Transcript Slide 1

Thoracoscopic Repair of
Esophageal Atresia with
Tracheoesophageal Fistula
George W. Holcomb, III, M.D., MBA
Children’s Mercy Hospital
Kansas City, Missouri
EA/TEF
History
Before 1670
Pre-recognition Era
1670 - 1939
Pre-survival Era
1939
Survival Era
1970
Salvage Era
EA/TEF
History
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, 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
Spitz
113 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, or
severe anomaly
(6% survival)
(71% survival)
EA/TEF
New 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, 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)
Mean Days Ventilation
Mean Hospitalization (days)
129.9 (± 55.5)
3.6 (± 5.8)
18.1 (± 18.6)
Thoracoscopic Repair EA/TEF
Associated Anomalies
(104 Patients)
Cardiac
ASD/VSD
Right aortic arch
Tetralogy of Fallot
Dextrocardia
PDA (ligation)
DORV
Tricuspid atresia
Gastrointestinal
High imperforate anus
Duodenal atresia
Low imperforate anus
Cloaca
Syndromes
VACTERL (>2 anomalies)
CHARGE
Down
15
6
3
3
2
1
1
7
4
3
1
10
3
3
Renal
Horseshoe kidney
Unilateral agenesis
Crossed fused ectopia
VUR > Grade 3
Duplex kidney
Ectopic kidney
3
2
1
1
1
1
Other
Vertebral anomalies
Radial aplasia
Tethered cord
Hydromyelia
Choanal atresia
6
3
1
1
1
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
( other than VSD/ASD)
5
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
to L thoracoscopy
3
• Conversion from R thoracoscopy
to L open
1
• 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
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
Patients needing 3 dilations
9
-
1
3
2
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
Death
6
1
1
-
2
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
Current
Number of
Patients
Mean length of
hospitalization
(days)
Anastomotic leak
Anastomotic
stricture
Patients requiring
at least 1 dilation
Anastomotic
revision
Fundoplication
Aortopexy
Mortality Related
EA/TEF
Not Related
Recurrent fistula
N.R.:
A:
B:
C:
D:
Engum, et al
(1971-93)
174
Spitz, Kelly
(1980-84)
18.1
(6-120)
N.R.
7.6%
N.R.
104
B
3.8%
C
32.7%
Randolph, et al
(1982-88)
39
Manning, et al
(1977-85)
63
N.R.
N.R.
24
(9-174)
21%
10.2%
17%
17.7%
33.3%
4.3%
148
A
D
31.7%
32.7%
N.R.
33.3%
N.R.
1.9%
0.9%
2.7%
5.1%
N.R.
24.0%
6.7%
25.2%
N.R.
18%
16%
15.3%
N.R.
16.9%
4.7%
0.9%
1.9%
2.8%
1.9%
4.5%
(overall)
14.8%
(overall)
2.2%
12%
0%
7.6%
7.6%
5.1%
3.1%
11.1%
14.2%
6.4%
Not reported
87% are Gross Type C
Stricture is defined as a significant narrowing on the initial esophagram
Stricture in this paper is defined as requiring > 4 dilations
Stricture in this paper is defined as requiring > 2 dilations
Preoperative Bronchoscopy
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
Absorbable
(N=62) Mean
Non-Absorbable
(N=32) Mean +/-
+/- Standard Error
Standard Error
36.4 +/- 0.6
36.7 +/- 0.4
PValue
0.64
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
5.66 +/- 0.09
5.20 +/- 0.10
0.003
Leak (%)
3.1%
4.8%
0.82
Sticture (%)
37.5%
45.2%
0.47
3.4 +/- 1.0
2.4 +/- 0.3
0.21
Estimated Gestational Age at Birth
(Weeks)
Weight at Repair (kg)
Suture Size
Number of dilations (per patient with
stricture)
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
EA/TEF
Operative Approach
Thoracoscopy
Thoracotomy
• Transpleural
• Extrapleural
• Longer operative time
• Shorter operative time
• Better visualization
• Adequate visualization
• Anesthesia important
• Anesthesia standard
EA/TEF
Why Thoracoscopy?
• Evolution of technology?
• Shorter operative time?
• Reduced hospitalization?
• Reduced short term morbidity?
• Reduced long term morbidity?
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
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/TEF
Advantages of Thoracoscopy
• Avoidance of
musculoskeletal sequelae
• Superior visualization of
anatomy
• Easy to identify fistula for
ligation
Thoracoscopic Repair EA/TEF
Concerns With Thoracoscopy
• Clip ligation/migration
• Transpleural route
• Anesthesia issues
recurrent TEF
Thoracoscopic Repair EA/TEF
• Surgisis placed b/w
esophagus & tracheal
suture line to help
prevent recurrent TEF
J LAST 17:380-382, 2007
How To Get Started
Ideal 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/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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