DOZ047.94: The thoracoscopic approach for esophageal atresia and tracheoesophageal fistula—lessons learnt from 178 cases

Purpose The aim of this study was to present an operative technique based on personal experience with 178 cases of thoracoscopic repair with different types of EA/TOF. Material and Methods From 2005 178 patients (111 boys, 47 girls) underwent thoracoscopic repair in different hospitals. The first author was involved in all cases except two final procedures of staged repair. Results There were 30 cases of type A, 10 of type B, 129 of type C, 2 of type D, and 7 of H-type isolated fistulas. There was no contraindication to thoracoscopy if the surgical intervention was considered. The smallest operated patient weighed 1000 g. If the patient was respiratory unstable, only the fistula was closed, and the anastomosis was completed later (3 cases). All cases of type C, type D, and H-type fistula were completed thoracoscopically without conversion. Four cases of type A had primary thoracoscopic anastomosis. For the remaining long-gap EA (type A and B exclusively) stage internal traction suture technique was used. There were 16 deaths with 3 related to postoperative surgical complications. The operative technique evolved with growing experience. At the beginning the lateral position was used, which finally changed to a complete prone position. Three trocars 2 × 2,5–3,5 mm and 1 × 5 mm in diameter were placed around the scapula. The 5 mm telescope 25–30 degrees was preferred. A pneumothorax was maintained with 4–6 mmHg. The azygos vein was never divided, and the anastomosis was almost in each case made above the vein. In the majority of cases the vein separated the anastomosis and the fistula closure site. At the beginning the TEF was closed with 5 mm titanic clips. As the clips in a few cases disappeared on X-ray taken later ligation of the fistula was started. The esophageal anastomosis was made over the nasogastric tube using routinely sliding (slipping) 4–0 or 5–0 absorbable knots. If there was a considerable tension two or three sliding knots were placed and closed gradually. If the anastomosis was successful, the chest drainage was not routinely used. For the primary cases there was no need to use the electrocautery—the procedure was bloodless with blunt tissue dissection. The first procedure took almost 360 minutes; the last cases were completed within 60 to 80 minutes. Conclusions The thoracoscopic repair of EA/TOF is an effective method and based on our experience it is the procedure of choice if performed by an experienced endoscopic pediatric surgeon.