CEA is a serious gastrointestinal malformation caused by impaired development of the esophagus in the third to sixth week of embryonic development, with a prevalence ratio of approximately 1:2500–4000(6). CEA is the third most common congenital gastrointestinal malformation (7, 8) after anorectal malformation and congenital megacolon. Although the exact cause of CEA pathogenesis is still unknown, it may be related to inflammation, vascular dysplasia, genetics, and environmental factors(9, 10). CEA is clinically classified into 5 types (types I-V) according to gross typing, with type III CEA being the most common and accounting for approximately 85% of cases (11). Type III CEA is divided into type IIIA and type IIIB according to the distance between the two ends of the esophagus, with distances exceeding 2 cm being type IIIA and distances not exceeding 2 cm being type IIIB. Surgery is the only way to treat CEA.
In recent years, with the development of thoracoscopic surgery, the minimally invasive concept has become the current focus of and primary direction for research on pediatric surgery. Since Lobe first reported thoracoscopic surgery for cases of esophageal atresia in 1999, the technique has been used in several treatment centers in China and internationally (12, 16), and this minimally invasive concept and technique is being increasingly considered (17). Thoracoscopy combines exploration, diagnosis and treatment into one procedure, avoiding the limitations of conventional open-heart surgery. In general, pulmonary compression of the pulmonary hook during open-heart surgery causes respiratory circulation instability and leads to recurrent surgical intervention, whereas thoracoscopy avoids this drawback and reduces the operative time to some extent. Although there is a certain learning curve for thoracoscopic surgery(17, 19), the operative time is significantly reduced as surgeons gain experience in lumpectomy. The duration of thoracoscopic surgery in this dataset was shorter than that of open thoracic surgery, and this result is generally consistent with the results found by Szava(20)and Cui (21), indicating that proficiency in thoracoscopic techniques can reduce the duration of surgery.
The incision made for traditional open-chest surgery is long and traumatic; it may lead to postoperative complications involving musculoskeletal changes in the chest wall, such as high scapular chest wall deformity, chest wall asymmetry, rib fusion, pectoral muscle dysplasia, and scoliosis. In contrast, thoracoscopic surgery requires only three 3-mm holes in the chest wall to complete the operation, and the incision is small, causing little damage to the chest wall, intercostal muscles and nerves, which can significantly reduce the incidences of surgical scarring and chest wall deformity. Suzuki M(22)and Bastard F (23) reported that the incision was significantly shorter and the incidence of chest wall deformity was significantly lower in thoracoscopic surgery than in open chest surgery. Similarly, in our study, the length of the surgical incision in the thoracoscopic group (1.12 cm) was shorter than that in the open-chest group (6.68 cm).
In thoracoscopy, the surgical field of view is larger and clearer, which is conducive to the identification and separation of tissues and organs and can help the operator precisely identify fine bleeding points in the surgical field and stop bleeding in a timely and accurate manner. As a result, surgical bleeding is significantly reduced. Data from a study by Zhang(24) suggest that intraoperative and postoperative transfusions of blood products are rarely needed. In the present study, the amount of surgical bleeding in the thoracoscopic group was less than that in the open-heart surgery group. That is, thoracoscopic surgery is associated with less surgical bleeding, a decreased risk of blood transfusion and lower treatment costs.
Postoperative type III CEA requires routine ventilator-assisted ventilation to reduce anastomotic tension and facilitate anastomotic healing. Zhang(24)et al. demonstrated that the duration of ventilator use after thoracoscopic surgery was significantly shorter than that after open-heart surgery; Elhattab A(25) et al. reported that the duration of mechanical ventilation in children in the thoracoscopic group was shorter than that in the open-chest group. Our study involved a postoperative ventilator use time of 125.6 h in the lumpectomy group, which was significantly shorter than that in the open-chest surgery group. The reduction in mechanical ventilation time is conducive to early tracheal extubation and restoration of spontaneous breathing, which facilitates faster postoperative lung function recovery, reduces the incidence of chest infection and promotes absorption of lung inflammation. Overall, it enables the child to recover quickly after surgery(26, 27).
Anastomotic stenosis and anastomotic leakage are common postoperative complications of type III CEA. Some studies have reported an incidence of anastomotic stenosis of 18–50% and anastomotic leakage of 12–22%(28, 29). In the lumpectomy group, the incidence of anastomotic stenosis was 21.15% versus 23.81% in the open-chest group, and the incidence of anastomotic leakage was 17.31% versus 19.05%. The incidence of both complications was significantly lower in the lumpectomy group than in the open-chest group, and although the difference was not statistically significant, these data suggest that thoracoscopic surgery does not increase the incidence of type III CEA anastomotic stenosis or anastomotic leakage, which is consistent with the results reported by Borruto FA et al.(30). Furthermore, Viñuela EF (31) showed that anastomotic tension and blood flow at the blind end of the esophagus are important factors affecting anastomotic healing. Additionally, thoracoscopic surgery with a large and clear field of view and adequate esophageal freeing can be performed upward to approximately 2 cm above the thoracic inlet and downward to approximately the upper edge of the esophageal fissure, thus reducing the difficulty of suture knotting and anastomotic tension at both ends of the esophagus and reducing the incidence of anastomotic stricture and anastomotic leak. In addition, Okata et al. (32) reported that CEA type is an important cause of postoperative anastomotic stenosis and anastomotic leak because of the large blind end spacing of type IIIA CEA, which makes surgery more difficult compared to type IIIB; thus, patients with type IIIA CEA are more prone to anastomotic stenosis or anastomotic leak than those with type IIIB. In the lumpectomy group, there was one child with type IIIA CEA who suffered anastomotic leakage combined with severe pneumonia on the 5th postoperative day, and the family abandoned treatment. In the other children with postoperative anastomotic leak, the anastomotic leak healed after 5–14 days of conservative treatment with anti-infection therapy and nutrition enhancement, based on angiogram review.
Tracheoesophageal fistula recurrence is a serious complication of type III CEA, and its etiology is unclear. Coran AG (33)suggested a correlation between the inflammatory response around the anastomosis after the initial procedure and the presence of other complications, such as combined anastomotic leakage. Nir V (34) suggested an association between respiratory symptoms and viral capillary bronchitis. Tracheoesophageal fistula recurrence requires reoperation as soon as it is diagnosed. In our study, there were 3 cases (5.77%) of tracheoesophageal fistula recurrence in the lumpectomy group and 2 cases (9.52%) in the open group; the difference between the two groups was not statistically significant, which shows that the surgical approach does not have a significant impact on the tracheoesophageal fistula recurrence rate. Of the five children who developed tracheoesophageal fistula, three had recurrent choking and pulmonary infections after surgery. According to the children's postoperative condition, one child underwent open tracheoesophageal fistula repair three months after surgery, and the other two underwent open tracheoesophageal fistula repair again six months after the first surgery. All three children recovered well after surgery. The remaining 2 children underwent tracheoesophageal fistula repair at another hospital at 6 months after surgery.
In our center, the incidence of postoperative complications after surgical management of recurrent tracheoesophageal fistulas due to CEA was reduced due to the following: ① The incidence of anastomotic stenosis can be reduced to a some extent by using a thicker gastric tube through the anastomosis and securely fixing it after surgery.② When suturing the esophagus, the first stitch suspends the esophagus on the chest wall to maintain tension on the esophagus, which helps to surgeon to suture the posterior wall of the esophagus, thus reducing the occurrence of anastomotic leakage.③ In children with recurrent tracheoesophageal fistula, surgery is performed after correction of pneumonia and improvement of nutritional status. During the operation, the location of the fistula is confirmed under fiberoptic bronchoscopy, the fistula is carefully repaired with free sutures, and the esophagotracheal fistula is isolated by wrapping the esophagus with pleura.
In conclusion, in thoracoscopic surgery, the surgical field of view is clear, thereby facilitating the success of the surgical procedure, shortening the postoperative ventilator use time, and leaving an aesthetically pleasing incision. The surgery is safe and reliable for neonates. It may become the preferred surgical approach for physicians who are skilled in thoracoscopic surgery.