JOURNAL OF LAPAROENDOSCOPIC & ADVANCED SURGICAL TECHNIQUES

Volume 30, Number 12, 2020

ª Mary Ann Liebert, Inc.
DOI: 10.1089/lap.2020.0642

Thoracoscopy Versus Thoracotomy in the Repair

of Esophageal Atresia with Distal Tracheoesophageal Fistula

Ahmad Elhattab, MS,1,2 Liza Ali, MD,3 Veronique Rousseau, MD,1 Pauline Clermidi, MD,1,2
Daphné Michelet, MD,4 Caroline Farnoux, MD,3 Alexandre Lapillonne, MD, PhD,5,6
Kamal Abdel-Elah Aly, MD, PhD,2 Sabine Sarnacki, MD, PhD,1,6
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Arnaud Bonnard, MD, PhD,3,6 and Naziha Khen-Dunlop, MD, PhD1,6

Abstract

Background/Objective: Thoracoscopic repair of esophageal atresia (EA) is gaining popularity, but it is a highly
technically demanding procedure. The aim of our study is to evaluate our outcomes in the management of type
C EA comparing the thoracoscopic and the open (thoracotomy) approaches.
Methods: This is a retrospective bicentric study of two major pediatric surgery centers, reviewing all the patients
operated for EA with distal tracheoesophageal fistula. Only patients who underwent primary anastomosis were
included. From 2008 to 2018, 187 patients were included.
Results: Forty-seven patients were operated thoracoscopically (TS group) and 140 by the open approach
(TT group). Mean gestational age was 38 – 2.4 weeks in TS group and 36.4 – 3.3 weeks in TT group (P = .005)
with a mean birth weight of 2785 – 654 g and 2404.9 – 651 g in TS and TT groups, respectively (P = .003). The
mean operative time was 127.6 – 35 minutes in TS group and 105.7 – 23 minutes in TT group (P = .0005). The
mean postoperative ventilation time and the mean length of stay were significantly shorter in the thoracoscopic
group (P = .004 and P < .0001, respectively).
The incidence of anastomotic leak was 8.9% in TS group versus 16.4% in TT group (P = .33). Anastomotic
stenosis occurred in 33.3% of TS group and in 22.4% of TT group (P = .17).
Conclusions: Surgical outcome of thoracoscopic repair of EA is comparable to the open repair with no higher
complication rate with the expected skeletal and cosmetic benefits. However, possible bias regarding prema-
turity, weight at surgery, and associated anomalies must be taken into consideration.

Keywords: congenital malformation, esophagal atresia, neonate, thoracoscopy, thoracotomy

Introduction cessful neonatal thoracoscopic repair of EA with distal

TEF was published.5 Since that date, thoracoscopic repair of

E sophageal atresia with tracheoesophageal fistula

(EA/TEF) is a rare congenital anomaly, estimated to
affect 1/2500–4000 live births.1 The outcome and survival
EA started to gain popularity among pediatric surgeons.
A literature review comparing both approaches for EA
repair showed that chest asymmetry in the horizontal plane
have improved over the past few decades with the im- was significantly less pronounced after thoracoscopic sur-
provement in surgical skills and the advances in neonatal gery. In addition, the incidence of grade I scoliosis was about
care.2 Although thoracotomy was considered to be the gold 10%, which was significantly lower than that after thoracot-
standard approach for EA/TEF repair for years, it was found omy that reached 54%.6 For this reason, thoracoscopic repair
to be associated with potential musculoskeletal dysfunctions for EA/TEF was adopted by increasing number of surgeons
that may interfere later with one’s daily activities.3 The first during the last two decades despite being a very technically
successful thoracoscopic repair for isolated EA was done in demanding procedure.7 Moreover, thoracoscopy was thought
1999 in a 2-month-old girl.4 One year later, the first suc- to be more advantageous in terms of better visualization of
1
Department of Pediatric Surgery, AP-HP, Hopital Necker-Enfants Malades, Paris, France.
2
Department of Pediatric Surgery, Mansoura University Children’s Hospital, Mansoura, Egypt.
Departments of 3Pediatric Surgery and 4Anesthesia, AP-HP, Hopital Robert Debre, Paris, France.
5
Neonatal Care Unit, AP-HP, Hopital Necker-Enfants Malades, Paris, France.
6
Université de Paris, Paris, France.

1289
 1290
the anatomy which, for example, may help more for proper
TEF detection and ligation at the optimal site.8
In contrast, the CO2 insufflation and the duration of the
surgery that may lead to hypercapnia and acidosis were
showed to be limitations of this approach, especially for the
newborns because of their lung immaturity. Thus, despite the
expected benefits, the safety and feasibility of this thoraco-
scopic approach in neonates remained controversial.9 There-
fore, this study aimed to compare the early outcome of this
approach compared to the conventional open surgery.
Materials and Methods
The study was approved by the Institutional Review Board
of Necker Enfants Malades Hospital (20200622172921).
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This is a retrospective bicentric review of all patients ad-
mitted for repair of EA in two major centers for pediatric
surgery in Paris between 2008 and 2018. To have a homog-
enous population, only patients with distal TEF who under-
went successful primary anastomosis were included.
In that period, 187 patients were included. One hundred and
forty patients were operated by open approach during the whole
period from 2008 to 2018 (TT group), and 47 were operated by
thoracoscopic approach starting from 2013 to 2018 (TS group).
All patients received entire physical examination. Chest X-ray,
abdominal ultrasound, and echocardiography were done.
Comparison between both groups was made regarding the pa-
tients’ demographic data, operative data, postoperative course,
and length of hospital stay. All patients were followed up till at
least the age of 1 year.
Collected data included patient’s gestational age (GA),
birth weight, age at surgery, and associated congenital
anomalies. Operative data were collected, including op-
erative time, conversion from thoracoscopic to open sur-
gery, blood loss, or other intraoperative events. End-tidal
CO2 (EtCO2) was recorded at the start and at the end of
the procedure. The maximum EtCO2 also was recorded.
Collected postoperative data included duration of ventila-
tion, occurrence of anastomotic leaks, anastomotic strictures,
recurrent TEF, and need for fundoplication. Anastomotic
stricture was defined as the need for at least one endoscopic
dilatation session.
Surgery
Preoperative laryngo-tracheoscopy was done in the oper-
ative theatre for all patients to confirm the site of distal fistula
and to exclude coexistence of a proximal fistula. The surgical
approach was chosen according to the surgeon in charge.
Thoracoscopic approach
Patient was placed in left lateral position (70) or semi-
prone position. First trocar 5 mm was inserted for the optic
below the tip of the scapula. Other two 3 mm trocars were
inserted for the working instruments. Rarely, a fourth trocar
was needed for lung retraction. Insufflation was started at
5 mmHg and was lowered later on during the procedure if
needed. Azygos vein was ligated and divided or controlled
with bipolar diathermy in all cases. Closure of the fistula was
done using absorbable sutures. Esophageal anastomosis was
done in single layer of interrupted sutures after passage of
nasogastric tube. Chest drain was inserted in all cases (Fig. 1).
ELHATTAB ET AL.
Thoracotomy approach
Patient was placed in left lateral position. Right postero-
lateral thoracotomy was done through 4th or 5th intercostal
space either extra-pleural or trans-pleural, depending on the
surgeon appreciation. Azygos vein division was done in all
cases. Section of the fistula and esophageal anastomosis were
done using absorbable or nonabsorbable sutures according to
surgeon’s preference. Chest drain was inserted in all cases.
Postoperative course
All patients were transferred from the operative theatre
to neonatal intensive care unit while remaining intubated.
Pressure controlled ventilation was used without muscle re-
laxant. Midazolam was used for sedation, and Sufentanil was
used for analgesia during the period of mechanical ventila-
tion in both groups. Enteral feeding was started through the
nasogastric tube on the 2nd or 3rd postoperative days if there
is no contradiction. Proton pump inhibitors were used in all
patients. Oral feeding could be started upon removal of the
nasogastric tube after making sure that there is no anasto-
motic leakage. Considering this point, the two centers have
different protocols. Esophagogram was routinely done in one
center to rule out anastomotic leakage before oral feeding,
whereas in the second center, oral feeding was started if there
were no detected respiratory problems on clinical evaluation
and chest X-ray.
Statistical analysis
Results were expressed as mean and standard deviation or
median and range, according to the data variations. Continuous
variables were compared using Mann–Whitney–Wilcoxon
test. Discrete variables were compared using Fisher’s exact
test. P value <.05 was considered significant.
Results
Among the 187 patients, 47 were operated thoracoscopically
(TS group) and 140 were operated by the thoracotomy
(TT group).
There were 2 deaths in neonatal period in TS group (4.26%).
Both were due to multiple congenital malformations, includ-
ing complex cardiac diseases. Six patients died in TT group
(4.29%). All of them suffered from severe forms of cardiac
problems: pulmonary atresia, aortic atresia, transposition of
great vessels, tetralogy of Fallot, and double outlet right ven-
tricle. There was no significant difference in death rate be-
tween the two groups (P = 1). Consequently, statistical analysis
of data included 45 patients in TS group and 134 in TT group.
Median age at surgery was 1 day in both groups with range
(0–29 days) in TS group and (0–7 days) in TT group (P = .99).
There were four conversions from thoracoscopic to open
approach (8.9%). The causes for conversion were ventilatory
problems that necessitated frequent right lung reinflation in
two cases, intolerable hypercarbia with CO2 insufflation in
one case, and long gap between the upper and the lower
esophageal pouches (more than three vertebral bodies) that
entailed open anastomosis in one case.
There was a significant difference between both groups in
terms of GA, birth weight, and prematurity. The mean GA
was 38 – 2.42 versus 36.4 – 3.34 (P = .005), and mean birth
weight was 2785.2 – 654.4 versus 2404.9 – 650.6 (P = .003)
 THORACOSCOPIC REPAIR OF ESOPHAGEAL ATRESIA 1291
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FIG. 1. Steps of thoracoscopic approach for EA/TEF repair. Thanks to the camera magnification the anatomic elements
are well-visualized. (A) Distal esophageal pouch connected to the posterior trachea through the fistula. Asterisk indicates the
vagus nerve. (B) Dissection of the proximal esophageal pouch. (C) Performing the anterior layer of esophageal anastomosis.
(D) Final view after completion of the anastomosis. EA/TEF, esophageal atresia with tracheoesophageal fistula.

in TS group and TT group, respectively. About 22% of pa- versus 5 days (1–94), respectively (P = .004). After exclud-
tients in TS group were premature (less than 37-week ges- ing babies with cardiac malformations, median duration was
tation) versus 45.5% in TT group (P = .008). still different with 3.5 days (2–7) in TS group versus 4 days
There were associated congenital anomalies in 47% (21 cases) (1–49) in TT group (P = .046). However, with adjustment
in TS group versus 48% (64 cases) in TT group (P = 1), while of the analysis to include only full-term babies, median
cardiac anomalies were found in 24% (11 cases) versus 28%
(37 cases) in TS and TT groups, respectively (P = .85). Table 1. Comparison of Operative Time
There were no intraoperative complications in both groups. and Intraoperative CO2 Values
The operative time was significantly longer in TS group with
mean 127.6 – 35.4 minutes compared to 105.7 – 22.9 minutes TS TT
in TT group (P = .0005). In addition, the recorded end-tidal group group P
Variable (n = 45) (n = 134) value
CO2 (EtCO2) values during operation were significantly
higher in the TS group although there was no statistically Mean operative time 127.61 – 35.43 105.7 – 22.9 .0005*
significant difference at the start of operation. The mean (minutes)
maximum EtCO2 recorded was 49.3 – 6.4 for TS group versus Mean EtCO2 at the 30.27 – 4.62 30.05 – 2.73 .809
36 – 2.5 for TT group (P < .0001). Although the CO2 values start of surgery
declined at the end of the operation in both groups, they were Mean EtCO2 at the 39.73 – 6.31 32.04 – 2.80 <.0001*
still significantly higher in TS group with a mean EtCO2 of end of surgery
39.7 – 6.31 versus 32 – 2.8 in TS and TT groups, respectively Mean maximum 49.32 – 6.36 35.97 – 2.48 <.0001*
EtCO2
(P < .0001) (Table 1).
Patients in TS group had significantly shorter time to ex- *Statistically significant.
tubation compared to TT group with median of 4 days (2–40) TS, thoracoscopic repair; TT, thoracotomy repair.
 1292 ELHATTAB ET AL.

intubation duration became comparable with 4 days (2–6) in

TS group versus 4 days (1–94) in TT group (P = .45).
Hospital stay was significantly shorter in TS group. Med-
ian hospitalization period was 25 days (9–98) for TS group
versus 42 days (8–130) for TT group (P < .0001). After ex-
cluding babies with cardiac malformation, median duration
was again still different with 23.5 days (9–98) in TS group
versus 32 days (8–115) in TT group (P = .009). With inclu-
sion of full-term babies only, median duration was no more
significantly different with 25 days (9–98) in TS group versus
27 days (8–115) in TT group (P = .05) (Table 2).
The incidence of postoperative complications carried no
significant difference between the two groups. Anastomotic
leakage occurred in 4 cases (9%) in TS group compared
to 22 cases (16%) in TT group (P = .33). All leaks healed
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spontaneously in TS group, but three cases in TT group

(2.2%) needed secondary thoracotomy for toilet and drain-
age after leakage. These surgeries were performed on the
10th postoperative day in one case and on the 14th day in the
other two cases.
Anastomotic strictures that required at least one endo-
scopic dilatation occurred in 15 cases (33%) of TS group
compared to 30 cases (22%) in TT group (P = .17). The
median number of needed dilatation sessions was 2 in both
groups (range 1–5) (Fig. 2). FIG. 2. Postoperative contrast study after open EA repair.
Six cases (13%) in TS group suffered from significant re- The contrast study shows an anastomotic stenosis at the
proximal third of the esophagus with a subsequent proximal
flux that required fundoplication where this happened in 10 dilatation.
cases (7.5%) in TT group (P = .24). Gastrostomy button
placement was done at time of fundoplication in 2 cases of 6
(33%) in TS group and in 5 cases of 10 (50%) in TT group.
Table 2. Postoperative Course Comparison The median age at fundoplication was 3.5 (1.7–14) months in
TS group compared to 4 (1.5–78) in TT group (P = .59).
TS TT P There was recurrent TEF in 3 cases (2.2%) in TT group
Variable group group value that were managed with second thoracotomy. All of them
were premature babies, while two of them (66%) suffered
Median time till 4 (2 – 40) 5 (1 – 94) .004* from cardiac problems. However, this complication was not
extubation (days) (n = 45) (n = 134) observed in TS group (P = .57) (Fig. 3).
Median time till 4 (2–6) 4 (1–94) .452
extubation (days) (n = 35) (n = 73) Aortopexy was done in 5 cases (3.7%) of TT group due to
excluding preterm severe tracheomalacia associated with life-threatening
babies events, while this was not required in TS group (P = .33). Two
Median time till 3.5 (2–7) 4 (1–49) .046* of the 5 cases were cardiac and premature babies, while 1 of
extubation (days) (n = 34) (n = 97) them was neither cardiac nor premature. In addition, there
excluding cardiac was 1 cardiac baby and 1 premature baby. Median age at
babies aortopexy was 14 months ranging from 4.5 to 72 months.
Median time till 4 (2–6) 4 (1–49) .975
extubation (days) (n = 25) (n = 56)
excluding both Discussion
preterm and The main aim of the thoracoscopic approach was to avoid
cardiac babies the skeletal deformities that may follow thoracotomy for
Median hospital stay 25 (9 – 98) 42 (8 – 130) <.0001*
(days) (n = 45) (n = 134) EA/TEF repair. In one review of 322 EA/TEF patients, about
Median hospital stay 25 (9–98) 27 (8–115) .0501 60% of them had skeletal sequelae after repair by thoracot-
(days) excluding (n = 35) (n = 73) omy.10 Another study compared chest deformities following
preterm babies thoracoscopy versus thoracotomy for EA/TEF. They found
Median hospital stay 23.5 (9–98) 32 (8–115) .009* significantly higher incidence of chest asymmetry, narrow
(days) excluding (n = 34) (n = 97) intercostal spaces, and scoliosis after thoracotomy compared
cardiac babies to thoracoscopy.6 Moreover, thoracoscopy for EA repair has
Median hospital stay 21 (9–98) 19 (8–53) .514 the great advantage of excellent visualization of posterior
(days) excluding (n = 25) (n = 56) mediastinal structures.11 In addition, it provides better visu-
both preterm and alization of esophageal pouches and mucosal layer during
cardiac babies
anastomosis.12 But on the other hand, thoracoscopic repair of
*Statistically significant. EA is considered a technically demanding procedure partic-
TS, thoracoscopic repair; TT, thoracotomy repair. ularly for the anastomosis in a relatively narrow working
 THORACOSCOPIC REPAIR OF ESOPHAGEAL ATRESIA
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FIG. 3. Endoscopic view of the trachea for recurrent fis-
tula. The anterior wall of the trachea is identified by the
cartilage rings. The posterior wall is partially collapsed be-
cause of mild tracheomalacia. The tracheoesophageal fistula
is confirmed by the introduction of a catheter. The distal part
of the catheter has to be visualized in the esophagus.
space. Consequently, with gaining more experience, there
was improvement in terms of operative time and incidence of
anastomotic leaks and strictures.13 This concept was proved
by a study comparing the first and second 5-year experience
in thoracoscopic EA repair.14
With the emergence of this technique, thoracoscopic
approach was not recommended in some circumstances.
For example, in 2005, Rothenberg considered that significant
prematurity (< 1500 g) was an absolute contraindication.15 In
another study comparing thoracotomy with thoracoscopy,
neonates with body weight >2000 g only were considered as
good candidates for thoracoscopic approach.11 However, in
another study, outcome in patients <2000 g was shown not
to be statistically different from those weighing >2000 g.16
Although, in our study, there was a significant difference
between body weight in the two groups, we did not use se-
lection criteria to determine the surgical approach. Moreover,
we had one patient in TS group who weighed only 1420 g
with uneventful perioperative and postoperative courses. To
go further, a randomized control study is now needed.
The time needed till extubation after thoracoscopy was
found to be significantly shorter in previous comparative
studies.7,11 This may be explained by the uniform collapse of
the lung by pneumothorax during thoracoscopy compared to
mechanical lung manipulation and retraction during thora-
cotomy and also by the less postoperative pain.7 However,
another study found no significant difference in the postop-
erative ventilation duration.17 In our study, the time needed
till extubation was significantly shorter in TS group than TT
group in the whole population, but we did not find a signifi-
cant difference in the duration of ventilation and hospital stay
after excluding preterm neonates from the statistical analysis
of this point.
1293
Apart from the technical hurdle, the two other main draw-
backs of thoracoscopic approach are the longer operative time
and the effect of CO2 insufflation. In our study, as well as other
comparative studies, the operative time was significantly lon-
ger in TS group.17 One meta-analysis that included 6 com-
parative studies also concluded that operative time was longer
in TS group.18 However, other studies concluded that there was
no significant difference.7,11 With the use of thoracoscopy in
pediatric surgical procedures, the tolerability of neonates to
CO2 insufflation was questioned. It was found that CO2 ab-
sorption from induced pneumothorax in thoracoscopy is more
than that from induced pneumoperitoneum in laparoscopy.19
Szavay et al. reported significantly higher intraoperative CO2
levels in thoracoscopy compared to thoracotomy.17 This comes
in line with our findings. However, Yamoto et al. and Bishay
et al. found no significant difference in intraoperative CO2
levels between thoracoscopy and thoracotomy.11,19 We would
however mention that the longer operative time and higher
intraoperative CO2 values in our study did not have burden on
the postoperative ventilation time and length of hospital stay in
TS group compared to TT group.
Regarding the common complications after EA repair,
including the rate of anastomotic leakage and stricture, two
meta-analyses concluded that there was no significant dif-
ference between thoracoscopy and thoracotomy, the finding
that comes in agreement with our results.18,20 So, thoraco-
scopy is comparable to thoracotomy in this point and does not
carry higher risk for postoperative complications.
For exclusion of anastomotic leakage, one of the two in-
cluded centers adopted doing contrast esophagography as a
routine in every patient before starting oral feeds. This meets
with the recommendations of Lovvorn Iii et al.12 However, one
study investigated the value of early postoperative esophago-
graphy and concluded that it is not systematically necessary,
showing that major leaks are usually apparent clinically and
that the radiological detection of minor asymptomatic leaks
does not affect the management.21 In the same vein, Patkowski
et al. found that anastomotic leak was almost always detected
before having esophagography in 5th or 6th postoperative
day, making the esophagography not essential unless to
have an idea about the size of anastomosis.22 In our second
center, contrast esophagography was done only when leak
was suspected. It depended on the clinical assessment of
chest condition and chest radiograph to suspect a leak. With
this protocol, all leaks were successfully suspected before
starting oral feeds (15 cases), and esophagography was
avoided in 82 (84.5%) of the patients.
The first limitation of this study is that it was a retrospec-
tive one. In addition, the study population was not completely
homogenous knowing that there was a significant difference
between the two groups regarding birth weight and GA.
Furthermore, the approach in our study was mainly selected
according to the surgeon’s personal preference with no obvi-
ous objective criteria. For these reasons, a prospective ran-
domized study is considered necessary for better judgment on
feasibility and safety of thoracoscopic approach compared to
the conventional open one.
Surgical outcome of thoracoscopic repair of EA/TEF is
comparable to the open repair with no higher complication
rate and with the expected benefits of avoiding skeletal de-
formities and better cosmesis. The additional probable ad-
vantages of thoracoscopy are shorter time of postoperative
 1294
ventilation and shorter hospital stay. However, randomized
control trial on large number of cases is needed to support
these results, controlling the possible bias regarding prema-
turity, weight at surgery, and associated anomalies.
Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.
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Address correspondence to:
Naziha Khen-Dunlop, MD, PhD
Department of Pediatric Surgery
AP-HP
Hopital Necker-Enfants Malades
149 Rue de Sevres
Paris 75015
France
E-mail: naziha.khen-dunlop@aphp.fr