Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018

Every year we try to do a session on technique and um so this year, uh, Doctor Rothenberg is going to talk to us about the thoracoscopic TEF. Uh, however, uh, not everyone believes that this is necessarily the better operation. Uh, and so what I've asked Doctor Alex Gibbons, uh, who is uh my research fellow here in Akron. To give us a brief presentation on what does the data really say of open versus thoracoscopic as it relates to the TEF repair, the esophageal chesa TEF repair. So Alex, uh, Alex is a, uh, Cleveland Clinic, uh, general surgery resident who's doing 2 years of research at Akron Children's. So Alex, thank you, Todd, and thank you to everybody around the world for tuning in. Uh, can I get the pass? So as Todd just said, today I'm going to be talking about uh what the data suggests so far in terms of thrachoscopic versus open repair of esophageal atresia and tracheoesophageal fistula. But before I get started, just wanted to kind of assess the audience here. For those who operate for oesophageal atresia and tracheoesophageal fistula, which surgical technique do you prefer, thoracoscopy or thoracotomy? This poll will be up for the duration of my talk, so take your time and get into it. Just a kind of brief overview of, uh, history of tracheoesophageal fistula repair. The first successful open repair was performed in 1941 by this man, Doctor Cameron Haight, and from 1941 until the, sure. And a little high is already plugging his ears. There's a huge difference between esophageal resia and TEF, and every resident calls it TEF when they mean esophageal tree. So please, that's precision is got, yeah, yeah, OK, go ahead. And from 1941 until the turn of the millennium, uh, open was the only way to go about repairing this. However, in the year 2000, Doctor Steven Rothenberg performed the first successful repair of a tracheoesophageal fistula. esophageal atresia had been the year before, um, with a minimally invasive approach, and in his first decade of experience, he operated on 62 patients and published his series, and he felt that. Um, the benefit of doing the thorachoscopic approach, uh, there were multiple ones, but he felt that it offered better visualization of the anatomy. He felt that, uh, by performing the operation entirely in situ, he had, uh, reduced manipulation of the trachea and therefore, uh, potentially a reduced risk for tracheomalacia, um, and decreased tension on the esophageal anastomosis. Um, he additionally felt that due to the smaller incisions, uh, there'd be, um, fewer musculoskeletal deformities, uh, such as scapular winging, chest wall asymmetry, um, and, uh, uh, scoliosis as well. So that's a, a single surgeon's experience. Um, Next we'll move to, uh, a single center. Um, so there was a group in, uh, tubing in Germany that, um, published their results from about a decade. And they had patients that underwent either open repair or minimally invasive repair, and they had this going on during the same time frame. And they noticed a couple of different differences in the baseline characteristics between the two groups. Specifically, the minimally invasive group was slightly larger at about 22,700 g compared to 2100 g in the open group, and there were slightly more associated anomalies in the minimally invasive group at about 40% compared to 31% in the open group. But with those different baseline characteristics in mind, uh, they had a couple of different areas that they wanted to look at. Specifically, they wanted to look at associated or any complication rates between the two. They wanted to look at length of time to postoperative extubation. They wanted to look at the the intraoperative PACO2 and postoperative PACO2, and they wanted to look at operative timing. So they found that there was no statistically significant difference between the groups in terms of complication rate or in time to postoperative extubation. Um, they found that it was a slightly longer operative time at about half an hour longer in the minimally invasive group than in the open group, and they found that there was a higher interoperative PACO2, but postoperatively there was no statistically significant difference between those two groups. Um, so moving from a single center then to a multi-center experience, uh, this was an article published by Doctor Holcomb as the first author, and Doctor Rothenberg was an author as well. It looked at 6 different hospitals around the world, uh, and there were a total of 104 patients, uh, included in the series. Those 6 hospitals were, um, moving from west to east in, uh, Stanford, California, in Kansas City, Missouri, in, uh, Denver, Colorado, in Buenos Aires, Argentina. In Utrecht, Netherlands, and in Hong Kong, China. And they found that in terms of they compared their data to that of historical controls that had been published describing open series, and they found that their findings were pretty much equivalent in terms of mortality rate and in terms of a need for a postoperative fundalplacation, and they found that their results compared favorably in terms of leak and in terms of recurrence. A different international study was published at 7 different Japanese hospitals, and they had a total of 58 patients included. Those 7 hospitals are shown here, 4 of them in Tokyo and 3 in southern Japan. And they also found that there was pretty much equivalence in terms of mortality, leak rate, and recurrence, but they found a higher stricture rate in the minimally invasive group. It was about 48% compared to 17% in the open group. One issue that they wanted to address but couldn't due to lack of longer term follow-up was those musculoskeletal deformities and sequela that Dr. Rothenberg had mentioned in his reports. Um, so there's a couple of pictures here to kind of demonstrate what some of those musculoskeletal deformities are. In this picture here you can see some scapular winging as well as some chest wall asymmetry, Specifically, the nipple is a different distance from the xiphoid, and there's another example of that here. Um, there's a group in Germany that, uh, that in Hanover that decided to kind of assess these musculoskeletal sequela, so they looked at patients that had had either minimally invasive or an open thoracic procedure done for a benign thoracic condition. So this wasn't limited to just esophageal atresia or tracheoesophageal fistula. But they found that um patients that they followed up in clinic for an average of 3 to 4 years, they decided to look at a rate of scoliosis, patient satisfaction with scarring. Chest wall asymmetry and range of motion differences in terms of their shoulder range of motion. And they found that in the patients who had a minimally invasive repair, they had an improved rate of mild scoliosis. It was over 50% in the thoracotomy group compared to less than 10% in the minimally invasive group. Patients overall were more satisfied with their scarring based on the Manchester scarring criteria. The chest wall asymmetry was improved in the minimally invasive group, specifically in terms of chest wall diameter and in terms of distance of the nipple to the xiphoid, and they found that there was no difference in terms of shoulder range of motion. Next, I just want to discuss some of the meta-analyses that have been done, two specifically. One of them was published in 2012, and it looked at a total of 4 articles representing 166 patients, uh, 69 of whom were repaired minimally invasively and 97 of whom were repaired with an open technique, and they wanted to look at 4 specific outcomes. They looked at stricture rate, rate of leak, operative time, and time to post-operative extubation. And they found that there was no statistically significant difference in any of these outcomes. However, a subsequent meta-analysis published 4 years later had a slightly larger sample size because it included 8 articles instead of 4. so they had 452 patients to draw from, 221 of whom were done minimally invasively and 231 of whom were done open. They also decided to look at those same measures, specifically the stricture rate, the leak rate, the operative time, and the time to extubation, but they included two other factors as well. So they looked at time to first postoperative feeding, as well as total hospital length of stay. They also found that there was no difference in terms of stricture rate or in terms of leak rate. They found a slightly longer operative time in terms of the minimally invasive group. It was about 20 minutes longer in the minimally invasive group, and they found that there was a shorter time to postoperative extubation and first postoperative feeding. So those kids were able to do both of those about 2.5 days sooner, and their length of stay was almost 11 days shorter. Finally, um, obviously the gold standard for any type of evidence is randomized control trial. Um, unfortunately not quite there yet in terms of, uh, comparing these techniques, but there was a, uh, pilot study that was done by an anesthesia group at Children's Hospital in London, uh, where they had 10 patients that they randomized to either a minimally invasive, uh, group or the open group, and they looked at different interoperative parameters for that. They found that there was no difference in terms of the intraoperative PACO2, the pH, the time in the OR, the peak inspiratory pressure, or the length of ICU stay. But they did find that there was only 1 stricture in the open group compared to 3 strictures in the thoracoscopic group, and there was also 1 leak in the thoracoscopic group compared to none in the open group. Um, so I can't really make any meaningful conclusions from that due to the small sample size, but just wanted to kind of mention that as the pilot randomized control trial that has been done for this discussion. So in conclusion, to kind of draw back around to the question of whether thoracoscopic repair is better than the open repair, and I think the data would suggest a qualified yes. So all the studies that have done have been done by surgeons who are extremely talented and minimally invasively, so there is a learning curve associated with it that has to be considered, but The retrospective data that we have would suggest that there's no difference in terms of the leak rate or the stricture rate. There is a potential benefit in terms of time to extubation, time to first oral feeding, overall hospital length of stay, and those musculoskeletal sequela that can potentially happen. And uh the chief limitation again remains the technical demand, specifically the challenge of the anastomosis done in situ, um, but again we're lacking uh level one evidence here, um, so there remains a need for a powered randomized controlled trial. All right, so I have to, uh, your slide's up right now. So I have to tell you something, uh, that, that I, we didn't tell you ahead of time that actually this was a test, and we wanted to see how you would handle yourself under pressure. So for those of you out there, to give you an idea of what happened, Alex just ran through his entire talk with animation and everything purely by feel and gut instinct on when he should be advancing, uh, his animation, and he did it perfect. That was like the Jedi Knight action I just saw there. Um, and you hit on, uh, a lot of good stuff. This is the question is what kind of data do we have? Um, you started with sort of experiential and then moved into some retrospective stuff, some metas analysis, but really we don't have anything prospective yet except for that very one limited, uh, analysis, so, um. I want comments here. Uh, uh, I'm wondering if I should go to Steve first. Uh, all right, Steve, what were your thoughts on what Alex presented? Well I think Alex, you did a great job. I think you know there, there is limited data. I think, I think that in most centers that that do advanced MIS, the procedure has proven to be equivalent, and if we had more numbers and more data, we might be able to show that it was slightly better. Or you know, perhaps I, I don't think it's been proven at all since Witt put our study together 10 years ago that um it's worse, so I think it's equivalent or the technique and some of us believe would be slightly better. I think the big thing here is that we're eliminating the thoracotomy, and I think that is the primary reason for doing this. Um, I think a lot of surgeons can do the operation very well open. But no matter what kind of thoracotomy you do, and, and I was a pioneer of the muscle sparing thoracotomy. I wrote the first paper on it in pediatrics, there is morbidity associated with having a thoracotomy as an infant and so if we can avoid that incision and end up with an equivalent operation. Then I think as pediatric surgeons who are looking for the long term care of our children not only as postoperatively but for the rest of their lives, we need to be committed to that and to me that's the driving force behind doing this. I personally think you can see the operation better. I mean, I, I think you know watching this operation on a big magnified high definition screen. You can see things better than you can see when we're all trying to look through small incisions with loops and all of that, but I really think the purpose of this is is avoiding that complication the same way that nobody gets an open gallbladder, nobody gets an open knee operation, because we're trying to avoid the morbidity of that incision. You know what's amazing to me is at the IPEC meetings we always keep watching over the years the polls changing and who does it thoracoscopically, but this audience is a true. Uh, slice of the pie of the world of who's doing what, and I am shocked that 45% of the audience does this operation thoracoscopically. That, that's surprising. Well, I, I mean, the more shocking thing to me was that I thought that's higher than I would have expected for the world. This is a representation of the whole world and 45% of the, of the world, of this slice of pie of 800 people, you know, or whatever, do it thocoscopically. I mean, I mean if you think about the fact that the first one was done almost 20 years ago. The fact that there was a recent study that was presented at IPEC from the Midwest Consortium, Consortium, I think at 10 hospitals, is it 10, but you know that they and that less than 15% of the cases were done thoracoscopically in major training centers in the US, that to me is remarkable that that a technique that has been shown. Not only feasible but comparable. so I would, I would challenge you just on that that it's comparable because I think that's what people, first of all, I think it is technical, your very last point, many people don't feel technically comfortable doing it and then the challenge is we have to demonstrate that they're comparable and, and you're never gonna get a randomized controlled study or at least it would be a very expensive study to run. To do that, a prospective randomized study, so I, I, I mean, and I'm a proponent of doing it. I just think it's taken a long time because people, it's taken a long time for people to acquire the skills to do that. I think the problem, at least in our country, is not the problem, but the issue is the training program paradigm that the fellows who are not as experienced as many staff are then being trained slash taught. To do the operation, but they are perhaps the least experienced person in the operating room so that we in our country, I think, need to somehow. get a training paradigm for this operation where there's a more experienced person doing it and I think more, more US centers will be doing it as opposed to having the trainee do it under the assistance of the experienced surgeon because at least in the report that Steve and I were involved with 13 or 14 years ago, the surgeons in there were very experienced. Which I think is sometimes lost and that's why the results are I think are quite good. We had 3 recurrences, I think, in 104 patients, which, and I, but I think it's because the surgeons were very experienced in MIS, not necessarily. In MIS, I think we're all saying the same thing. It requires people who are skilled to do this and then pass that on to the trainees. It takes a while for those trainees who get that experience to then come back around and actually teach the faculty wherever they go how to do it. And that's why I think that that there's been a lag in a lot of acceptances, if that's the right word, among the US, uh, I think there's a couple and we do both, but I think I'd be very cautious about a broad paint stroke of all. EA's being repaired thoracoscopically because there's, uh, we selectively choose the ones, so that we can get optimize the outcomes based on the technique and skill of the surgeon. So, Uh, but that's looking at it from the surgeon's perspective, not the patient's. No, we're looking for, we're trying to get good patient outcomes. That's ultimately our goal. The difficulty with the MIS approach is that you can't take down easily the common law between the of the TE. I, I strongly disagree. I think you can do it better. You can see it better. I see so much better. Yeah, but let me, let me just make an argument. Do you put a bronchoscope in? And make sure that you have a flat repair, or do you just leave a diverticulum? Well, I never, you, you actually have less of a diverticulum thoracoscopically than you do open because you get, I'll show it, you, you get a perpendicular view. And so you, because I've had to resect a number of diverticulums and they were all done open. I've never had to resect the diverticulum thoracoscopically. And if you brought the kids who were done thoracoscopically, again, assuming that it's done by a skilled surgeon. What you get to see thoracoscopically is you get to see the fistula come in direct directly perking at 90 degrees, which you don't see when you do it open. So let's, that's a great segue. Let's go ahead and, and guys show us how this is done.