Thoracoscopic Repair of Esophageal Atresia with Tracheoesophageal Fistula George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital Kansas City, Missouri
Thoracoscopic Repair of Esophageal Atresia with
Tracheoesophageal Fistula
George W. Holcomb, III, M.D., MBAChildren’s Mercy Hospital
Kansas City, Missouri
EA/TEFHistory
Before 1670 Pre-recognition Era
1670 - 1939 Pre-survival Era
1939 Survival Era
1970 Salvage Era
EA/TEFHistory
1941
Haight, Ann Arbor: March 15
Left extrapleural approach
Single layer anastomosis
Leak/stricture/single dilation
Esophageal Atresia
Rat Model of Esophageal Atresia/ Tracheoesophageal Fistula
E14 TEF-AP E14 TEF-Lateral
Fistula originates as a bud from the lung as a trifurcation
Fistula
E12 Trifurcation
Neonatal fistula tract expresses a respiratory lineage molecule
E13 TEF whole mount for TTF1
TTF1 in e19 TEF
J Pediatr Surg 37:1065-1067, 2002J Pediatr Surg 37:1065-1067, 2002
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
EA/TEF
Waterston Spitz113 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, orsevere anomaly(6% survival) (71% survival)
EA/TEFNew 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)
Postoperative Problems
• GER: 40% (20% require fundoplication)• Mgmt: treat aggressively postoperatively
partial vs complete fundoplication
• Tracheomalacia: 10% symptomatic (<5% require aortopexy)
Thoracoscopic Repair EA/TEF
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, 2005American Surgical Association, 2005
Ann Surg 242:422-430, 2005Ann Surg 242:422-430, 2005
Thoracoscopic Repair EA/TEFInstitution Location Authors
Children’s Mercy Hospital Kansas City, MO Holcomb, Ostlie
Hospital for Infants and Children at Presbyterian-St. Luke’s Medical Center
Denver, CO Rothenberg
Wilhelmina Children’s Hospital
Utrecht, The Netherlands
Bax, van der Zee
J.P. Garrahan National Children’s Hospital
Buenos Aires, Argentina
Martinez-Ferro
Lucille Packard Children’s Hospital
Palo Alto, CA Albanese
Chinese University of Hong Kong
Hong Kong, China Yeung
Thoracoscopic Repair EA/TEF
• Retrospective study
• Six international centers
• 2000 – 2004
• 104 Pts
Thoracoscopic Repair EA/TEF104 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)Cardiac Renal
ASD/VSD 15 Horseshoe kidney 3 Right aortic arch 6 Unilateral agenesis 2 Tetralogy of Fallot 3 Crossed fused ectopia 1 Dextrocardia 3 VUR > Grade 3 1 PDA (ligation) 2 Duplex kidney 1 DORV 1 Ectopic kidney 1 Tricuspid atresia 1
Gastrointestinal Other
High imperforate anus 7 Vertebral anomalies 6 Duodenal atresia 4 Radial aplasia 3 Low imperforate anus 3 Tethered cord 1 Cloaca 1 Hydromyelia 1 Choanal atresia 1
Syndromes
VACTERL (>2 anomalies) 10
CHARGE 3 Down 3
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 Arch
6 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 Open
5 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 problemsWaterston B: 4-5.5 lbs. or higher weight with moderate pneumonia or congenital anomalyWaterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly
Waterston A 62 Patients
Waterston B 30 Patients
Waterston C 12 Patients
Operation converted 2 2 1
Operation staged 1 - -
Esophageal anastomotic leak 2 3 3
Stricture (on initial esophagram) 3 1 -
Patients needing only 1 dilation 7 5 -
Patients needing 2 dilations 9 1 2
Patients needing 3 dilations - 3 1
Patients needing >3 dilations 3 2 -
Recurrent tracheoesophageal fistula 1 1 -
Fundoplication 19 6 1
Imperforate anus operations 4 4 2
Duodenal atresia repairs - 2 2
Aortopexy 6 1 -
Death 1 - 2
Thoracoscopic Repair EA/TEF
N.R.: Not reportedA: 87% are Gross Type CB: Stricture is defined as a significant narrowing on the initial esophagramC: Stricture in this paper is defined as requiring > 4 dilationsD: Stricture in this paper is defined as requiring > 2 dilations
Current Engum, et al (1971-93)
Spitz, Kelly (1980-84)
Randolph, et al (1982-88)
Manning, et al (1977-85)
Number of Patients
104 174 148A
39 63
Mean length of hospitalization (days)
18.1
(6-120)
N.R. N.R. N.R. 24 (9-174)
Anastomotic leak 7.6% N.R. 21% 10.2% 17%
Anastomotic stricture
3.8%B
32.7%C
17.7% 33.3% 4.3%D
Patients requiring at least 1 dilation
31.7% 32.7% N.R. 33.3% N.R.
Anastomotic revision
1.9% 0.9% 2.7% 5.1% N.R.
Fundoplication 24.0% 25.2% 18% 15.3% 16.9%
Aortopexy 6.7% N.R. 16% N.R. 4.7%
Mortality Related EA/TEF Not Related
0.9% 1.9% 2.8%
4.5% (overall)
14.8% (overall)
0% 7.6% 7.6%
3.1% 11.1% 14.2%
Recurrent fistula 1.9% 2.2% 12% 5.1% 6.4%
Preoperative Bronchoscopy
Preoperative Bronchoscopy
Patient Position
Port/Instrument Positions
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, 2006AAP, 2006
Absorbable (N=62) Mean
+/- Standard Error
Non-Absorbable (N=32) Mean +/-
Standard Error
P-
Value Estimated Gestational Age at Birth (Weeks)
36.4 +/- 0.6 36.7 +/- 0.4 0.64
Weight at Repair (kg) 2.50 +/- 0.13 2.63 +/- 0.09 0.87
Age at Repair (days) 5.3 +/- 2.0 3.2 +/- 0.6 0.21
Congenital anomaly 53% 48% 0.43
Gender (% Male) 59% 61% 0.51
Suture Size 5.66 +/- 0.09 5.20 +/- 0.10 0.003
Leak (%) 3.1% 4.8% 0.82
Sticture (%) 37.5% 45.2% 0.47
Number of dilations (per patient with stricture)
3.4 +/- 1.0 2.4 +/- 0.3 0.21
Impact Of Suture MaterialCMH
AAP, 2006AAP, 2006
• There is no difference in leak rates based on suture material or size
• Suture material or type has no effect on stricture formation
Impact Of Suture MaterialCMH
AAP, 2006AAP, 2006
EA/TEFOperative Approach
Thoracoscopy Thoracotomy
• Transpleural • Extrapleural
• Longer operative time • Shorter operative time
• Better visualization • Adequate visualization
• Anesthesia important • Anesthesia standard
EA/TEF
• Evolution of technology?
• Shorter operative time?
• Reduced hospitalization?
• Reduced short term morbidity?
• Reduced long term morbidity?
Why Thoracoscopy?
EA/TEF
89 pts/16 yrs
• shoulder elevation: 24%
• chest deformity: 20%
• abduction limited: 100%
• spine deformities: 18%
• breast deformities: 27% (3/11)
Why Thoracoscopy?
Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy Jaureguizar E, et al: Morbid musculoskeletal sequelae of thoracotomy for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985for tracheo-esophageal fistula. J Pediatr Surg 20: 511-514, 1985
Musculoskeletal Morbidity Following Thoracotomy for EA/TEF
1. Durning RP, et al: J Bone Joint Surg AM 62:1156, 1980
2. Gilsanz V, et al: Am J Roentgenol 141:457, 1983
3. Chetcuti P, et al: J Pediatr Surg 24: 244, 1989
4. Goodman P, et al: J Comput Assist Tomogr 17:63, 1993
5. Frola C, et al: Am J Roentgenol 164: 599, 1995
6. 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/TEFConcerns With Thoracoscopy
• Clip ligation/migration recurrent
TEF
• Transpleural route
• Anesthesia issues
Thoracoscopic Repair EA/TEF
• Surgisis placed b/w
esophagus & tracheal
suture line to help
prevent recurrent TEF
J LAST 17:380-382, 2007J LAST 17:380-382, 2007
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
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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