**7. Other complications**

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

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% after open repair 21,27.

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

MAS and open repair.

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

but will have to be followed very carefully.

What do these findings mean?

terms of early post-operative results.

(Thoracoscopic Repair) of Esophageal Atresia with Tracheo-Esophageal Fistula (EA-TEF) 315

Manometry and 24-hours pH monitoring did not demonstrate any differences between

There is only one paper 11 mentioning the consequences of *tracheomalacia* requiring aortopexy. There seem to be no differences between MAS and studies after open repair.

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

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

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

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

in postoperative pCO2 max levels as in postoperative PH and base excess.

50%) and even paraplegia is reported after thoracotomy 36,37,38.

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 was not reported in any of these papers.

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 reported.
