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 Table of Contents  
ORIGINAL ARTICLE
Year : 2018  |  Volume : 51  |  Issue : 3  |  Page : 105-110

Thoracoscopic repair of esophageal atresia: Comparison with open approach


1 Department of Surgery, Division of Pediatric Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
2 Department of Surgery, Division of Pediatric Surgery, Mackay Memorial Hospital, Hsinchu, Taiwan
3 Department of Surgery, Division of Pediatric Surgery, Changhua Christian Hospital, Changhua, Taiwan
4 Department of Surgery, Division of Pediatric Surgery, Shuang Ho Hospital; Department of Medicine, School of Medicine, Taipei Medical University, Taipei City, Taiwan

Date of Submission31-Aug-2017
Date of Decision23-Oct-2017
Date of Acceptance02-Jan-2018
Date of Web Publication21-Jun-2018

Correspondence Address:
Dr. Chin-Hung Wei
Division of Pediatric Surgery, Department of Surgery, Shuang Ho Hospital, No.291, Zhongzheng Rd., Zhonghe Dist., New Taipei City 235
Taiwan
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/fjs.fjs_145_17

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  Abstract 

Background: The aim of the present study is to evaluate our initial experiences of thoracoscopic repair (TR) for esophageal atresia with/without trachoesophageal fistula (EA/TEF) and also to compare the results with open repair (OR).
Subjects and Methods: Patients with EA/TEF who received surgeries in our institution between July 2009 and June 2015 were included in the study. The medical records were retrospectively reviewed. Patients are divided into two groups as follows: TR and OR. Parameters collected includes demographics, operation time, conversion, time to oral feeding, length of hospital stay, complications, and growth status.
Statistical Analysis Used: Wilcoxon rank sum test, Chi-square, and Fisher's exact test.
Results: A total of 21 patients with EA/TEF, 19 with type C and 2 with type A, were enrolled. There were 9 and 12 patients in TR and OR groups, respectively. There was no significant difference in demographics between both groups. Median operation time was significantly longer in TR (197.5 vs. 115 min, P < 0.01). The operations were converted in the initial three patients. In the following six patients, only one patient with pure EA required conversion. Median time to oral feeding was significantly longer in TR (12 vs. 7 days, P = 0.04). Anastomotic leakage occurred in three and one patients, respectively (33.3% vs. 8.3%, P = 0.27). Esophageal dilatation was required in 3 (33.3%) and 4 (33.3%) patients for esophageal stenosis in TR and OR groups, respectively (P = 0.999). Fundoplication was required in 2 (22.2%) and 3 (25%) patients of TR and OR groups, respectively (P = 1.00). Recurrent TEF developed in one patient (11.1%) of TR. The bodyweight fell behind 3 percentiles of the growth curve in 6 (66.7%) and 6 (50%) patients (P = 0.660).
Conclusions: TR for EA/TEF is feasible. The initial experiences revealed longer operation time and higher complication rate compared to OR.

Keywords: Esophageal atresia, tracheoesophageal fistula, esophageal dysmotility, thoracoscopy


How to cite this article:
Lin CH, Duh YC, Fu YW, Hsu YJ, Wei CH. Thoracoscopic repair of esophageal atresia: Comparison with open approach. Formos J Surg 2018;51:105-10

How to cite this URL:
Lin CH, Duh YC, Fu YW, Hsu YJ, Wei CH. Thoracoscopic repair of esophageal atresia: Comparison with open approach. Formos J Surg [serial online] 2018 [cited 2018 Nov 18];51:105-10. Available from: http://www.e-fjs.org/text.asp?2018/51/3/105/234877


  Introduction Top


Esophageal atresia with or without tracheoesophageal atresia (EA/TEF) is a congenital malformation with the incidence of 1/4000 live births.[1] These patients generally present with feeding intolerance, respiratory distress, or failure to pass an orogastric tube shortly after birth. It can be either an isolated defect or associated with VACTERL syndrome. Relatively, emergent surgical intervention within 48 h after birth is required to prevent aspiration of saliva or reflux gastric acid.

Since the first successful repair was achieved in 1944,[2] thoracotomy had become a standard approach. With the development of thoracoscopy for pediatric thoracic diseases, delayed thoracoscopic repair (TR) was first accomplished in a 2-month-old infant with an isolated EA in 1999.[3] Rothenberg then performed this technique primarily in newborns.[4]

Since 2009, attempts were made to perform TR for EA/TEF in our institution. The aim of this study was to evaluate the safety and efficacy of TR of EA/TEF as well as compare the results with open repair (OR).


  Subjects and Methods Top


Between July 2009 and June 2015, patients who underwent EA/TEF repair were enrolled in the study. The medical records were retrospectively reviewed. Patients were divided into two groups based on the surgical approach, TR and OR. The selection of the surgical approach was based on surgeons' preference. Parameters collected included demographics, operation time, TR conversion to OR, time to oral feeding, length of hospital stay (LOS), complications, and bodyweight percentile in the latest follow-up.

Postoperative care and monitoring were conducted in the neonatal intensive care unit. The timing of weaning and extubation depended on the postoperative course of individual patients. Esophagogram was arranged on the postoperative day 7th–10th. After confirmation of esophageal continuity, enteral feeding was started and the chest tube was removed.

Surgical techniques

Thoracoscopic repair

Patients were placed at left semiprone position to allow lung retracted away from posterior mediastinum by gravity. A 5 mm port for the telescope was placed at 1 cm below the tip of the scapula. Two cannulas (3–5 mm) were placed at the 4th and 6th intercostal space along the middle axillary line. Insufflation of carbon dioxide (CO2) was initiated with 0.5–2 L/min to collapse with the intrathoracic pressure between 3 and 5 mmHg. The azygos vein was cauterized. The TEF was ligated with clips or sutures and then divided. The proximal pouch was identified with the guidance of a Fr. 6 or 8 feeding tube. It was fully mobilized to decrease the tension of anastomosis. Esophagoesophagostomy was fulfilled with interrupted sutures. After the posterior wall was repaired, the feeding tube was advanced through the proximal esophagus down to the distal esophagus, and finally into the stomach. The anterior wall was then repaired. A chest tube was inserted into the tip adjacent to the anastomosis.

Open repair

The extrapleural approach was undertaken through right lateral thoracotomy at the 4th intercostal space. The TEF was double ligated. After mobilization of the proximal and distal esophagus, the anastomosis was carried out in an interrupted fashion. A chest tube is placed extrapleurally with the tip adjacent to the anastomosis.

Statistics

Continuous variables were expressed as median (minimum-maximum). Categorical variables were expressed as numbers (percentage). Wilcoxon rank sum test was used to compare continuous variables. Chi-square and Fisher's exact test were used for categorical variables. Statistical analysis was accomplished with IBM ® SPSS statistics 20.0. The value of P < 0.05 represents statistical significance.

Ethical approval

The study was conducted in accordance with the Declaration of Helsinki and was approved by the local ethics committee of the institute.


  Results Top


A total of 21 patients, 19 patients with type C and 2 patients with type A, were enrolled in this study. There were 12 and 9 patients who underwent OR and TR groups, respectively. [Table 1] shows the demographics of the patients. The median gestational age was 37 weeks (range: 36–39 weeks) and 36.5 weeks (range: 32–40 weeks) in TR and OR groups, respectively (P = 0.43). The median weight was 2.5 kg (range: 2.1–2.8 kg) and 2.4 kg (range: 1.6–3.1 kg) in TR and OR groups, respectively (P = 0.50). Gender distribution was similar in both groups (P = 0.68). The median age of operation was 1 day in both TR and OR groups (range: 1–3 days, P = 0.41). With regard to the associated abnormalities, there were 4 (44%) and 6 (50%) patients with tracheomalacia in TR and OR groups, respectively (P = 1.0). There were 2 (22%) and 4 (33.3%) patients with concomitant anorectal malformations, respectively (P = 0.44). A high incidence of congenital heart disease was similarly observed in both groups (55.6% vs. 66.7%, P = 0.83).
Table 1: Patient demographic data

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[Table 2] shows the detail of operations. The median esophageal gap was 1 cm in both groups (P = 0.999). The median operation time was 197.5 min (range: 125–240 min) and 115 min (range: 70–240 min) in TR and OR groups, respectively (P = 0.001) [Table 3]. [Figure 1] illustrates the operation time of each patient in TR. Conversion to OR was required in four patients. The first conversion was due to azygos vein tearing and bleeding. The second conversion was due to failed one-lung ventilation. In the third patient, it was due to intraoperative lung parenchymal injury and incapability of maintaining one-lung ventilation. In the last patient with a long-gap pure EA after thoracoscopic Foker's procedure, it was converted for the intense tension of anastomosis.
Table 2: Comparison of operation data (thoracoscopic repair versus open repair)

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Table 3: Comparison of postoperative clinical data

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Figure 1: The serial operation time of thoracoscopic repair. Black dots represent type C EA/TEF. Black triangles represent type A pure EA. Arrow heads indicates conversions

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Postoperative pneumothorax occurred in 7 (77.8%) and 6 (50%) patients in TR and OR groups, respectively (P = 0.367). A second chest tube was needed in 4 (44.4%) and 1 (8.3%) patients, respectively (P = 0.119). Anastomotic leakage occurred in 3 (33.3%) patients in TR and 1 (8.3%) patient in OR (P = 0.272). Leakage was resolved with conservative treatment in all patients. The median time to oral feeding was significantly longer in TR (12 days, range: 6–43 days) than in OR (7 days, range: 4–16 days) (P = 0.041). The median LOS was 35 days (range: 18–80 days) and 35 days (range: 12–196 days) in TR and OR groups, respectively (P = 0.808). Endoscopic esophageal dilatation was required in 3 (33.3%) and 4 (33.3%) patients with esophageal stenosis in TR and OR groups, respectively (P = 0.999). Recurrent TEF developed in one patient of TR, who was treated with bronchoscopic ablation and occlusion. Four (44.4%) and six (50%) patients in TR and OR were diagnosed with gastroesophageal reflux, respectively (P = 0.999). One half of these patients received fundoplication. A gastrostomy tube had been placed in 2 (22.2%) and 3 (25%) patients of TR and OR, respectively (P = 0.999). The bodyweight fell behind 3 percentiles of the growth curve in 6 (66.7%) and 6 (50%) patients of TR and OR, respectively, (P = 0.660). The median follow-up duration was 16 months (range: 12–19 months) and 34.5 months (range: 9–63 months), respectively (P = 0.139).

[Table 4] compares the outcomes of the present study with the literature.[5],[6],[7],[8] The conversion rate and anastomotic leakage are apparently higher in this study. The birth bodyweight and gestational age are fairly similar to the literature. The operation time is comparable. Our results reveal higher complication rate, such as anastomotic leakage and recurrent TEF. Fundoplication is required in 22.2% of our patients which is similar to the experience from other institutions.
Table 4: Comparison with the literature

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  Discussion Top


EA/TEF has been the most known congenital malformation of esophagus. Early back to 1703, Thomas Gibson first depicted an infant with EA/TEF.[9] However, it had been centuries with no documentation in the regard of surgical repair. In 1936, Thomas Lanman performed the first case of the primary extrapleural anastomosis, but the infant died in a few hours.[10] It continued to be uniformly fatal until the 1940s when the survivors after repair were reported by Leven and Ladd.[11],[12] Later on, the survival rate has been continuously increasing to more than 90%.[13],[14],[15] The results reflect the advancement in neonatal intensive care, nutritional support, and improvement of anesthetic and surgical management.

With the advent of minimally invasive techniques, thoracoscopic surgery has been utilized in a variety of pediatric diseases. Thoracoscopy for EA/TEF has also become popular in many pediatric centers. It provides excellent visualization of posterior mediastinal structures. In addition to better cosmesis, it spares intercostal muscle from trauma by thoracotomy and also prevents the consequence of rib fusion and scoliosis.[8] Wing scapula caused by long thoracic nerve injury during thoracotomy is also evitable by thoracoscopy.

Although the thoracoscopic approach is increasingly adapted for EA/TEF,[16],[17] it requires meticulous techniques since the working space in newborn's hemithorax is extremely small. During the early period of the learning curve, patient selection is essential for successful operations. Some authors put efforts to identify the risk factors for TR. Low birthweight, congenital heart disease, long gap length, and compromised physiologic status were considered to be common exclusion criteria. The cutoff value of bodyweight varies from 1.5 to 3.0 kg based on the surgeon's expertise.[18],[19] In our experiences, a normally-weighted infant without major congenital heart diseases is an appropriate candidate so that there will be a larger working space and better tolerance for hypercapnia. With the accumulation of experiences, the patient selection criteria can be widened. The bottom line of weight limit can be down to 2000 g in our practices.

In TR of EA/TEF, every detail from preoperative to intraoperative settings matters remarkably. The unnecessary mechanical respirator should be avoided before operations. Positive pressure pumps air into the stomach through TEF. Distended abdomen impairs one-lung ventilation during operations. Port arrangement in a triangular fashion prevents instruments fighting each other. A 5 mm cannula is preferred to the inferior working port that facilitates the utility of 5 mm clips or hemlocks and the passage of needles. The size of the wound is also appropriate for a Fr. 12 chest tube. A three-quarters prone position allows the lung to automatically fall away from the posterior mediastinum by gravity. With such positioning, surgeons can directly look down to the esophagus and work behind the majority of the lung rather than over it, which leads to very little, if any, manipulation to the lung. Collaboration between two experienced endoscopic surgeons is helpful to eliminate the stress and increase the success rate, particularly during the very first few attempts.

Due to the necessity of CO2 insufflation to compress the lung, hypercapnia is almost inevitable. High-frequency ventilation up to 100–150 times/min with handbagging is sometimes necessary to wash out CO2. Continuous communication between the surgeon and anesthesiologist is imperative during operations. The leading causes of conversion are respiratory distress and failed respiratory adaptation. The decision of conversion should be made interdisciplinarily. Surgeons should not hesitate about converting operations when encountering surgical obstacles. Delay in conversion may result in serious consequences. Even with conversions, surgeons learn lessons to overcome the difficulty in the upcoming patients. With gaining experiences from the first three patients, none of the thoracoscopic procedures thereafter was converted to the open approach except a patient with pure EA and a long gap. A decline in operation time during the entire period has been observed.

Although it does not reach statistical significance, there is a relatively higher chance of postoperative pneumothorax and placement of the 2nd chest tube in TR group. It may be because the intrapleural procedure of TR damages the visceral pleura and causes visually undetectable air leakage. Moreover, the small caliber of a Fr. 8 chest tube is easily occluded by the surrounding tissues or discharge. Therefore, surgeons should be extremely gentle to avoid excessive manipulation. Pneumothorax occurred more often in the early few cases with a Fr. 8 chest tube. A Fr. 12 chest tube is helpful to provide better drainage and prevent pneumothorax in the later patients.

The postoperative gastroesophageal functional disorder is a major concern for EA/TEF. It may cause dysphagia, reflux, recurrent strictures, and failure to thrive. However, it has been frequently neglected and also underestimated. Those symptoms are considered to be secondary to intrinsic motor dysfunction of the esophagus. A recent study demonstrated that extremely high percentage of patients had been proven to have esophageal dysmotility and deteriorate with age.[20] Swallow difficulty also occurred in 60% of patients in a variety of degrees. Other retrospective studies revealed that esophageal dysfunction occurs regardless of the type of repair and adversely affect the quality of life.[21] In this current series, more than a half of the patients in both TR and OR groups equally had poor weight gain that fell behind 3 percentiles of the growth curve. Twenty-two percent of patients required an anti-reflux procedure during childhood. The results implicate the clinical significance of esophageal dysmotility. The problems that can persist into adulthood are under-reported.[22],[23],[24],[25]

The comparison with the literature shows the existence of learning curve. Despite the conversion diminished in the last few patients and the operation time has been comparable to the literature, it appears that the occurrence of leakage and recurrent TEF seems higher. According to the literature, when surpassing the learning curve, the leakage rate can decrease down close to open approach.


  Conclusions Top


Thoracoscopic approach for EA/TEF is technically feasible. Despite the complication rate is relatively higher compared to the open approach in our early experiences, it can be improved with more experiences. Long-term follow-up is essential for gastroesophageal functional disorder regardless of the operations that the patients receive.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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