Advertisement

Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium

Published:September 24, 2022DOI:https://doi.org/10.1016/j.jpedsurg.2022.09.015

      Abstract

      Background/purpose

      Controversy persists regarding the ideal surgical approach for repair of esophageal atresia with tracheoesophageal fistula (EA/TEF). We examined complications and outcomes of infants undergoing thoracoscopy and thoracotomy for repair of Type C EA/TEF using propensity score-based overlap weights to minimize the effects of selection bias.

      Methods

      Secondary analysis of two databases from multicenter retrospective and prospective studies examining outcomes of infants with proximal EA and distal TEF who underwent repair at 11 institutions was performed based on surgical approach. Regression analysis using propensity score-based overlap weights was utilized to evaluate outcomes of patients undergoing thoracotomy or thoracoscopy for Type C EA/TEF repair.

      Results

      Of 504 patients included, 448 (89%) underwent thoracotomy and 56 (11%) thoracoscopy. Patients undergoing thoracoscopy were more likely to be full term (37.9 vs. 36.3 weeks estimated gestational age, p < 0.001), have a higher weight at operative repair (2.9 vs. 2.6 kg, p < 0.001), and less likely to have congenital heart disease (16% vs. 39%, p < 0.001). Postoperative stricture rate did not differ by approach, 29 (52%) thoracoscopy and 198 (44%) thoracotomy (p = 0.42). Similarly, there was no significant difference in time from surgery to stricture formation (p > 0.26). Regression analysis using propensity score-based overlap weighting found no significant difference in the odds of vocal cord paresis or paralysis (OR 1.087 p = 0.885), odds of anastomotic leak (OR 1.683 p = 0.123), the hazard of time to anastomotic stricture (HR 1.204 p = 0.378), or the number of dilations (IRR 1.182 p = 0.519) between thoracoscopy and thoracotomy.

      Conclusion

      Infants undergoing thoracoscopic repair of Type C EA/TEF are more commonly full term, with higher weight at repair, and without congenital heart disease as compared to infants repaired via thoracotomy. Utilizing propensity score-based overlap weighting to minimize the effects of selection bias, we found no significant difference in complications based on surgical approach. However, our study may be underpowered to detect such outcome differences owing to the small number of infants undergoing thoracoscopic repair.

      Level of evidence

      Level III.

      Keywords

      Abbreviations:

      EA (Esophageal atresia), TEF (Tracheoesophageal fistula)
      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Surgery
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Lee S.
        • Lee S.K.
        • Seo J.M.
        Thoracoscopic repair of esophageal atresia with tracheoesophageal fistula: overcoming the learning curve.
        J Pediatr Surg. 2014; 49: 1570-1572
        • Thakkar H.
        • Mullassery D.M.
        • Giuliani S.
        • Blackburn S.
        • Cross K.
        • Curry J.
        • et al.
        Thoracoscopic oesophageal atresia/tracheo-oesophageal fistula (OA/TOF) repair is associated with a higher stricture rate: a single institution's experience.
        Pediatr Surg Int. 2021; 37: 397-401
        • Woo S.
        • Lau S.
        • Yoo E.
        • Shaul D.
        • Sydorak R.
        Thoracoscopic versus open repair of tracheoesophageal fistulas and rates of vocal cord paresis.
        J Pediatr Surg. 2015; 50: 2016-2018
        • Wu Y.
        • Kuang H.
        • Lv T.
        • Wu C.
        Comparison of clinical outcomes between open and thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: a systematic review and meta-analysis.
        Pediatr Surg Int. 2017; 33: 1147-1157
        • Koga H.
        • Yamoto M.
        • Okazaki T.
        • Okawada M.
        • Doi T.
        • Miyano G.
        • et al.
        Factors affecting postoperative respiratory tract function in type-C esophageal atresia. Thoracoscopic versus open repair.
        Pediatr Surg Int. 2014; 30: 1273-1277
        • Yang Y.F.
        • Dong R.
        • Zheng C.
        • Jin Z.
        • Chen G.
        • Huang Y.L.
        • et al.
        Outcomes of thoracoscopy versus thoracotomy for esophageal atresia with tracheoesophageal fistula repair: A PRISMA-compliant systematic review and meta-analysis.
        Medicine. 2016; 95 (Baltimore): e4428
        • Drevin G.
        • Andersson B.
        • Svensson J.F.
        Thoracoscopy or thoracotomy for esophageal atresia: a systematic review and meta-analysis.
        Ann Surg. 2021; 274: 945-953
        • Zani A.
        • Lamas-Pinheiro R.
        • Paraboschi I.
        • King S.K.
        • Wolinska J.
        • Zani-Ruttenstock E.
        • et al.
        Intraoperative acidosis and hypercapnia during thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia/tracheoesophageal fistula.
        Paediatr Anaesth. 2017; 27: 841-848
        • Laberge J.M.
        • Blair G.K.
        Thoracotomy for repair of esophageal atresia: not as bad as they want you to think!.
        Dis Esophagus. 2013; 26: 365-371
        • Bishay M.
        • Giacomello L.
        • Retrosi G.
        • Thyoka M.
        • Garriboli M.
        • Brierley J.
        • et al.
        Hypercapnia and acidosis during open and thoracoscopic repair of congenital diaphragmatic hernia and esophageal atresia: results of a pilot randomized controlled trial.
        Ann Surg. 2013; 258: 895-900
        • Borruto F.A.
        • Impellizzeri P.
        • Montalto A.S.
        • Antonuccio P.
        • Santacaterina E.
        • Scalfari G.
        • et al.
        Thoracoscopy versus thoracotomy for esophageal atresia and tracheoesophageal fistula repair: review of the literature and meta-analysis.
        Eur J Pediatr Surg. 2012; 22: 415-419
        • Way C.
        • Wayne C.
        • Grandpierre V.
        • Harrison B.J.
        • Travis N.
        • Nasr A.
        Thoracoscopy vs. thoracotomy for the repair of esophageal atresia and tracheoesophageal fistula: a systematic review and meta-analysis.
        Pediatr Surg Int. 2019; 35: 1167-1184
        • Lal D.R.
        • Gadepalli S.K.
        • Downard C.D.
        • Ostlie D.J.
        • Minneci P.C.
        • Swedler R.M.
        • et al.
        Perioperative management and outcomes of esophageal atresia and tracheoesophageal fistula.
        J Pediatr Surg. 2017; 52: 1245-1251
        • Bence C.M.
        • Rymeski B.
        • Gadepalli S.
        • Sato T.T.
        • Minneci P.C.
        • Downard C.
        • et al.
        Clinical outcomes following implementation of a management bundle for esophageal atresia with distal tracheoesophageal fistula.
        J Pediatr Surg. 2021; 56: 47-54
      1. Zhou T., Tong G., Li F., Thomas L.E. Psweight: An r package for propensity score weighting analysis. arXiv preprint arXiv:201008893. 2020.

        • Thomas L.E.
        • Li F.
        • Pencina M.J.
        Overlap weighting: a propensity score method that mimics attributes of a randomized clinical trial.
        JAMA. 2020; 323: 2417-2418
        • Lal D.R.
        • Gadepalli S.K.
        • Downard C.D.
        • Ostlie D.J.
        • Minneci P.C.
        • Swedler R.M.
        • et al.
        Challenging surgical dogma in the management of proximal esophageal atresia with distal tracheoesophageal fistula: Outcomes from the Midwest Pediatric Surgery Consortium.
        J Pediatr Surg. 2018; 53: 1267-1272
        • Fusco J.C.
        • Calisto J.L.
        • Gaines B.A.
        • Malek MM.
        A large single-institution review of tracheoesophageal fistulae with evaluation of the use of transanastomotic feeding tubes.
        J Pediatr Surg. 2018; 53: 118-120
        • Wang C.
        • Feng L.
        • Li Y.
        • Ji Y.
        What is the impact of the use of transanastomotic feeding tube on patients with esophageal atresia: a systematic review and meta-analysis.
        BMC Pediatr. 2018; 18: 385
        • LaRusso K.
        • Joharifard S.
        • Lakabi R.
        • Nimer N.
        • Shahi A.
        • Kasasni S.M.
        • et al.
        Effect of transanastomotic feeding tubes on anastomotic strictures in patients with esophageal atresia and tracheoesophageal fistula: The Quebec experience.
        J Pediatr Surg. 2022; 57: 41-44
        • Zani A.
        • Eaton S.
        • Hoellwarth M.E.
        • Puri P.
        • Tovar J.
        • Fasching G.
        • et al.
        International survey on the management of esophageal atresia.
        Eur J Pediatr Surg. 2014; 24: 3-8
        • Okuyama H.
        • Tazuke Y.
        • Ueno T.
        • Yamanaka H.
        • Takama Y.
        • Saka R.
        • et al.
        Learning curve for the thoracoscopic repair of esophageal atresia with tracheoesophageal fistula.
        Asian J Endosc Surg. 2018; 11: 30-34