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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
• Retrospective study
• 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
• 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) 129.9 (± 55.5)
Mean Days Ventilation 3.6 (± 5.8)
Mean Hospitalization (days) 18.1 (± 18.6)
Thoracoscopic Repair EA/TEF
Associated Anomalies
(104 Patients)
Cardiac Renal
ASD/VSD 15 Horseshoe kidney 3
Right aortic arch 6 Unilateral agenesis 2
Tetralogy of Fallot 3 Crossed fused ectopia 1
Dextrocardia 3 VUR > Grade 3 1
PDA (ligation) 2 Duplex kidney 1
DORV 1 Ectopic kidney 1
Tricuspid atresia 1
Gastrointestinal Other
High imperforate anus 7 Vertebral anomalies 6
Duodenal atresia 4 Radial aplasia 3
Low imperforate anus 3 Tethered cord 1
Cloaca 1 Hydromyelia 1
Choanal atresia 1
Syndromes
VACTERL (>2 anomalies) 10
CHARGE 3
Down 3
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 5
( other than VSD/ASD)
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
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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
Thoracoscopy Thoracotomy
• Transpleural • Extrapleural/Transpleural
• Longer operative time • Shorter operative time
• Avoidance of
musculoskeletal sequelae
• Superior visualization of
anatomy
• Metal clip
• Weck clip
• Tie (x2 ?)
• Oscillating
ventilator
• U-clips
anterior
anastomosis
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• 2007 – 2010
• 17 neonates
- 12 EA/TEF
- 5 CDH
- Mean age - 4 days
- Mean wt - 2.9 ±1.0 kg
- Median vent changes – 3/pt
J Laparoendosc Surg 21:877-879, 2011
How To Get Started
Not The Ideal Case
• 2 - 2.5 kg
• Very high upper pouch
• Complex single ventricle
physiology
• Prostaglandin dependent
How To Get Started
Ideal Case
• Baby – 2.5-3 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
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