QUAD #10 Pt.3: Advantages of Thoracoscopic Repair of Esophageal Atresia with Dr. Steve Rothenberg

Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi, I'm M Goti 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 Airodigestive Society Conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's pediatric dysphagia series. And today, we're going to hear from Dr. Steve Rothenberg, a pioneer in minimally invasive repair of TEF and esophageal atresia, and chief of pediatric surgery at the Rocky Mountain Hospital for Children. This time, we'll talk about the advantages of minimally invasive repair. I think that when we operate on these patients, we create some of the tracheomalacia that they develop, because we crank on the trachea as we're trying to do the dissection. This patient is a 35-week premature baby that was too small to put together. In another institution, they did open surgery and ligated the fistula. And I wanted to show this because this is one of the things that I think is more common than we know. This baby has a huge pouch because where they ligated the fistula was way below where he should have been gone. One of the beauties of thoracoscopic repair is how you can elevate the esophagus and dissect down and see right where the fistula goes into the membranous portion of the trachea. This is his pouch. This is how much esophagus was left on his trachea. And so, I think we do this better thoracoscopically than we do open. Although, I know people can leave significant pouches. I've operated six of these pouches thoracoscopically where I've had to go in and resect this leftover pouch by using a little stapler and it makes it quite easy. And then you can see here that he had a high upper pouch. And according to Dr. Rothenberg, the key to getting this together is gaining the length. It's the ability to stack way up into the thoracic inlet so the surgeon can dissect all the way up to the posterior oropharynx if they need to and do it under direct vision. So I think that's really key. This is him and this was his anastomosis after we did it because it was under fair amount of tension, but we dilated him up and he's eating everything now. We no longer classify type Cs as long gap. Dr. Rothenberg mentioned that in Rocky Mountain Hospital for Children, they have never not been able to get together a type C fistula. The initial procedure might have been a ligation and coming back later, but we've never had to sacrifice the esophagus for that. And I think it's because of the mobilization of the upper pouch. Their technique is to put a G tube in, allow growth for three to eight weeks, do bolus feeds, toughen up the lower pouch, and get a gap study. Then somewhere between four to eight weeks, go in and do the repair. And the key to me is extensive mobilization of the upper pouch. And here you can see this pouch when it started was right at thoracic inlet and I'm able to dissect all the way up and I was able to bring this down. Here, we see a patient with a six vertebral body gap. This patient's anastomosis is actually in the lower third of the chest because of how Dr. Rothenberg's team was able to mobilize the upper pouch. I'm going to be honest. It sounds very simple when Dr. Rothenberg explains it, but I don't think that's the case. So how long does it take to do these kind of repair? So, in these long gaps, the operative time is between 50 minutes to a little over 2 hours. We do have some documented leaks, but we were able to treat them all with conservative therapy. And now, we see the H-type fistulas. We now approach all of our H-type fistulas thoracoscopically. All these fistulas are in the same place. They're all right at the thoracic inlet. We can directly see the Vegas, we can see the recurrent laryngeal and I think we can avoid it better than doing it through a neck dissection and trying to do that. And again, the key is that they don't have to crank on the trachea and they're not retracting it out of the way to get to the fistula. With a minimally invasive approach, they can do it just under direct vision. And in these cases, I use the the stapler. You can see the staple line right there to divide it. And then put a little tissue between it. Dr. Rothenberg states that you have to be comfortable operating in this space and it's important to understand that these cases can be done just as well if not better thoracoscopically because of the visualization you get. And then I think there is the added benefit that we cause less tracheomalacia. I think we can avoid a lot of that morbidity if we approach these the right way. So let's summarize what we talked about in this video. In pediatric surgery, thoracoscopic techniques as opposed to open surgery, offer significant advantages in treating tracheal esophageal fistulas. This minimally invasive approach allows for precise dissection and reduces complications like tracheomalacia. It's particularly effective in mobilizing the upper pouch and handling type C fistulas. Dr. Rothenberg and his team's methods at Rocky Mountain Hospital for Children exemplifies successful outcomes, highlighting the efficacy of thoracoscopic surgery in these complex cases. Don't forget to subscribe to the StayCurrent MD YouTube channel. Follow our social media channels and download the StayCurrent 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.