|Year : 2016 | Volume
| Issue : 3 | Page : 120-124
Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: Basics of technique and its nuances
Ravi Prakash Kanojia1, Neerja Bhardwaj2, Deepak Dwivedi2, Raj Kumar2, Saajan Joshi2, Ram Samujh1, K. L. N. Rao1
1 Department of Pediatric Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
2 Department of Anesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research, Chandigarh, India
|Date of Web Publication||18-May-2016|
Ravi Prakash Kanojia
Block 3A, Advanced Pediatric Center, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh - 160 012
Source of Support: None, Conflict of Interest: None
| Abstract|| |
Aim: To review the technique of thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (TREAT) and results reported in literature and with authors' experience. Patients and Methods: The technique of TREAT was reviewed in detail with evaluation in patients treated at authors' institution. The patients were selected based on selection criteria and were followed postoperatively. The results available in literature were also reviewed. Results: A total of 29 patients (8 females) were operated by TREAT. Mean age was 2.8 days (range 2-6 days). Mean weight was 2.6 kg (range 1.8-3.2 kg). There was a leak in four patients, and two patients had to be diverted. They are now awaiting definitive repair. Twenty-one patients have completed a mean follow-up of 1.5 years and are doing well except for two patients who had a stricture and underwent serial esophageal dilatations. The results from current literature are provided in tabulated form. Conclusions: TREAT is now a well-established procedure and currently is the preferred approach wherever feasible. The avoidance of thoracotomy is a major advantage to the newborn and is proven to benefit the recovery in the postoperative patient. The technique demonstrated, and the tweaks reported make the procedure easy and is helpful to beginners. The outcome is very much comparable to the open repair as proven by various series. Various parameters like leak rate, anastomotic stricture are the same. The outcome is comparable if you TREAT these babies well.
Keywords: Esophageal atresia, neonatal laparoscopy, thoracoscopy, tracheoesophageal fistula
|How to cite this article:|
Kanojia RP, Bhardwaj N, Dwivedi D, Kumar R, Joshi S, Samujh R, Rao K. Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: Basics of technique and its nuances. J Indian Assoc Pediatr Surg 2016;21:120-4
|How to cite this URL:|
Kanojia RP, Bhardwaj N, Dwivedi D, Kumar R, Joshi S, Samujh R, Rao K. Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: Basics of technique and its nuances. J Indian Assoc Pediatr Surg [serial online] 2016 [cited 2018 Apr 23];21:120-4. Available from: http://www.jiaps.com/text.asp?2016/21/3/120/182585
| Introduction|| |
Repair of esophageal atresia with tracheoesophageal fistula (EA-TEF) is the epitome of neonatal surgery. We have read this statement in almost every textbook of pediatric surgery and stand true in its meaning. The open EA-TEF repair is a test of surgical skills of a pediatric surgeon. The postoperative management is also considered a test of standards of neonatal care. In the current era of laparoscopic surgery with the advent of smaller size instruments, the repair of this complex anomaly is now practiced by minimal access surgery and is the current state of the art.  The thoracoscopic repair of esophageal atresia with tracheoesophageal fistula (TREAT) is now being practiced at various centers across the world and India is not far behind. The series reported so far [Table 1] have shown the feasibility and comparable (even better) results with the open technique. The present discussion will try to outline the basics of the technique and some of the practical details which can help a pediatric minimal access surgeon to adopt the technique. The paper also reviews the results available in literature including authors' experience.
|Table 1: Summation of major series reported in literature for thoracoscopic repair of esophageal atresia with tracheoesophageal fistula|
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| The technique|| |
Timing, patient selection, and preparation
If the condition is detected at birth within the first few hours, the initial management is same as one would prepare for open repair. Similarly, the patients presenting late will need preoperative stabilization and some basic investigations. This will include routine hematological investigations and imaging. The imaging will be chest and abdomen X-ray to see the level of upper pouch. The patient selection largely depends on three factors weight, overall general condition and the level of upper pouch. In general, low birth weight, septic babies tend to tolerate hypercarbia, and hypoxia very poorly and do not sustain the longer duration of the procedure hence are less suitable. Similarly, the long gap atresias with gap more than vertebral length are difficult to handle at the time of anastomosis laparoscopically, and we have avoided such scenarios in the early part of our experience. A known cardiac abnormality is another relative contraindication to this procedure as it is with any other laparoscopic procedure due to issues related to oxygenation during anesthesia. Right aortic arch is one such anomaly where the anatomy is distorted, and it is difficult to manoeuvre around in small space and is difficult to accomplish thoracoscopically.
Positioning and anesthetic and ventilation strategy
The patient is positioned in similar manner as in open surgery. There is minimal rolling of the table to make the patient somewhat semi-prone and closer to surgeon and on left edge of table [Figure 1]. There will be a preplaced upper pouch identification tube before draping. The intubation is done in a way that the ET tube bevel is away from the fistula. We have used the technique of lung isolation using the Fogarty balloon occlusion. It works well and acts as an on-off switch for the right lung. The Fogarty placement is done by bronchoscopy and the occluding balloon is placed under vision [Figure 2]. The preoperative bronchoscopy although adds time to the entire procedure also gives added information on the level of fistula. Some surgeons prefer to place a guide wire to be sure of fistula identification during thoracoscopy, though this is not our practice.
|Figure 1: Patient position on the left edge of table with surface markings and port sites|
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|Figure 2: Fogarty balloon placed bronchoscopically occluding the right bronchus|
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Ports and instrumentation
The ports used are 5 + 3 + 3. The first optical port is planned as per the surface anatomy after positioning the patient [Figure 1]. The surgeon has to see the triangulation is perfect because in an infant every millimeter of space will make a large difference. The port positions are shown in [Figure 1]. The 5 mm port is placed by open method somewhere near the anterior axillary line close to the lower chest so that there is leverage to move in and out. The target is to align the scope with the transverse fissure to avoid lung lobes occluding the view. The subsequent two ports are then placed by seeing the anatomy from inside trying to space out and triangulate. The right-hand port usually lands below and medial to the tip of the angle of scapula. The 3 mm instruments used are the hook, Maryland, bowel grasper, and fine scissors.
| Steps|| |
Identification of regional anatomy
Once inside the lung is made to collapse with gentle pressure by instruments by pressing them and by 4-6 mm of intrathoracic pressure. The major landmarks identified are the azygos vein, vagus nerve [Figure 3]. The subclavian at the apical area. If not known before the surgeon will be able to see the right aortic arch if present at this time. The anesthetist then pushes the upper pouch with the preplaced feeding tube helping to identify the position and distance; this then decides the pace of the procedure because now you know the exact gap distance.
| Control of Fistula - The Esophageal Hitch|| |
The endothoracic fascia is incised to identify the medially curving lower pouch with the vagus nerve overlying it. This is precisely found below the azygos and easily identified with the expansile impulse synchronized with ventilation. The lower pouch fistula is then gently grasped with the nontraumatic bowel grasper and dissected preserving the vagus nerve. We prefer to gently hitch the fistula with a 4/0 prolene to the chest wall. This serves two purposes. It keeps the left hand free for aiding in dissection and also prevents air going down to the stomach through the fistula. The fistula once hitched shows the T-junction with the trachea precisely, and this can now be transfixed just the way it is done in open surgery. Once the fistula is transfixed we do not divide it at the same time as it will retract and fall away towards diaphragm, rather the hitch stitch is now relaxed, and the surgeon now concentrates on the upper pouch.
| Dissecting the upper pouch and its mobilisation|| |
While an anesthetist is probing the oro-pouch tube from above, the upper pouch is identified, and the fascia above it is incised with hook. The upper pouch is now gently grabbed in the nontraumatic bowel grasper and lifted up. The crucial part of dissection lies in the medial aspect where the upper pouch is to be separated from the trachea. This dissection is sharp, and a good scissor is a great asset for this step. The upper pouch is mobilized all around to gain length and at the same time, a rare upper pouch fistula is ruled out. Once mobilized the pouch is opened with an oblique cut and the two ends are now prepared for anastomosis. It is at this point, the hitch looping he lower pouch fistula is now lifted again, and the fistula is divided.
| Anastomosis-The First Stitch|| |
The first stitch is the difficult stitch because the two ends tend to fall apart, and one may have to take a longer length suture (12 cm) for this step. Although the position of knot does not matter the knot lying outside makes the anastomosis look neat. Once the first knot is in placed the posterior row sutures are done one on either side of the midline making sure mucosa is included following which size 6 nasogastric tube is passed through the anastomosis. The anastomosis is then completed and at the most 5-6 knots are required for completion. The anastomosis is more about laparoscopic suturing skills in small space.
Concluding the operation
After the anastomosis is done, the area is then washed with warm saline and the operation concludes with the placement of a 14 Fr chest drain exiting through the 5 mm port placed under vision. The 3 mm ports do not require any closure except for the skin. The local incision sites are infiltrated with local anesthesia, and the patient is handed over to the anesthesia team with the caution to secure the nasogastric and prevent pulling out during turning and shifting the patient. The chest drain is checked for water level and any air leaks.
Postoperative management: The postoperative management is no different from the conventional repair except for the fact that in the absence of a thoracotomy the ventilator requirements are far less and so are the pain medications.
Role in long gap atresia and other conditions
With growing experience the surgeon can attempt the longer gap TEF, which pose greater difficulty at the time of anastomoses. Rothenberg and Flake have reported 14 such patients.  For patients with poor general condition simply clipping the fistula and then later going in for anastomosis is an attractive option and gives the advantage to the child as the sans thoracotomy procedure is easily tolerated by the infant even if the condition is poor.
Postoperative and follow-up management
Once stabilized the infant undergoes an esophagogram if there is no evidence of a leak in the chest drain and the orals feeds are supplements with the ongoing tube feeds. The chest drain is removed following 1 st day of feeds and decision to discharge is then taken by the Intensive Care Unit team based on the well-being of the child.
Review of literature and its results with our experience
The first case of thoracoscopic repair was reported by Lobe et al. in 1999 which was reported as surgical first. This was followed by Rothenberg reporting again in the year 2000 in a newborn infant.  Since then there are several series coming from various centers across the world reporting TREAT. [Table 1] gives a short summary of major series reported so far (series with 10+ patients). The outcome reported in these series have uniformly been demonstrated to be good with conversion rate of <10%. There are several series which have compared open versus TREAT. Koga et al.  compared 45 patients of open repair versus 25 of TREAT and concluded it to be better on various parameters such as lung function and postoperative recovery. A larger data set comparison was done in a multi-institutional analysis of TREAT with that of large open series of open repair reported in literature by Holcomb et al.  they aggregated 104 patients of TREAT from 6 centers across the world and concluded that musculoskeletal sequele is much less. The need for esophageal dilatation and fundoplication later are no different from the open repair and ultimately concluded that TREAT is safe and efficacious. A similar multi-institutional analysis was done by Okuyama et al.  They aggregated 58 patients from 7 institutes. They also reported comparable results with open repair.
The author's experience
Our current experience is quite limited in number. Still we have been able to make refinements in the steps of the complex operative procedure to make it easy for surgeons wanting to adopt this procedure. The author advocate the use of a Fogarty balloon occlusion to control the ventilation of right lung this will, in turn, obviate the need of 4 th port which have been used by many surgeons for retraction of the lung. It is really difficult to maintain the ergonomics in a small chest area of a newborn with 4 ports. The Fogarty balloon acts as an on-off switch for the lung and avoids use of higher pneumothorax pressures during the procedure. The other tweak is the use of the lower pouch esophageal hitch which helps in accurate dissection and control of fistula. We have shown that it is possible to spare the azygos vein during TREAT and anastomosis is possible above and medial to azygos. This has benefit in avoiding edema in the lower pouch and decreasing the leak rate. This fact needs further verification and evidence through trials.
Since 2012, a total of 29 patients (8 females) were operated by TREAT. Mean age was 2.8 days (range 2-6 days). Mean weight was 2.6 kg (range1.8-3.2 kg). Four were converted into open due to difficulties as poor anesthetic stability and long gap (2 out of the 4). The long gap patients when converted were difficult to anastomose. The mortality in this series was 6 and is attributed to sepsis. These patients were the one who had initially come in poor condition. There was leak in four patients, and two patients had to be diverted. They are now awaiting definitive repair. Twenty-one patients have completed a mean follow-up of 1.5 years and are doing well [Figure 4] except for two patients who had stricture and underwent serial esophageal dilatations. We have currently undertaken a study to see the anastomotic caliber in these patients in follow-up and comparing it with open repair to see if there is any difference.
| Conclusions|| |
TREAT is now a well-established procedure and currently the preferred approach wherever feasible. The feasibility depends on surgeons experience the equipment available and the anesthetic expertise. The avoidance of thoracotomy is a major advantage to the newborn and is proven to benefit the recovery in postoperative patient. The technique demonstrated and the tweaks reported for the control of lung ventilation with Fogarty catheter and lower pouch hitch makes the procedure easy and is helpful to beginners. The outcome is very much comparable to the open repair as proven by various series. Various parameters like leak rate, anastomotic stricture are the same. The pediatric minimal access surgeon should give a chance to the newborn the advantage of this approach. The outcome is comparable if you TREAT these babies well.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3], [Figure 4]