1. 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

2. Esophageal Atresia

3. 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

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

5. 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

6. Thoracoscopic Repair EA/TEF

7. 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: , 2005

8. 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

9. Thoracoscopic Repair EA/TEF
Retrospective study
Six international centers
2000 – 2004
104 Pts

10. Thoracoscopic Repair EA/TEF (104 Patients)
Tracheal intubation
º prone position
3 ports (99 pts)
4 ports (5 pts)
CO2 insufflation used

11. Thoracoscopic Repair EA/TEF (104 Patients)
Fistula Ligation
37 pts: suture ligation
67 pts: clip ligation

12. 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

13. Thoracoscopic Repair EA/TEF Results (104 Patients)
Mean Age (days) (± 1.1)
Mean Wt (kg) (± 0.5)
Mean Operative Time (min) (± 55.5)
Mean Days Ventilation (± 5.8)
Mean Hospitalization (days) (± 18.6)

14. Thoracoscopic Repair EA/TEF Associated Anomalies (104 Patients)

15. 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)

16. 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

17. 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

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

19. 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

20. Thoracoscopic Repair EA/TEF 104 Patients
Waterston A: > 5.5 lb with no significant associated problems
Waterston B: lbs. or higher weight with moderate pneumonia or congenital anomaly
Waterston C: weight < 4 lb or higher weight with severe pneumonia or congenital anomaly

21. 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

22. Preoperative Bronchoscopy

23. Patient Position

24. Port/Instrument Positions

25. 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

26. Impact Of Suture Material CMH
AAP, 2006

27. 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

28. 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

29. 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: , 1985

30. 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

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

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

33. Second TE Fistula

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

35. Tips/Tricks
Oscillating ventilator
U-clips anterior anastomosis

36. How To Get Started Not The Ideal Casekg
Very high upper pouch
Complex single ventricle physiology
Prostaglandin dependent

37. How To Get Started Ideal Case
Baby – kg; no other anomalies
Esophageal segments close together (CXR, Bronchoscopy)
Start thoracoscopically – Go as far as comfortable
Try it again

38. 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

39. QUESTIONS