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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