**1. Introduction**

308 Front Lines of Thoracic Surgery

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> Surgical correction of esophageal atresia with tracheo-esophageal fistula (EA-TEF) has been performed since 1943 (Cameron Haight) via postero-lateral thoracotomy using an extrapleural approach in most cases. This procedure can be considered as the standard treatment of EA. The pitfalls of the operation, the incidence of complications and the outcomes, both short term and long term, have been analysed and reported by many pediatric surgeons around the world.

> Since 1999, minimal access surgery (MAS) has been practised for the correction of EA 1. The risk of complications and short term outcomes have been reported as equal to the open approach. MAS has been advocated because of a possibly reduced risk of impairment of shoulder function, and a possible reduction in occurrence of postoperative scoliosis. Next to that, it has been postulated the MAS repair might lead to a better cosmesis.

> Several advantages and disadvantages of both procedures have been described. The open approach is well standardized and is resorted to in difficult cases. Disadvantages of the open approach are the presence of a scar, possible chest wall deformities and rib fusion. The occurrence of scoliosis and possible shoulder function impairment has been related to the open approach as well.

> The thoracoscopic approach has the advantage of magnification of view. Next to that the chance on a postoperative scoliosis and impaired shoulder function may be reduced due to the small incisions which also might lead to better cosmesis. Technically, the thoracoscopic approach is more demanding than the open approach which has consequences for training and education.

> So far, it seems that there is no difference between open and MAS approach in the frequency of anastomotic leakages, strictures, recurrent fistulas, tracheomalacie or GERD.

> In 2005, Holcomb et al presented their results of MAS (thoracoscopic) EA-TEF repair in 104 patients in multiple centres. This landmark paper has been extensively discussed by leaders

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

experience in 104 patients.

(Table 2)

Table 2.

D (proximal and distal fistula) 7.

thoracoscopic repair was studied 17.

(Thoracoscopic Repair) of Esophageal Atresia with Tracheo-Esophageal Fistula (EA-TEF) 311

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

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

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.

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

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.

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) does not list a study on this subject.


Table 1.
