**10. Studies on systemic effects of MAS**

314 Front Lines of Thoracic Surgery

There were no reports on any cosmetic benefit in any of the papers on MAS. And although there is more awareness of the effect of thoracotomy on shoulder-function and *scoliosis* this

The duration of follow-up after discharge from the hospital was reported in 7 papers with means varying between 6 and 30 months. No further *long-term complications* as dysphagia, late pulmonary disease both restrictive and obstructive and late sequelae from GER are

In summary a total of 22 papers reporting on 332 EA-TEF repairs performed via MAS revealed no prospective studies and only four comparative studies with historic and

The focus of this chapter is on the type C, or esophageal atresia with fistula (TEF) as this is the most common form in esophageal atresia. Even with these numbers data are sometimes

Allthough it is not the aim of this chapter a special mention has to be made of the role of MAS in correction of type A (long gap) EA. In some of the reviewed papers, these patients have been included because a esophago-esophagostomy was performed 3,5,6. And there are a number of other reports on the role of MAS in esophageal replacement. For example Stanwell 29 describes 7 patients in whom gastric transposition was performed and were laparoscopically assisted. In this study five of these had a long gap EA. Esteves 30 reported on laparoscopically assisted colon interposition in 5 children with long gap EA. Nevertheless because of the small numbers in these studies, the different nature and the conflicting views on the various procedures (primary anastomosis vs replacement by stomach,

When analyzing the results on *patients characteristics* it does not appear that there is a difference in the selection of patients in favour of any of the procedures. The gestational age, birth weight and associated malformations were similar to data recorded in open

There is a wide variety between reports when focusing on post-operative results and complications. Consistent differences are lacking when compared with results reported for open thoracotomies as is seen in Table 1 and 2. The biggest problem however is the definition of a complication in these cases like anastomotic leakage and anastomotic stricture. For example esophagrams are not made routinely everywhere. Therefore, a difference in the incidence of esophageal strictures is likely to be present due to the difference in classification and not due to an incidence of occurrence of anastomotic

Also the follow-up data on MAS repair of EA-TEF is scarce, but again, they do not indicate that the incidence of *gastro-oesophageal reflux (GER)* and GER requiring anti-reflux surgery is different from that in patients who had open repairs of the esophageal atresia with TEF. Kawahara 8et al studied the influence of MAS on esophageal motor function and gastroesophageal reflux in 7 patients in comparison to 10 patients who had an open repair.

colon or jejunum), these papers have not been included in this review.

was not reported in any of these papers.

contemporary open repairs as controls.

scarce and difficult to compare.

**9. Clinical outcomes** 

repair.

strictures.

reported.

**8. Discussion** 

In several papers the systemic effects of thoracoscopy in neonates are emphasized. In the findings of Bishay 15 (6 Congenital Diafragmatic Hernias and 2 EA-TEF) on decreased cerebral oxygen saturation measured by Near Infra Red Spectrometry (NIRS) might cause concern. These changes and also the decreased arterial pH values had not recovered after 24 hours. However the real value of NIRS is still not clear and is extensively discussed in a study by Pennekamp 31. So far, the long term effect on brain development remains unknown but will have to be followed very carefully.

In the study by Kalfa et al 32 a cohort of 49 neonates who underwent MAS was investigated, among them five with esophageal atresia. They also found decreased values of saturation due to thoracic insufflation of CO2. Some other data are reported, such as thermic loss, which is proportional to duration of operation, and a decreased systolic arterial pressure, responding to vascular expansion. But these data are not comparative to open surgery.

Krosnar 16 also noted a decrease of oxygen saturation, and their patients required 100% inspired oxygen in order to maintain the saturation above 85%. They also experienced difficulties in end-tidal CO2 monitoring. But on the other hand Szavay 10 in his retrospective comparative analysis in 68 patients of which 25 were operated via MAS showed no differences in postoperative pCO2 max levels as in postoperative PH and base excess.

What do these findings mean?

To begin with, all papers are retrospective studies with inconsistent reporting of results. Obviously, the multi-center study by Holcomb 11 et al should be seen as the standard at this moment with only few institutions reporting on datasets of more than 20 MAS procedures 5,13,2,10,12,4 of which one comparative multicenter study 4. Even if these papers are compiled no consistent pattern arises to show superiority or inferiority of MAS versus open repair in terms of early post-operative results.

Secondly, almost all reports come from pioneers in this field who have endeavoured with great zeal to advance the skills in pediatric MAS. On one hand, this implies that these studies represent early experiences and learning curves. On the other hand, these results were obtained by the experts and therefore may be difficult to attain by less experienced surgeons. There is still a world to win in MAS as spreading of MAS is possible in centres without pioneers. After passing their learning curves their results would become better and the patients could benefit from it. Already from adult literature we know that there are benefits of minimal invasive surgery when compared with open surgery by means of better cosmesis, body-image, lenght of stay and reduced postoperative complications 33 <sup>34</sup> 35.

One of the reasons to advocate MAS for EA-TEF repair is the cosmesis and elimination of shoulder function disturbances and scoliosis, that in the past has been reported after open thoracotomies. But until now hard evidence is not available for either for the contention that MAS gives better cosmetic and functional results, or for the better results of muscle-sparing thoracotomies in children. It is interesting that also breast-development, chronic pain (in 50%) and even paraplegia is reported after thoracotomy 36,37,38.

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

gastroesophageal reflux. *J Pediatr Surg* 2009; 44(12):2282-2286.

multi-institutional analysis. *Ann Surg* 2005; 242(3):422-428.

ventricle physiology. *Anesth Analg* 2005; 101(4):1000-2, table.

*Laparoendosc Adv Surg Tech A* 2009; 19 Suppl 1:S19-S22.

*Surg Tech A* 2008; 18(5):753-756.

*Adv Surg Tech A* 2011; 21(5):439-443.

fistula. *Semin Pediatr Surg* 2005; 14(1):2-7.

*Paediatr Anaesth* 2005; 15(7):541-546.

*Adv Surg Tech A* 2006; 16(2):174-178.

over two decades. *Arch Surg* 1995; 130(5):502-508.

distal fistula. *J Pediatr Surg* 2002; 37(2):192-196.

2011; 15(6):615-620.

(Thoracoscopic Repair) of Esophageal Atresia with Tracheo-Esophageal Fistula (EA-TEF) 317

[8] Kawahara H, Okuyama H, Mitani Y, Nomura M, Nose K, Yoneda A et al. Influence of

[9] Lugo B, Malhotra A, Guner Y, Nguyen T, Ford H, Nguyen NX. Thoracoscopic versus

[10] Szavay PO, Zundel S, Blumenstock G, Kirschner HJ, Luithle T, Girisch M et al.

[11] Holcomb GW, III, Rothenberg SS, Bax KM, Martinez-Ferro M, Albanese CT, Ostlie DJ et

[12] Patkowsk D, Rysiakiewicz K, Jaworski W, Zielinska M, Siejka G, Konsur K et al.

[13] Rothenberg SS. Thoracoscopic repair of esophageal atresia and tracheo-esophageal

[14] Mariano ER, Chu LF, Albanese CT, Ramamoorthy C. Successful thoracoscopic repair of

[15] Bishay M, Giacomello L, Retrosi G, Thyoka M, Nah SA, McHoney M et al. Decreased

[17] Ceelie I, van DM, Bax NM, de Wildt SN, Tibboel D. Does minimal access major surgery

[18] Nguyen T, Zainabadi K, Bui T, Emil S, Gelfand D, Nguyen N. Thoracoscopic repair of

[19] Engum SA, Grosfeld JL, West KW, Rescorla FJ, Scherer LR, III. Analysis of morbidity

[20] Bax KM, van der Zee DC. Feasibility of thoracoscopic repair of esophageal atresia with

[21] Manning PB, Morgan RA, Coran AG, Wesley JR, Polley TZ, Jr., Behrendt DM et al. Fifty

children with esophageal atresia. *J Pediatr* 2010; 156(5):755-760.

hernia and esophageal atresia in infants. *J Pediatr Surg* 2011; 46(1):47-51. [16] Krosnar S, Baxter A. Thoracoscopic repair of esophageal atresia with tracheoesophageal

thoracoscopic esophageal atresia repair on esophageal motor function and

open repair of tracheoesophageal fistula and esophageal atresia. *J Laparoendosc Adv* 

Perioperative Outcome of Patients with Esophageal Atresia and Tracheoesophageal Fistula Undergoing Open Versus Thoracoscopic Surgery. *J Laparoendosc* 

al. Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a

Thoracoscopic repair of tracheoesophageal fistula and esophageal atresia. *J* 

esophageal atresia with tracheoesophageal fistula in a newborn with single

cerebral oxygen saturation during thoracoscopic repair of congenital diaphragmatic

fistula: anesthetic and intensive care management of a series of eight neonates.

in the newborn hurt less? An evaluation of cumulative opioid doses. *Eur J Pain*

esophageal atresia and tracheoesophageal fistula: lessons learned. *J Laparoendosc* 

and mortality in 227 cases of esophageal atresia and/or tracheoesophageal fistula

years' experience with esophageal atresia and tracheoesophageal fistula. Beginning with Cameron Haight's first operation in 1935. *Ann Surg* 1986; 204(4):446-453. [22] Yanchar NL, Gordon R, Cooper M, Dunlap H, Soucy P. Significance of the clinical

course and early upper gastrointestinal studies in predicting complications associated with repair of esophageal atresia. *J Pediatr Surg* 2001; 36(5):815-822. [23] Castilloux J, Noble AJ, Faure C. Risk factors for short- and long-term morbidity in

Another argument for MAS could be the reduced need for opioid administration postoperatively.The effects of MAS on *post-operative pain* as measured by opioid requirements were studied by Ceelie 17 et al in 10 CDH and 14 EA patients. No differences were found compared to matched controls (20 CDH and 28 EA) concerning cumulative opioid doses at different time points postoperatively.

An improved esophageal function after thoracoscopic repair, represented by more effective motility and less gastro-esophageal reflux have not been demonstrated in the patients series of Kawahara 8.

Could MAS have negative influences in comparison to open repair?

The insufflation of the pleural cavity appears to have greater impact on arterial oxygen saturation particularly in cerebro than open repair, as demonstrated by Bishay 15 using NIRS. But as mentioned earlier no comparative study has been done and the validation in open surgery for EA with TEF has not been done.

In summary, making up the balance between MAS and open repair, there appear to be no differences in short term results, both in terms of complications and postoperative pain or ICU-stay. Little is known about the long term outcomes, but again, no differences have been recorded. So far there is no data available on the cosmetic or shoulder/spine/chestwall outcomes after MAS. However Holcomb is mentioning that ample literature is now available about long term sequelae from thoracotomies such as, besides scoliosis, mammary maldevelopment and chronic postoperative pain, even after muscle-sparing thoracotomy 39. Some concern has been raised about the harmful effects of MAS in newborns on cerebral perfusion and subsequent development.

This emphasises the need for a prospective, randomised trial as has already been stated by Holcomb 11 in 2005.

#### **11. References**


Another argument for MAS could be the reduced need for opioid administration postoperatively.The effects of MAS on *post-operative pain* as measured by opioid requirements were studied by Ceelie 17 et al in 10 CDH and 14 EA patients. No differences were found compared to matched controls (20 CDH and 28 EA) concerning cumulative

An improved esophageal function after thoracoscopic repair, represented by more effective motility and less gastro-esophageal reflux have not been demonstrated in the patients series

The insufflation of the pleural cavity appears to have greater impact on arterial oxygen saturation particularly in cerebro than open repair, as demonstrated by Bishay 15 using NIRS. But as mentioned earlier no comparative study has been done and the validation in

In summary, making up the balance between MAS and open repair, there appear to be no differences in short term results, both in terms of complications and postoperative pain or ICU-stay. Little is known about the long term outcomes, but again, no differences have been recorded. So far there is no data available on the cosmetic or shoulder/spine/chestwall outcomes after MAS. However Holcomb is mentioning that ample literature is now available about long term sequelae from thoracotomies such as, besides scoliosis, mammary maldevelopment and chronic postoperative pain, even after muscle-sparing thoracotomy 39. Some concern has been raised about the harmful effects of MAS in newborns on cerebral

This emphasises the need for a prospective, randomised trial as has already been stated by

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[4] Al TT, Zamakhshary M, Aldekhayel S, Mandora H, Sayed S, AlHarbi K et al.

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18(1):20-22.

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Holcomb 11 in 2005.

**11. References** 

Could MAS have negative influences in comparison to open repair?

of Kawahara 8.


**Part 5** 

**Cardiothoracic Anaesthesia** 

