Pediatric Anesthesia 2005 15: 541–546 doi:10.1111/j.1460-9592.2005.01594.

Review article
Thoracoscopic repair of esophageal atresia with
tracheoesophageal fistula: anesthetic and intensive
care management of a series of eight neonates
SUZANNE KROSNAR MBChB FRCA* A N D AL IS TAI R B A XT ER
MBChB FRCA†
*Department of Anaesthesia, Royal Infirmary of Edinburgh and †Department of Anaesthesia,
Royal Hospital for Sick Children, Edinburgh, UK

Summary
Advances in minimally invasive techniques have made pediatric
laparoscopic surgery commonplace. Thoracoscopic surgery in chil-
dren however is still performed in only a few centers throughout the
world. Between July 2001 and January 2004, the first eight esophageal
atresia with tracheoesophageal fistula repairs were performed
thoracoscopically at the Royal Hospital for Sick Children in
Edinburgh. This article presents their anesthetic management, their
postoperative management in the pediatric intensive care unit and
reviews the complications seen in both the intraoperative and
postoperative periods. Finally we discuss how our experience to date
influences our perioperative management of these challenging cases.

Keywords: thoracoscopic surgery; tracheoesophageal fistula; esopha-

geal atresia; perioperative management

choking during feeding or dusky episodes associ-

Introduction
Esophageal atresia (EA) affects one in 3000–5000
births. Thirty percent are preterm, 85% have an
associated tracheoesophageal fistula (TEF) and 50%
have at least one of the recognized list of associated
abnormalities (1) (Table 1). In our series of eight
cases (Table 2) two were preterm (born before the
37th completed week of gestation), all eight had EA
with an associated distal TEF, and the commonest
associated abnormalities were cardiac and musculo-
skeletal. The first of our eight cases had an antenatal
diagnosis of EA with TEF. The other seven all
presented within an hour of birth, with either
Correspondence to: Dr S. Krosnar, Department of Anaesthesia,
Royal Infirmary of Edinburgh, 51 Little France Crescent,
Edinburgh EH16 4SA, UK (email: skrosnar@dsl.pipex.com).
ated with copious oral secretions. All eight neonates
demonstrated the diagnostic chest X-ray (CXR)
appearance, a nasogastric tube coiled in the upper
esophagus with air present in the stomach. Their
immediate management involved supplementary
oxygen, insertion of a Replogle tube on continuous
suction, maintenance intravenous (i.v.) fluids (0.18%
saline + 10% dextrose) and early transfer to our
surgical neonatal unit, awaiting definitive surgery.
Preoperative management
The eight neonates were well when they presented
for surgery, between day 2 and 4 of life. All were
spontaneously ventilating, with minimal oxygen
requirements, and were hemodynamically stable.

2005 Blackwell Publishing Ltd 541

542 S . KR O S N A R A N D A . B A X T E R

Table 1
Organ system Incidence (%) Examples Congenital abnormalities
associated with EA + TEF
Cardiac 15–25 VSD, PDA, tetralogy of Fallot, ASD, right-sided aortic arch
Gastrointestinal 15 Duodenal atresia, imperforate anus, malrotation
Genitourinary 10 Renal agenesis/dysplasia, horseshoe/polycystic kidney,
ureteric/urethral abnormalities, hypospadias
Musculoskeletal 10 Radial abnormalities, polydactyly, lower-limb defects,
hemivertebrae, rib defects, scoliosis
Vater (vacterl) 10 Vertebral defects, anorectal malformations, TEF, esophageal atresia,
renal/radial abnormalities (cardiac and limb abnormalities)

VSD, ventricular septal defect; PDA, patent ductus arteriosus; ASD, atrial septal defect.

All had Replogle tubes on continuous suction,
maintenance fluids running and stable electrolytes.
Case 5 was on i.v. coamoxiclav, for CXR changes
consistent with aspiration pneumonia. Cardiac echo-
cardiography and renal ultrasound scans were
performed preoperatively, and elective admission
to pediatric intensive care unit (PICU) postopera-
tively was arranged for all cases.
Intraoperative management
All cases had an inhalational induction, three with
halothane and four with sevoflurane. Four were
intubated orally and three nasally, four with the aid
of a neuromuscular blocker and three under deep
inhalational anesthesia (intraoperative data for case
4 were incomplete and therefore not included in
these figures). In case 7 the tracheal tube (TT) was
deliberately placed in the left main bronchus, using
fiberoptic bronchoscopy to confirm tube placement.
Regarding vascular access, all cases had an arterial
line inserted following induction of anesthesia. To
supplement the one peripheral i.v. line, which all
cases had in situ preoperatively, three cases had one
further peripheral line sited and four cases had a
femoral venous line inserted, again following
induction.
The neonates were then carefully positioned and
supported in a semi-prone position, their right side
elevated 45 and the right arm placed above their
head. In all cases anesthesia was maintained
throughout the procedure with a volatile anesthetic
agent. Analgesia was primarily provided by opioids,
supplemented with local anesthesia infiltration to the
three thoracoscope port sites. In all but case 7
neuromuscular blockade was maintained through-
out surgery by continuous infusion or regular
boluses. Intermittent positive pressure ventilation
was delivered mechanically in four cases, whereas in
cases 2, 3 and 6 it was the preference of the consultant
anesthetists involved in these cases to ventilate by
hand throughout the procedure. Problematic gastric
distension related to ventilation did not occur at any
stage in the management of these cases.
Blood loss was documented as <10 ml in all cases.
Fluid replacement intraoperatively consisted of
hourly maintenance (based on 100 mlÆkg)1 24 h)1)
as a dextrose/saline combination crystalloid, plus
boluses of either colloid or crystalloid totalling
between 10 and 40 mlÆkg)1.
All eight cases were completed thoracoscopically,
with procedure duration averaging 164 min (range
130–220 min). The intraoperative management of
each individual case is summarized in Table 2.
Intraoperative complications
Anesthesia complications occurred during the peri-
ods of one lung ventilation (OLV), and could broadly
be divided into problems with oxygenation and
problems with carbon dioxide (CO2) elimination
and monitoring. All cases experienced a reduction
in oxygen saturation (SpO2) to between 84 and 91%
when the right pleural cavity was insufflated with
CO2 (to a pressure of 5 mmHg) resulting in collapse of
the right lung. Case 5 managed to maintain SpO2
>90% on a maximal inspired oxygen concentration of
50%, however, all the other cases required 100%
oxygen to maintain SpO2 >85%. Case 6 desaturated to
75% on commencing OLV. As this was associated
with loss of the endtidal CO2 (PECO2) trace and
difficulty hand ventilating the patient, the TT was
removed and replaced. During periods of OLV all
cases experienced falsely low PECO2 readings, associ-
ated with raised arterial CO2 and reduced pH on
arterial blood gases. During four cases the PECO2 trace

2005 Blackwell Publishing Ltd, Pediatric Anesthesia, 15, 541–546

 Table 2
Summary of the demographic data, anesthetic management and postoperative progress in PICU of the first eight neonates to have thoracoscopic repair of EA + TEF in the RHSC,
Edinburgh

Gestation Weight Induction Maintenance Operation Extubation (hours PICU discharge

Case Sex (weeks) (g) Associates abnormalities technique technique duration (min) postoperative) (postoperative day)

1 F, S 38 + 4 1640 Maternal polyhydramnios O2, H, BA O2, air, I, AI, BF 190 41 2

(TEF diagnosed antenatally) (3 lgÆkg)1 · 3)
radial aplasia, absent left thumb
2 F, S 37 + 2 2250 Maternal polyhydramnios O2, air, H O2, air, I, BA, BF 160 71.7 4
(TEF not diagnosed antenatally) (2 lgÆkg)1 · 3)
large PDA, polydactyly right

2005 Blackwell Publishing Ltd, Pediatric Anesthesia, 15, 541–546

hand, abnormal left thumb
3 F, S 41 + 6 3940 Small PFO, floppy septum secundum O2, H, BA O2, air, I, AI, FI 155 23.7 2
(5 lgÆkg)1Æh)1)
4 M, T 37 2930 Nil Data incomplete 220 43.5 3
5 M, T 36 + 5 2015 Small perimembranous VSD, PDA, O2, S, BV O2, air, S, VI, RI 135 39 2
mild hypospadios, talipes, sacral
dimple, prominent coccyx
6 M, S 40 3920 PDA O2, S O2 S, AI, FI 195 15.7 2
(5 lgÆkg)1Æh)1)
7 M, S 42 2590 Small PFO and PDA O2, air, S, BA O2, air, S, RI 130 0 2
8 M, T 34 + 5 2030 Bilateral hydroceles, O2, S O2, air, S, BF 130 66.5 7
small sacral dimple (5 lgÆkg)1 · 1), VI, RI

F, female; M, male; S, singleton; T, twin; PFO, patent foramen ovale; O2, oxygen; H, halothane; S, sevoflurane; I, isoflurane; BA, bolus atracurium; BV, bolus vecuronium; AI,
atracurium infusion; VI, vecuronium infusion; BF, bolus fentanyl; FI, fentanyl infusion; RI, remifentanil infusion.
T H O R A C O S C O P I C R E P A I R O F EA W I T H TE F
543
544 S . KR O S N A R A N D A . B A X T E R
was lost completely for the period of time taken to
anastamose the upper and lower esophageal pouches.
Surgical complications occurred in two cases. In
case 4 leakage of CO2 from around downsizing ports
resulted in a suboptimal view. This required repea-
ted instrumentation through the chest wall resulting
in increased bruising and prolonged surgical time.
Case 1, despite a normal preoperative cardiac
echocardiograph, was found intraoperatively to
have a right-sided aortic arch. This precluded
anastamosis of the upper and lower esophageal
pouches. After ligation of the TEF a gastrostomy was
inserted and the EA was not repaired.
Postoperative management
At the end of the surgical procedure, all patients
were commenced on a morphine infusion at 20–
40 lgÆkg)1Æh)1 and admitted to PICU. Case 7 also
had intercostal nerve blocks performed and was
extubated at the end of the procedure, prior to PICU
admission. The other seven cases were admitted to
PICU for a period of elective postoperative ventila-
tion. Oxygen and ventilation requirements were
minimal in all cases.
Over the first 24 h all eight neonates required
between 10 and 20 mlÆkg)1 as fluid boluses, in
addition to their maintenance fluids, to improve
urine output or base deficit. Transanastamotic tube
(TAT) feeds were commenced (except in case 1) on
the first postoperative day, and i.v. fluids were
weaned as enteral feeding became established. A
contrast swallow was performed between day 5 and
7. If no areas of narrowing or leak were identified
around the anastamosis site, the TAT was removed
and oral feeding was allowed to commence. The
number of hours each case remained intubated
postoperatively and the number of days each
remained in PICU is shown in Table 2.
Early postoperative complications
During their PICU admission cases 1, 4, 5 and 6
experienced no complications whatsoever. Cases 2,
3, 7 and 8 all required correction of mild electrolyte
disturbances (hyponatremia, hypokalemia, hypo-
magnesemia and hypoglycemia). Significant compli-
cations occurred in two cases. Case 7, who had been
extubated at the end of surgery prior to PICU
admission, presented 12 h postoperatively with a
respiratory arrest. Spontaneous respiratory effort
returned immediately following a brief period of
positive pressure ventilation via a face mask. CXR
showed left-upper lobe collapse, which persisted for
several days. Case 8, a preterm twin weighing
2030 g, developed hypoalbuminemia, dependent
edema and a persistent metabolic acidosis, which
was treated with i.v. sodium bicarbonate until the
fifth postoperative day. As all investigations were
normal this was presumed to be secondary to renal
immaturity. Following extubation on the third post-
operative day this neonate developed stridor. There
was minimal improvement following nebulized
epinephrine and i.v. dexamethasone, and nasal
CPAP was required to provide respiratory support
until the fifth postoperative day.
Late postoperative complications
Follow-up of our series of eight thoracoscopic
repairs revealed that two cases had feeding
problems secondary to esophageal dysmotility,
one had gastroesophageal reflux (GER) and two
had strictures which required balloon dilatation.
Three cases had proven tracheomalacia on bron-
chosopy. Of two cases with leaks on their initial
postoperative contrast swallow, one suffered recur-
rent lobar pneumonia and presented at the age of
5 months for ligation of a bronchoesophageal fis-
tula. There was one death in our series. Case 1 was
1640 g and had multiple congenital abnormalities.
A right-sided aortic arch, not identified on preop-
erative cardiac echocardiography, prevented EA
repair and necessitated insertion of a gastrostomy
tube. When enteral feeding commenced on day 3
postoperatively she acutely deteriorated. Following
a period of stabilization on PICU she returned to
the theater, and at laparotomy was found to have a
ruptured duodenum. Postoperatively she devel-
oped multiorgan failure, and following genetic
confirmation of Edward’s syndrome on day 6, her
parents agreed that treatment should be with-
drawn.
Discussion
Thoracoscopic repair of EA and TEF is a procedure
still very much in its infancy, however, over the last

2005 Blackwell Publishing Ltd, Pediatric Anesthesia, 15, 541–546
 T H O R A C O S C O P I C R E P A I R O F EA W I T H TE F
3 years over 50% of the neonates presenting to our
institution with EA and TEF have been repaired
thoracoscopically.
From the surgical perspective the principle
advantage of performing this innovative technique
is the avoidance of a thoracotomy. Thoracotomy in
infancy is associated with multiple long-term seque-
lae including: weakness of latissimus dorsi, winging
of the scapula, rib deformities, hemithorax hypo-
plasia, thoracic scoliosis and a cosmetically signifi-
cant scar (a 1-in. scar in a neonate becomes a scar of
8–12 in. in adulthood).
Following open EA and TEF repair recognized
complications include stricture, GOR, anastamotic
leak and recurrent fistula, the incidences of which
are quoted to be 52, 31, 8 and 8%, respectively (2).
No such data yet exist for the minimally invasive
technique, as so far the number of cases performed
worldwide remains small and the majority have
been performed too recently. Again following open
repair of EA and TEF only infants weighing <1800 g,
or with multiple congenital abnormalities, have a
recognized risk of dying (3) and in full-term infants
without pneumonia or congenital abnormality sur-
vival should approach 100% (4). In our series of
eight thoracoscopic repairs the only death was a
1640-g neonate with genetic confirmation of
Edward’s syndrome.
Reviewing our experience of the first eight tho-
racoscopic repairs performed in our institution, in
particular focusing on the complications encoun-
tered in the intraoperative and early postoperative
periods, has allowed our perioperative management
of these cases to evolve and our preferred technique
for managing these cases to develop.
Preoperative management in our experience is
relatively straightforward. These infants present for
surgery on day 2–4 of life and are generally well.
Results of a cardiac echocardiograph and renal
ultrasound, along with blood results demonstrating
normal electrolytes and normoglycemia, should be
documented. Elective postoperative PICU admission
should be arranged for all cases.
On presentation to the theater all cases should
have a dextrose/saline combination crystalloid run-
ning at calculated maintenance rate and a Replogle
tube, which should remain in situ, clearing secretions
from the blind ending upper esophageal pouch,
until replaced by a TAT intraoperatively during

2005 Blackwell Publishing Ltd, Pediatric Anesthesia, 15, 541–546
545
esophageal anastamosis. Although these infants
have one functioning peripheral i.v. line when they
present for induction of anesthesia, we recommend
an inhalational induction. Diaphragmatic splinting,
secondary to gastric insufflation via the TEF, is a
recognized complication of positive pressure venti-
lation via a face mask. Inhalational induction and
intubation under deep inhalational anesthesia, main-
taining spontaneous ventilation, provides good in-
tubating conditions and minimizes potential
complications associated with airway management
in this patient group. TT placement should be
guided by bronchoscopy, aiming to position the
tube tip distal to the fistula but still within the
trachea. In our experience, deliberate left main
bronchus intubation (case 7) resulted in prolonged
postoperative left upper lobe collapse, presumed to
be secondary to bronchial edema. We therefore
would not recommend this technique, although we
recognize it may be necessary and has been used
successfully when the fistula is located just above the
carina (5).
Neonates have very short airways and are at high
risk of TT displacement. As this operation requires
turning to a semi-prone position following intuba-
tion we recommend bronchoscopic confirmation of
TT placement following positioning for surgery.
Unrecognized TT migration into the right main
bronchus was thought to be responsible in case 6 for
the inability to ventilate following insufflation of the
right hemithorax and collapse of the only ventilated
lung.
Following induction and intubation these cases
warrant a second venous line (peripheral or femoral)
and an arterial line. The latter provides not only
accurate and continuous measurement of blood
pressure, but also a route for assessing the levels of
oxygen and CO2, the monitoring of which during
OLV can be problematic. In our experience, desat-
uration to 85–90% on initiating OLV in these cases is
almost guaranteed, and we recommend that oxygen-
enriched air be replaced by 100% O2 prior to and
during any periods of OLV.
As discussed earlier, all cases experienced prob-
lems with inaccurate or absent PECO2 monitoring
during the period of esophageal anastamosis. The
reason for this remains uncertain but is likely to be
secondary to a transient reduction in minute venti-
lation. Intentional reduction in the delivered tidal
546 S . KR O S N A R A N D A . B A X T E R
volume, aiming to minimize mediastinal movement
and optimize conditions for esophageal repair or
surgical manipulation of the mediastinum resulting
in an increased leak from around the TT, at present
are our most likely explanations. Hand ventilation
by the anesthetist during this part of the procedure
is reassuring and worthwhile, however, these cases
demonstrated no clear advantage of hand ventila-
tion for the entire procedure over mechanical
ventilation.
Blood loss can be expected to be minimal during
this procedure. Our intraoperative fluid regime
consists of hourly maintenance (based on
100 mlÆkg)1 24 h)1) as 0.45% saline/5% dextrose,
with any additional boluses being given as 0.9%
saline or Hartmann’s solution.
Postoperatively these neonates are commenced on
a morphine infusion and transferred to PICU for a
period of elective ventilation. Case 7 demonstrated
one potential problem of early postoperative extu-
bation in this patient group; he had a witnessed
respiratory arrest 12 h postoperatively.
The use of intraoperative remifentanil, or even
regional techniques in the future, could potentially
allow rapid wake up and extubation, but for several
reasons we still feel a period of elective ventilation
postoperatively would be beneficial. EA and TEF
repair is a procedure performed in a patient group at
risk of postoperative apneas, neonates in the first
few days of life, who will commonly be preterm or
of low birth weight. It is an operative procedure
involving OLV, associated with intraoperative res-
piratory acidosis and which requires analgesia in the
form of a morphine infusion postoperatively. Bear-
ing this in mind, we conclude that a short period of
elective postoperative ventilation provides optimal
conditions for CO2 levels and pH to normalize and
pain to be controlled. Our series demonstrates that
oxygen and ventilation requirements of these cases
are minimal and that term neonates over 3 kg can be
expected to extubate easily within 24 h.
Finally, a similar number of conventional, open
EA and TEF repairs were performed in our institu-
tion over the same period of time. Their average time
to extubation postoperatively was 54 h (range
21–134 h) and to PICU discharge was 3.4 days
(range 2–8 days). With the thoracoscopic approach
these times averaged 37.6 h and 2.75 days,
respectively. Therefore, although the total numbers
are small, the cases we have presented suggest
postoperative recovery should be more rapid fol-
lowing the minimally invasive procedure.
Acknowledgements
We would like to thank Mr Fraser Munro, Consult-
ant Paediatric Surgeon, Royal Hospital for Sick
Children (RHSC), Edinburgh, and Dr Jillian McF-
adzean, Consultant in Anaesthesia and PICU, RHSC,
Edinburgh, for their contributions to this manu-
script.
References
1 Clark DC. Esophageal atresia and tracheoesophageal fistula. Am
Fam Physician 1999; 59: 910–916.
2 Konkin DE, O’hali WA, Webber EM et al. Outcomes in eso-
phageal atresia and tracheoesophageal fistula. J Pediatr Surg
2003; 38: 1726–1729.
3 Dunn JCY, Fonkalsrud EW. Simplifying the Waterston’s strati-
fication of infants with tracheoesophageal fistula. Am Surg 1999;
65: 908–910.
4 Koop CE, Schnaufer L, Broennlie AM. Esophageal atresia and
tracheoesophageal fistula: supportive measures that affect
survival. Pediatrics 1974; 54: 558–564.
5 Tercan E, Sungun MB, Boyaci A et al. One-lung ventilation of a
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Accepted 9 December 2004

2005 Blackwell Publishing Ltd, Pediatric Anesthesia, 15, 541–546