QUAD #10 Pt.1: History of Thoracoscopic Repair of Esophageal Atresia (EA) & Tracheoesophageal Fistula (TEF) with Dr. Steve Rothenberg

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi, I'm M. Goddy from Cincinnati Children's Hospital Medical Center, and last year in October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination of four conferences the International Organization for Esophageal atresia. The Aerodigestive Society conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia Series, and today we're going to hear from Doctor Steve Rothenberg, a pediatric surgery legend and chief of pediatric surgery at the Rocky Mountain Hospital for. Children, he'll tell us more about the history of tchoscopic repair of oesophageal atresia and tracheoesophageal fistula. See, you won't get to hear stories often of the history of a surgical technique from the surgeon himself, so we're very excited to bring this to you. Thoracoscopic repair of esophageal atresia is an idea whose time has come. And you advocates for kids and patients with oesophageal atresia, I hope the one message I give to you is that it does make a difference. And that we should be doing everything we can to be approaching these patients in a minimally invasive fashion. A thoracotomy is the most morbid incision that we do. And when you do a thoracotomy in a newborn or an infant or a small child, there's a 30 to 40% chance that the child will develop some degree of shoulder girdle weakness, chest wall asymmetry, and scoliosis because we're operating on infants and because there's significant morbidity. It is our duty to try and minimize that morbidity if we can, certainly not compromise the operation we do, but to improve it. So Dr. Rothenberg became focused on minimizing morbidity early on. The operation that convinced him that we could actually do an esophageal atresia or a TEF repair torchoscopically was a PDA ligation. This procedure was first described in 1995 by Labour in Paris, and shortly after that we did the first one in Denver. We were the second to do it in the US, but you can see that for the surgeons in the room, we're going in the left chest, but this looks a lot like ligating the fistula to a TEF. And then the opportunity came in IPEC, which is the International Pediatric Endosurgery Group meeting in 1999 in Berlin. And this was the year before Dr. Rothenberg became the president of the organization. And then about 6 weeks before the meeting, Professor Waldschmidt, who was in Berlin, called myself and, and Tom Loeb, who was one of the early pioneers in minimally invasive surgery in kids, and he said, I have this baby with pure oesophageal atresia. What do you think about fixing it while you're here at the meeting doing live surgery in front of 1000 surgeons? And of course Tom and I said. Yeah, that sounds like a great idea. Let's go operate in a country we're not in our shop with instruments we don't know and do it live in front of 100 surgeons. They had actually been taking the child to the OR every other day and putting metal bougies in his upper and lower pouch and stretching him so that you can see on the X-ray it overlap. We spent about 2 hours trying to get single lung anesthesia, which was a ridiculous effort. And finally I took a Fogerty catheter, put it down the endotracheal tube, and I went down into the right main stem, and we used that to block it, something which we no longer do or need to do. And then with a random combination of maybe not so appropriate instrumentation, they did the operation and they were able to get the two ends together. So it was the first repair of an esophageal aresion in the world done thoracoscopically. And he did actually quite well. He had a stricture. It was dilated a few times, but he went on without any significant problems. The next year, Dr. Rothenberg was the president of IPEC. Just 4 days before he was leaving for the meeting, he'd been waiting for the right patient to come in, and This was at 3.2 kg, full term male with no other congenital anomalies, and he had a type C esophageal atresia. I talked to the parents and I said, I think I can do this operation thoracoscopically. I explained to them what I thought the benefits would be. We waited till later in the evening after everybody had left, so no one really knew what was going on. He said back in the day, you didn't go to an IRB and ask permission. You just went and did what you need to do and then you ask for forgiveness afterwards. And we did it and 2 hours later we'd done the first thochoscopic TEM and then I ran home, took that video, edited down into a little 10 minute video, left for the IPEG meeting for which I was the president, also the program chair. The chief cook, fundraiser, pretty much everything else, and I slipped it in the program in a spot where someone who couldn't make the meeting made it. He showed the video in front of 250 pediatric surgeons who just stared with their jaws open, not quite sure what they had seen, but it showed that they could do. This operation and actually the results would do well. This is his esophagram a week after surgery. That patient's name was Connor, and he is the first baby in the world to have torchoscopic repair of TEF, and both his bronch and his esophagram looked great. I never had to dilate him. And he just graduated from engineering school and is doing great. It set the stage for what I believed would be a transformative period for the repair of oesophageal atresia. In summary, torchoscopic repair is a minimally invasive alternative to traditional tchotomy for esophageal atresia, reducing post-surgical complications like scoliosis and shoulder girdle weakness in children. And Doctor Rothenberg pioneered tchoscopic repair for these kind of cases to shift management of these cases towards less invasive methods. The first successful surgery of this kind on a baby named Connor was performed under unique circumstances and led to significant advancements in pediatric surgery. And Connor's successful recovery and subsequent life achievements highlight the procedure's long-term effectiveness. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.