A Retrospective Study Of Thoracoscopic Versus Open Thoracotomy Repair Of Esophageal Atresia And Tracheoesophageal Fistula

Objective:The purpose of this study was to evaluate the treatment outcome of the thoracoscopic versus thoracotomy for esophageal atresia(EA)and tracheoesophageal fistula(TEF).Methods:A retrospective review of EA cases performed from 2010 to 2017 in Zhujiang Hospital,Southern Medical University.68 patients were included in our research,all the patients were definite diagnosed by upper digestive tract imaging,46 patients were treated with thoracoscopic operation and 26 with thoracotomy.Thoracotomy:The patient was in prone position with a slight elevation of the right side of the thorax.The skin is incised in the 5th intercostal area on the posterolateral side of the right breast.And then separated the muscles between the ribs.An extra-pleural approach was utilized to gain exposure to the EA.The TEF was ligated initially,followed by mobilization of the proximal pouch and subsequent mobilization of the distal esophageal segment.The esophageal ends were then anastomosed in a single layer with a monofilament absorbable suture to achieve esophageal continuity.Then the gastric tube was advanced through the distal esophagus and located in the stomach.Thoracoscopic:The patient was in an almost prone position with a slight elevation of the right side of the thorax.The 5 mm camera port was inserted below the tip of the scapula.The first 3 mm port was located paravertebrally.Under direct visualization,the second 3 mm port was inserted in the anterior auxiliary line.At the beginning of the operation,the distal esophagus was mobilized with dissection of the azygos vein and ligatured the fistula close to the trachea.At this step of the operation,the distal esophagus was not transected.The esophageal tube inserted by the anesthesiologist helped in the localization of the upper esophagus.The upper pouch was dissected proximally.A firm connection between the upper pouch and the trachea,which might result in accidental opening of the esophagus,was usually observed.The proximal esophagus was elongated by blunt dissection.Once adequate mobilization was obtained,the tip was cut The distal esophagus was transected from the trachea,and an anastomosis was performed.Usually,4 stitches(5-0,Braun)were knotted on the rear wall of the esophagus with the knots made on the outside,then the gastric tube was advanced through the distal esophagus and located in the stomach.Then the anterior wall of the anastomosis was completed.Thoracic tubes were left in the pleural space with the tip of the tube located near the anastomosis,but subsequently the pleural cavity was closed without drainage.Observation indexes:Duration of operation and intraoperative blood loss;Postoperative ventilator time;The removal time of drainage tube after operation;Postoperative feeding time;Postoperative hospital stay;The incidence of postoperative complications:anastomotic fistula,anastomotic stenosis,tracheal softening,recurrent esophageal tracheal fistula,esophageal diverticulum,etc.Postoperative routine digestive tract angiography was performed in 1 month after surgery,for example,there was a narrow line of dilatation,followed by 3 months of follow-up every 3 months,followed by 1~2 years.Statistical methodSPSS 22.0 was used for statistical analysis,and t test or rank and test were used for measurement data.The counting data was tested by the chi 2 test,and P<0.05 was considered to be statistically significant.Results:According to the Gross 's pathological classification of esophageal atresia,1 case of type ?;19 cases of type ?a,46 cases of type III B and 2 cases of type IV were found in this group.The average operation times in the thoracoscopic group were longer than that in the open group(P=0.002).But the amount of blood was less than open group(P=0.021).There was no statistically difference in extubating time,feeding time and postoperative hospitalization time(P both>0.05).The rates of anastomotic leakage and stenosis were similar in both groups(P both>0.05).Open group has 4 cases of wound infection,1 case of thoracic deformity,2 cases of recurrent TEF,1 case of tracheal diverticulum and 1 case of achalasia.Three patients in open group died and the rest survived.Conclusion:Thoracoscopic surgery to repair esophageal atresia and tracheoesophageal fistula is safe and feasible,and the amplification effect and fine operation of endoscope can reduce the total incidence of postoperative complications.