Dariusz Patkowski, MD, PhD - Best of the Best in Pediatric Surgery 2024

We are ready for the 3rd presentation of the day. For that, we have Doctor Darius Patkowski. He, well, I think we all know who Doctor Patkowski is. He's a pediatric surgeon from Poland, and he is representing IPEC, the International Pediatric Endosurgery Group, with the work Thoragoscopic Approach for Long Gap esophageal attricia using the internal traction technique. So, let's see the presentation. Once again, thank you very much for choosing our technique to present at the symposium Best of the Best. The technique was designed to bridge the gap between the esophageal pouches of long gap esophageal essia, which for me means type A and B, using stage thorachoscopic approach. All 27 cases of long gap were operated tchoscopically. Both ends of the esophagus are brought together under tension with internal traction suture. This is a static, not active tension. The preoperative rigid bronchoscopy is a standard procedure to check for upper fistula and any tracheal malformation. The patient lies in a prone position on the edge of the operating table. The right scapula is the anatomical reference point for trochal placement. The distal esophagus is usually located at the level of the diaphragm. It is dissected bluntly from surrounding tissues. The upper esophageal pouch and if present, the fistula are dissected in a similar manner. There is no need to use electrosurgery. The fistula is ligated on both sides and cut. Instead of a ligature, you can use clips or a 5 millimeter stapler. Placing the internal traction suture requires full thickness of tissue, including the mucosal layer. For internal traction, we use a 20 non-absorbable braided suture. The technique of tying a sliding knot in a small space requires a lot of skill and experience. It is one of the bases for success. Two sliding knots are made on both arms of the suture. The clips are placed to cover the entire thickness of the tissue and part of the suture. This method prevents leaks and allows for greater force to be used for traction. If necessary, both sliding knots can be converted to move in both directions. There's no need to rush. Time is needed for the tissue to stretch. Wait a moment. Be careful when applying traction force so as not to damage the tissues. Finally, the sliding knots must be blocked. Subsequent stages are performed every 1 to 5 days. There is no need for a gastrostomy. The patient remains intubated in the intensive care unit on parenteral nutrition. We don't use chest drainage. I am personally against suction with the repro tube, as it dries the mucosa, in my opinion. I prefer intermittent suction on demand. Anastomosis is possible if both ends overlap, but care must be taken when deciding. There is no way back. Any failure will result in the loss of part of the esophagus. After pouches opening. The 8 French nasogastric tube is passed down into the stomach. Traction must be maintained until the first sutures are placed, because both esophageal pouches can easily retract, making anastomosis very difficult. The basis of the perfect anastomosis is a sliding knot. Typically you need to place two or more sliding knots and then gradually close them. It doesn't matter whether the anastomosis begins from the anterior or posterior wall, as the anastomosis can be rotated freely around. If anastomosis is not possible, the sliding knots can be reopened and used again to bring pouches closer together. We use the thoracoscopic internal traction technique in 25 cases of long gap esophageal atrasa and completed with anastomosis in 23 cases. Most cases were completed in 2 stages, but we also had 2 cases operated on in 5 and 6 stages. Initially, the time between stages was about 4 weeks, but this was reduced to a few days. This is our last series of 9 primary cases without gastrostomy, with an average. Hospital stay of 31 days. One stomach pull up complication was later successfully treated laparoscopically. In the conclusion, the lachoscopic approach using internal traction technique has the potential to change the way we manage the long gap esophageal tracia. Uh, Darius, as always, you know how I feel about you, uh, as one of the greatest surgeons of our time. Um, I have a lot of questions. Um, So, you, when you're going in and putting the two ends together, And you could probably think you could get them together. Like you, it would be tight, but you could probably get them together and it would be super tight. Is it, are those the ones where you say, I'm not even gonna try, I'm just gonna do this first, or is it only if there's just a big distance between them? In other words, would you do this instead of having a tension repair repair? You know, that's always a very difficult decision when you Try when you decide to make the anastomosis. So when you see that both ends overlap each other, OK, you can start with the anastomosis, but Right now with our very good experience, probably if there is any tension, even if, if they overlap each other, I would like to connect them with one suture and just live it for 2 or 3 days more and then go again. OK. No, this is because, you know, if you do stage repair, especially with minimally invasive surgery, so I mean about the thochoscope. So it's not so harmful to the patient. So even if you repeat every 2-3 days. And you give the chance for the baby to have its own native esophagus, it's really a great success. Yeah, Um, Miguel, Miguel asked the question. I was wondering about what for, actually, you use this, I'm assuming for pure atresias as any long gap, whether it's a, a type C or a pure atresia, right? I am very strict about the definition of long gap. OK. Long gap, it's just only type A and B. It's my definition, of course, many people agree with them because if you say that type C is a long gap, it's quite a different story. It's quite a different, so I don't want to mix them together, just separate type A and B and type C. To my experience. Uh, type C was always possible to make the anastomosis primary anastomosis. Only the only exception is that the patient was unstable, so this was just the only exception. And uh I don't know, do I Cecilia, can I ask another question, or are we out of time? Yes, we have a little time. OK, so, um, if first of all, I think the two big things here that um are something that I, that are relatively new that are big for these cases are number one, the concept of going back to surgery, sequential surgery. We used to always try to do it in one, I like this concept, especially with thoracoscopy. But the sliding knot is something that not everybody is facile with, and it is critical to become really good at a sliding knot as you just showed, uh, both in the anastomosis and in the tension. If you're doing the, if you go into the, you, you put the stitch, you go back 3 or 4 or 5 days later, and it's still not there, you said you cut it out and put a whole new stitch in, or you just keep tightening it. You just open it. If you are very familiar with the sliding note, yeah, you locked it, blocked it, then you can reopen it. So I use the same, OK, I use every time I entered the chest again, I use the same sliding notes. You unlock it. Yes, that's it. That's why it is so fantastic. And in your video you show how best to unlock it, which by pulling the two just so this is why, uh, what I said you must be very familiar because you, you should know which line to straight up. That's always the problem, you know, you must see it exactly. So this is always that one end is a little bit longer, the other end is a little bit shorter. The long one is going up, for instance, the, uh, short one is going down. That's very important. So this is what I said. You, that's my quotation, that sliding knot changed my surgical life. Yeah, we need to do a whole course in sliding knots. It's just for young generation because many young surgeons are here. You have to attend good meetings. I was at the IPEC meeting in 2005 at Venice. And someone, my friend Peter Chaudderna, showed me how to do the sliding knot. And suddenly, for me, it was like a revolution. Everything changed. Jasmine Jeff is so cheek. I totally agree how to use it. It's a perfect, yeah, I totally agree. Um, Darius, there's a lot of questions for you in the chat that we're not gonna be able to get to, so we can, um, maybe you can answer it here and then we'll put it back in the chat for you. OK, I will answer it. All right, Darius, thank you so much. Thank you so much. Thank you. Thank you.