**3. Results**

The initial search resulted in 55 articles. After critical review by two independent reviewers twenty-one articles were included, based on the criteria stated above.

There were no RCT's or prospective studies. All papers were based on retrospective analysis, mostly single center cohort or case studies. The largest population was reported in a multicenter review by experts in minimally invasive pediatric surgery combining the experience in 104 patients.

Together the 22 articles contained 332 patients who had (type C) EA-TEF repair via the thoracoscopic approach, 11 patients with isolated (type A) 3,4,5,6 and one case report of type D (proximal and distal fistula) 7.

At a closer look there are different study-designs in those 22 articles in which only four papers 4,8,9,10 did a retrospective analysis with historic 4 or contemporary 8,9,10 open approaches as controls. (Table 1) Seven papers reported the results of thoracoscopic EA-TEF repair containing at least 20 patients per report for a total of 312 patients 4,11,5,12,13,2,10. (Table 2)

Several papers, particularly in the early period, concentrated on technical and feasibility aspects dealing with the initial diagnosis of esophageal atresie. Other studies highlighted special characteristics of the patients, like cardiac malformations 14. Also on anesthesiological subjects, including the effects of CO2 inflation 15,16 and pain after thoracoscopic repair was studied 17.


#### Table 2.

310 Front Lines of Thoracic Surgery

in the field and highlights the need for a randomized clinical trial. Since that discussion, several more articles have been published on MAS repair of EA-TEF, but no prospective comparative studies, let alone RCT's. The Clinical Trials Register (www.clinicaltrials.gov)

EmBase and PubMed (Medline) search using keywords (MESH terms): <Minimal access surgery> OR <thoracoscopic surgery> OR <thoracoscopy> AND <esophageal atresia> Only full text papers in English were included. If more than one paper had been published by the same author or group of authors 2, only the most recent paper was included in order

Two authors reviewed all papers and selected those that contained sufficient data on patients characteristics and outcome parameters to enable comparison with reports on open

The initial search resulted in 55 articles. After critical review by two independent reviewers

does not list a study on this subject.

Table 1.

**2. Methods**  Search strategy:

to avoid duplications.

3. follow-up data

**3. Results** 

repair of EA-TEF of patients operated after 1995. Parameters recorded are represented in table 1.

2. intra-operative and post-operative data, including complications

twenty-one articles were included, based on the criteria stated above.

Three categories can be discerned 1. patients' characteristics

> To compare the results of the minimal invasive operations with open operations, data were distilled from the literature (Table 3). This represents the results from textbooks and standard papers on open repair of EA-TEF. Also these results on open approach are based on retrospective studies and did not comprise RCT's or prospective studies.

Systematic Review of the Literature: Comparison of Open and Minimal Access Surgery

concerning extubation time (extt) and discharge to PICU(DPICU) .

a better postoperative recovery of the MAS approach.

parameter no difference could be demonstrated.

**6. Complications** 

and recurrent TEF. (Table 1, 2, 3)

**7. Other complications** 

18 to 32.2% of cases 19,27,28,21,22.

after open repair 21,27.

(Thoracoscopic Repair) of Esophageal Atresia with Tracheo-Esophageal Fistula (EA-TEF) 313

operative ventilation 11,3,20,9,13 (range 1-4.6). Of interest is the paper of Krosnar 16 where, although in a small number, a comparison between open and MAS approach is done

These results were for an open approach with an extt of 54 hrs and DPICU discharge of 3.4 days and for the MAS approch extt 37.6 hrs and DPICU of 2.75 days. This numbers suggest

*Length of hospital stay* was reported in 7 articles, some giving mean, others median values so a good comparison of these numbers is not justified. The mean length of stay in Hollcombs' paper compares favorably with open repairs as reported by Manning 21 18.1 days for MAS and 24 for the open method. This historic group however might not be representative for present l.o.s so the evidence is not clear. Also Lugo 9 found a difference in l.o.s as it is 21 days in MAS (n=8) and 66 days in the open approach (n=25) but in here hard evidence seems to be scarce as the numbers are small. *Mortality* related to the procedure was recorded in 14 articles and 11 reported no mortality; in the other three it varied between 1 and 16%. But these were small numbers also 18. In the series reported by Holcomb the mortality rate was 0.9 %. Yanchar 22, reported 1.1 % mortality after open repair in 90 patients. For this

The main short term complications are leakage of the anastomosis, anastomotic strictures

*Anastomotic leakage* was reported in 18 papers. Important is that the definition may differ between the papers depending on whether routine esophagograms were performed or not. Most leaks were described as minor and healed spontaneously. The incidence varies between 0 and 30% with a median 15%. There is no difference with the reported leak rates in

A clear definition of *anastomotic stricture* is an important factor. Most authors define stricture by the need for (repeated) dilatations however others state that narrowing of more than 50% of the lumen or every narrowing detected on an esophagram with a symptomatic patient can be seen as an anastomic stricture 25,26. Sixteen papers reported an incidence between 9 and 45%, with a median of 22%. This incidence is comparable to the rates reported after open repair (6-52%) by Holland 24 and in the literature (Table 3). The incidence of the serious complication of a *recurrent tracheo-oesophageal fistula* was noted in 8 articles. The incidence varied between 0 (in 5 papers) and 4%. In the open repair series

Allthough *gastro-oesophageal reflux* is often seen after repair of esophageal atresia with TEF, the need for anti-reflux surgery was mentioned in 4 articles. The incidence of anti-reflux surgery varied from 22 to 50% (1,3,4,19). Procedures performed, if reported, were Thal or Nissen-fundoplication. Antireflux surgery numbers after open approach was performed in

The need for aortopexy in case of a severe *tracheomalacia* is mentioned in only one paper 11 were it was performed in 6.8% of the cases. This is compatible with the rate of 4.7% and 16%

the open thoracotomies in the papers 8,9,23,24,22 and in the literature.(Table 3)

and in the literature, similar incidences have been reported (Table 3).


Table 3.

#### **4. Patiens' characteristics**

The *gestational age and the birth weight* of MAS patients were not different from open repairs in the comparative studies (2.7-2.8 kg MAS vs 2.0-2.4 open Table 1). In the minimal invasive group the thoracoscopic approach was succesfully performed even in premature babies with weights below 1500 g 18,5,2 but these are not different from data in the literature for open repair (19 , mean 2557 with range 1100-4460 g).

Concerning the *associated malformations and risk classification* only Holcomb 11 et al present data on Waterston classification(A 62, B 30 and C12) respectively. The reported associated malformations were seen in up to 87.5% 9 of the thoracoscopically repaired babies, but in the comparative studies no difference is seen between MAS (39-87%) and open (47-72%) concerning these associated malformations

#### **5. Perioperative data**

Mean *duration of operation* was recorded in 12 articles and ranged between 95 and 260 minutes. In the comparative studies the paper of Szavay 10 reveals a significantly longer operation time (open 106 min versus MAS 141). But Al Tokhais 4 and Lugo 9 did not find a significant difference in operation time between them with 179 and 123 min open and 149 and 156 min.for MAS.

*The conversion rate* was reported in 15 papers, in which no conversion was done in 9 papers and in the remaining 6 papers the rates varied between 5 and 16%.

The *duration of postoperative ventilation* was mentioned in 10 papers. One reported no difference between open and MAS patients 4, others reported mean duration of 4 days postoperative ventilation 11,3,20,9,13 (range 1-4.6). Of interest is the paper of Krosnar 16 where, although in a small number, a comparison between open and MAS approach is done concerning extubation time (extt) and discharge to PICU(DPICU) .

These results were for an open approach with an extt of 54 hrs and DPICU discharge of 3.4 days and for the MAS approch extt 37.6 hrs and DPICU of 2.75 days. This numbers suggest a better postoperative recovery of the MAS approach.

*Length of hospital stay* was reported in 7 articles, some giving mean, others median values so a good comparison of these numbers is not justified. The mean length of stay in Hollcombs' paper compares favorably with open repairs as reported by Manning 21 18.1 days for MAS and 24 for the open method. This historic group however might not be representative for present l.o.s so the evidence is not clear. Also Lugo 9 found a difference in l.o.s as it is 21 days in MAS (n=8) and 66 days in the open approach (n=25) but in here hard evidence seems to be scarce as the numbers are small. *Mortality* related to the procedure was recorded in 14 articles and 11 reported no mortality; in the other three it varied between 1 and 16%. But these were small numbers also 18. In the series reported by Holcomb the mortality rate was 0.9 %. Yanchar 22, reported 1.1 % mortality after open repair in 90 patients. For this parameter no difference could be demonstrated.
