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Dariusz Patkowski, MD, PhD - Best of the Best in Pediatric Surgery 2024
With Dr. Darius Patkowski
Chapter 1 of 5 · Fundamentals
Introduction
Introduction of presenter and topic
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
The technique was designed to bridge the gap between esophageal pouches of long-gap esophageal atresia, which for the presenter means type A and B, using staged thoracoscopic approach.
All 27 cases of long-gap esophageal atresia were operated thoracoscopically.
Both ends of the esophagus are brought together under tension with internal traction suture using static, not active tension.
Preoperative rigid bronchoscopy is a standard procedure to check for upper fistula and any tracheal malformation.
The patient lies in prone position on the edge of the operating table with the right scapula as the anatomical reference point for trocar placement.
There is no need to use electrosurgery for dissection of the esophageal pouches and fistula.
For internal traction, a 2-0 non-absorbable braided suture is used.
Clips are placed to cover the entire thickness of the tissue and part of the suture to prevent leaks and allow greater force for traction.
Subsequent stages are performed every 1 to 5 days.
There is no need for a gastrostomy with this technique.
The patient remains intubated in the intensive care unit on parenteral nutrition between stages.
Chest drainage is not used with this technique.
The presenter is personally against suction with the Replogle tube as it dries the mucosa, preferring intermittent suction on demand.
Anastomosis is possible if both ends overlap, but care must be taken when deciding as there is no way back and any failure will result in loss of part of the esophagus.
If anastomosis is not possible, the sliding knots can be reopened and used again to bring pouches closer together.
The thoracoscopic internal traction technique was used in 25 cases of long-gap esophageal atresia and completed with anastomosis in 23 cases.
Most cases were completed in 2 stages, but there were also 2 cases operated on in 5 and 6 stages.
Initially, the time between stages was about 4 weeks, but this was reduced to a few days.
With current experience, if there is any tension even when pouches overlap, the presenter would connect them with one suture and leave it for 2 or 3 days more before completing anastomosis.
In the last series of 9 primary cases without gastrostomy, the average hospital stay was 31 days.
One gastric pull-up complication occurred and was later successfully treated laparoscopically.
The presenter strictly defines long-gap as only type A and B esophageal atresia, not type C.
In the presenter's experience, type C esophageal atresia was always possible to make primary anastomosis, with the only exception being when the patient was unstable.
The same sliding knots can be unlocked and reused at each subsequent operation rather than placing new sutures.
When unlocking a sliding knot, one end is a little bit longer and the other end is a little bit shorter; the long one goes up and the short one goes down.
Peter Chaudderna showed the presenter how to do the sliding knot at the IPEC meeting in 2005 in Venice.