Use of Thoracoscopic Traction to Repair Long-Gap Esophageal Atresia

Abstract

Introduction:

This video describes the use of thoracoscopic traction to repair a long-gap esophageal atresia (LGEA) in a newborn. There remains a large variability in surgical techniques and management of infants with LGEA. Bogusz et al. ¹ provided an alternative strategy for the repair of LGEA. Rather than the traditional thoracotomy, the novel repair strategy is a multistage thoracoscopic technique that uses internal traction sutures. The process involves repeat thoracoscopic lengthening performed at 5-day intervals with increasing tension until definitive repair is achieved without tension.

Materials and Methods:

We present an effective case using multistage thoracoscopic internal traction suture for repair of a long-gap type A (pure) esophageal atresia. A 2.41 kg 37-week estimated gestational age infant underwent gastrostomy tube placement on day of life (DOL) 3. Initial thoracoscopic internal traction sutures were placed on DOL 15. Before the procedure, the gastrostomy tube was removed and a guidewire was advanced into the distal esophagus for identification. A gastroscope was placed into the proximal esophagus allowing accurate measurement of the gap length at four vertebral bodies. An internal locking barbed traction suture was placed through the distal esophagus and then the proximal esophagus. Tightening of the sutures reapproximated the two ends to within 2.5 vertebral bodies. Five millimeter clips were placed over the two sutures to disperse force and allow identification of the ends on X-ray. Repeat thoracoscopic lengthening was performed on DOL 20 and DOL 24, allowing opposition of the two ends. Definitive repair was achieved on DOL 28, or 13 days after the initial thoracoscopic repair.

Results and Conclusions:

Effective repair of LGEA is achievable with multistage thoracoscopic internal traction sutures. After definitive repair, the patient had a small leak shown on the esophagram that resolved within a week. The patient was discharged 24 days after definitive repair on goal feeds by mouth and gastrostomy tube. The entire hospital course from birth to discharge was 7 weeks and 3 days. Postoperatively, the patient returned for three elective outpatient esophageal dilatations, and no longer requires a gastrostomy tube for feeds. Use of thoracoscopic internal traction to repair a long-gap esophageal atresia can transform the way we treat and manage LGEA.

Acknowledgment:

The surgical approach to repair and strategy was facilitated by the Midwest Pediatric Surgery Consortium.

No competing financial interests exist

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Runtime of video: 5 mins 59 secs