George W. Holcomb, III, M.D., MBA Children’s Mercy Hospital 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 Deficiency of tracheal cartilage 50% have 1 or more associated anomalies: cardiac, anorectal, GU, vertebral/skeletal, others

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

EA/TEF Preoperative 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

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, 2005 Ann Surg 242:422-430, 2005

Thoracoscopic Repair EA/TEF Institution 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/TEF (104 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/TEF Results (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/TEF Associated Anomalies (104 Patients)

Thoracoscopic Repair EA/TEF Results (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/TEF Complications (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/TEF Right 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/TEF Staged Operation 1 pt: long gap – thoracoscopic ligation 3 mos later – repair via thoracotomy (2 myotomies needed)

Thoracoscopic Repair EA/TEF Conversion 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/TEF 104 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

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

Preoperative Bronchoscopy

Patient Position

Port/Instrument Positions

Impact Of Suture Material CMH 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

Impact Of Suture Material CMH AAP, 2006

Impact Of Suture Material CMH 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

Thoracoscopy Thoracotomy EA/TEF Operative Approach Thoracoscopy Thoracotomy Transpleural Extrapleural/Transpleural Longer operative time Shorter operative time Better visualization Adequate visualization Anesthesia important Anesthesia standard

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

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

Thoracoscopic Repair EA/TEF Advantages of Thoracoscopy Avoidance of musculoskeletal sequelae Superior visualization of anatomy Easy to identify fistula for ligation

Thoracoscopic Repair EA/TEF Fistula Ligation Metal clip Weck clip Tie (x2 ?) Suture ligature (x2 ?) Suture closure – tracheal side

Second TE Fistula

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

Tips/Tricks Oscillating ventilator U-clips anterior anastomosis

How To Get Started Not The Ideal Case 2 - 2.5 kg Very high upper pouch Complex single ventricle physiology Prostaglandin dependent

How To Get Started Ideal 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

Thoracoscopic Repair EA/TEF Summary 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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