in both the intraoperative and postoperative periods. Finally we discuss how our experience to date influences our perioperative management of these challenging cases.

Thoracoscopic ligation of a tracheoesophageal H-type fistula in a newborn

An H-type fistula represents the isolated form of tracheoesophageal fistula, and it is relatively uncommon. Conventional thoracotomy is associated with significant late sequelae; scapula alata, scoliosis, and excessive scarring [Konkin DE, O'hali WA, Webber EM, Blair GK. Outcomes in esophageal atresia and tracheoesophageal fistula. J Pediatr Surg 2003;38:1726-9]. Thoracoscopic approaches avoid these consequences. Thoracoscopic repair of esophageal atresia, together with fistula ligation, has been performed earlier [van der Zee DC, Bax NM. Thoracoscopic repair of esophageal atresia with distal fistula. Surg Endosc 2003;17:1065-7]. Thoracoscopic repair of H-type fistula was not attempted before. This is probably because most H-type fistulas are high enough to be accessible through a neck incision. Low fistulas are better approached via the thorax. To our knowledge, this is the first report of a thoracoscopic approach to an H-type tracheoesophageal fistula in a newborn.