Left thoracoscopic two-stage repair of tracheoesophageal fistula with a right aortic arch and a vascular ring.

A right aortic arch (RAA) is found in 5% of neonates with tracheoesophageal fistulae (TEF) and may be associated with vascular rings. Oesophageal repairs for TEF with an RAA via the right chest often pose surgical difficulties. We report for the first time in the world a successful two-stage repair by left-sided thoracoscope for TEF with an RAA and a vascular ring. We switched from right to left thoracoscopy after finding an RAA. A proximal oesophageal pouch was hemmed into the vascular ring; therefore, we selected a two-stage repair. The TEF was resected and simple internal traction was placed into the oesophagus at the first stage. Detailed examination showed the patent ductus arteriosus (PDA) completing a vascular ring. The subsequent primary oesophago-oesophagostomy and dissection of PDA was performed by left-sided thoracoscope. Therefore, left thoracoscopic repair is safe and feasible for treating TEF with an RAA and a vascular ring.

INTRODUCTION

A right aortic arch (RAA) is found in 5% of neonates with oesophageal atresia and tracheoesophageal fistulae (TEF)[1] and is often associated with vascular rings that encircle the trachea and oesophagus. Their presence may require left-sided thoracoscopy as an operative approach. To the best of our knowledge, our report is the first case of a successful two-stage repair by left-sided thoracoscope of a patient showing TEF with an RAA and a vascular ring.

CASE REPORT

After 37-week gestation, an infant was born by normal vaginal delivery with no foetal diagnosis but with difficulty breathing on the 1st day of life and was subsequently intubated. A nasogastric tube could not proceed through the upper oesophagus, and chest X-rays revealed a potential TEF. Cardiac ultrasonography could not detect any cardiac abnormalities.

We performed an operation by right thoracoscope using an optical 5-mm port, placed in the 6th intercostal posterior axillary line on the 1st day after birth and found an RAA and a right descending aorta. We changed the thoracoscopy to the left side using three ports: An optical 5-mm port, placed in the 6th intercostal posterior axillary line, and two 3-mm ports, placed in the 3rd intercostal mid-axillary line and 7th intercostal space just below the inferior angle of the scapula. A substantial artery was found, forming a complete vascular ring. A proximal oesophageal pouch was hemmed into the vascular ring [Figure 1]. We planned a two-stage repair. We dissected the TEF and used simple internal traction in the upper and lower oesophagus.[2]

Figure 1

Left-sided thoracoscopic view. The patient's head is to the left of this figure. An Lt-PDA and an RAA were found. They completed a vascular ring. A proximal oesophageal pouch (E) was hemmed in by the vascular ring. Lt-PDA: Left patent ductus arteriosus, RAA: Right aortic arch

After the first operation, we examined the cardiac anomaly by three-dimensional reconstruction of computed tomography [Figure 2] and repeated cardiac ultrasonography. The first branch from the aorta was the left common carotid artery. The second was the right common carotid artery. The right subclavian artery arose next, and the last branch of the aorta was the aberrant left subclavian artery (ALSA). The substantial artery, which was the left patent ductus arteriosus (Lt-PDA), passed from the Diverticulum of Kommerell[3] to the left pulmonary artery and completed a vascular ring. The lumen of the Lt-PDA almost closed naturally. After examinations, paediatric cardiovascular doctors permitted the Lt-PDA to be divided.

Figure 2

Computed tomography from (a) anterior and (b) left diagonal backward view. 1: Left common carotid artery, 2: Right common carotid artery, 3: Right subclavian artery, 4: Left subclavian artery, 5: Diverticulum of Kommerell, 6: Lt-PDA. Lt-PDA completed a vascular ring. Lt-PDA: Left patent ductus arteriosus

At 10 days old, we performed left thoracoscopic oesophago-oesophagostomy. The Lt-PDA was divided with suture clips. The proximal oesophageal pouch was mostly separate from the surrounding tissues and oriented downward without disrupting the Lt-PDA. Using left-handed sutures, the surgeon easily performed the left thoracoscopic oesophago-oesophagostomy.

The infant showed no surgical complications. A post-operative fluoroscopic contrast examination indicated no anastomotic leakage or stenosis of the oesophagus.

DISCUSSION

An RAA with oesophageal atresia and TEF may significantly complicate exposure and repair of the oesophagus via the right side of the chest. The proximal oesophageal pouch lies on the left side of the aortic arch, and the distal TEF lies to the left side of the descending aorta. Recently, some reports show repairs via right chest without complications,[4] whereas others propose that repairs via the left chest are safer than the right.[1]

An RAA may be associated with a vascular ring that encircles the trachea and oesophagus. There are two main types of RAA comprising 98% of cases: (1) RAA with mirror image branching (59.3%) and (2) RAA with an ALSA and left ductus arteriosus (39.9%).[5] We found the vascular ring during the first operation without pre-operative diagnosis, and planned to divide the vascular ring following further evaluation. If the vascular ring had been left intact at the time of oesophago-oesophagostomy, the patient could become symptomatic at a later date. Respiration and swallowing could be disrupted[3] by vascular rings compressing the trachea and oesophagus, and the formation of scar tissue can complicate subsequent operations through adhesion to oesophageal anastomosis. During the first operation, we examined the vascular ring in detail, finding it to be the Lt-PDA, which could be dissected during the subsequent operation.

CONCLUSION

We conclude that left thoracoscopic repair could be more suitable than right thoracoscopic repair for TEF with an RAA, as left thoracoscopy is a more manageable treatment for vascular rings, should they occur. We propose that left-sided thoracoscopic anastomosis of the oesophagus should be sutured by the left hand due to the angle of the needle holder.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.