The Modified Posterior Thoracotomy for Esophageal Atresia.

AIMS: Right dorsolateral thoracotomy with splitting or sparing the latissimus dorsi is the standard approach to the esophageal atresia. The thoracoscopic approach to the treatment of esophageal atresia is a demanding procedure used only by few surgeons in few centers. The purpose of this study is to present the modified posterior thoracotomy for neonates with esophageal atresia. PATIENTS AND METHODS: Between January 2007 and May 2016, the modified posterior thoracotomy was performed in 56 neonates with esophageal atresia.
RESULTS: The modified posterior thoracotomy preserves the latissimus dorsi and the thoracodorsal nerve. Neither the latissimus dorsi nor the serratus anterior is mobilized or skin flaps elevated. Satisfactory exposure, functional, and cosmetic results were obtained. No complication related to the approach was encountered.
CONCLUSION: The modified posterior thoracotomy is a reliable approach in the treatment of esophageal atresia in neonates.

INTRODUCTION

Right dorsolateral thoracotomy is the standard approach in the treatment of esophageal atresia with distal fistula. The thoracoscopic approach is a demanding procedure used only by few surgeons; furthermore, it is not available in all centers. We present a modified posterior approach in the treatment of esophageal atresia, sparing the latissimus dorsi. There is no need for anterior mobilization of the latissimus dorsi or serratus or the elevation of skin flaps.

PATIENTS AND METHODS

The modified posterior thoracotomy was performed in 56 neonates with esophageal atresia. The male to female ratio was 1:5. Patient age at diagnosis ranged from 1 day to 1 week. Prenatal diagnosis was made in 2 patients. Twenty-eight patients were admitted after attempts at oral feeding. Twenty patients were admitted with sepsis. The modified posterior approach was performed in all patients. A bilateral modified posterior thoracotomy was performed in one patient because of a right-sided aortic arch.

Surgical technique

The patient is positioned prone with a towel under the left side of the chest and the right hemithorax elevated 45°–60°. The right arm is in horizontal adduction. A 4 cm incision is made parallel and a cm way from the medial border of the scapula in the interscapular region [Figure 1a and b]. With a forceps, the medial border is elevated, and through the auscultatory triangle, the avascular fascia is entered with a pair of scissors perpendicular to the medial border of the scapula [Figure 1c]. A retractor is placed to elevate the scapula and to identify the fourth intercostals space [Figure 1d]. The intercostal musculature is divided with a pair of scissors without opening the parietal pleura. The parietal pleura is carefully swept off the thoracic wall. A rib-spreading retractor is placed in the intercostal space, carefully opened and a blunt extrapleural dissection started toward the posterior mediastinum. The azygos vein can be divided or preserved. The vagus nerve is located closer to the tracheoesophageal fistula and the upper pouch of the esophagus [Figure 1e and f]. After closing the fistula and testing the airtightness of the closure, the dissection of the upper pouch makes the end-to-end esophageal anastomosis possible [Figure 2a]. The extrapleural space is drained. The closure begins by bringing ribs together [Figure 2b] and approximating the avascular fascia with the lower border of the rhomboid major muscle by a running suture [Figure 2c]. The subcutaneous fat is closed with a running absorbable suture and the skin with an intradermal suture [Figure 2d].

Figure 1

Various steps of the modified posterior thoracotomy (a) Interscapular region Red arrow: Trapezius. Yellow arrow: Scapula. Green arrow: Rhomboid major. Blue arrow: Latissimus dorsi. (b) Newborn positioned. (c) Medial border of the scapula elevated, passage created by splitting the avascular fascia. (d) Elevation of the scapula to identify the fourth intercostals space. (e) Exposure of the posterior mediastinum. Blue arrow: Azygos vein. Orange arrow: Distal esophagus with a tape. (f) Posterior mediastinum. Yellow arrow: Vagus nerve. Blue arrow: trachea. Green arrow: Distal esophagus with a tape

Figure 2

Various steps of the modified posterior thoracotomy: (a) Another view of a posterior mediastinum: Orange arrow: End-to-end esophageal anastomosis performed. Blue arrow: Azygos vein preserved. (b, c) Chest tube is placed and the fourth intercostal space closed: Blue arrow: Latissimus dorsi. Green arrow rhomboid major. Black arrow Trapezius. (d) Final result after closing the incision

RESULTS

The follow-up period ranged from 4 months to 9 years (median 48 months). An easy and fast approach with satisfactory exposure was reported in all patients. Because of the late diagnosis, sepsis, and associated malformations 15 patients died. Anastomotic leak with spontaneous closure was noted in 5 patients. Esophageal stricture, diagnosed in one patient, was successfully treated by dilatation. The recurrent tracheoesophageal fistula was reported a year later in one patient who was reoperated using the same approach. However, the access was transpleural route with a good outcome. No complications such as seroma, infection, winged scapula, scoliosis, and death related to the approach were reported. Good functional and cosmetic results were noted [Figure 3a–c].

Figure 3

Long-term result: (a-c) Good cosmetic and functional long-term results, good abduction without winged scapula or scoliosis in a 3-year-old boy

DISCUSSION

Adequate exposure is the key to successful thoracic surgery.[1] The commonly used approach in the treatment of esophageal atresia with distal fistula is the dorsolateral thoracotomy. It can be performed by splitting or sparing the latissimus dorsi. The muscle split is painful and responsible for varying degrees of immediate or late functional impairment.[23] The muscle sparing technique to preserve the latissimus dorsi after the elevation of skin flaps can cause seromas.[145] This issue of skin flaps elevation can be prevented using the vertical skin incision.[1] The modified posterior thoracotomy we have reported preserves the latissimus dorsi and the thoracodorsal nerve without the need for skin flaps elevation and its complications. Furthermore, the latissimus dorsi, the trapezius, and the serratus anterior are not lifted nor retracted as the trapezius is posterior and the serratus is more anterior in this approach. This total muscle preservation result in the complete preservation of function with less postoperative pain. The closure of muscle sparing thoracotomy is simple and rapid,[6] in our experience, we need less time for entering the chest and also in the closure than we do in the dorsolateral thoracotomy with muscle splitting or sparing. The parietal pleura seems to be easily dissected in this posterior part of the chest and the dorsal mediastinum and esophagus is easily accessed. A small malleable retractor can be used to gently retract the lung and the pleura anteriorly. The exposure is adequate with a minimal injury to the lung. Other authors have attributed the satisfactory exposure in the dorsal minithoracotomy to the proximity between the dorsal chest wall and the posterior mediastinum and thoracic cage pliability.[7] The vertical incision parallel to the medial border of the scapula in the modified posterior thoracotomy allows an excellent and easy access to the subscapular fossa where the fourth intercostal space is well exposed without need to lift or retract the latissimus dorsi muscle, the serratus and the trapezius. In contrast, with the horizontal incision of the dorsal minithoracotomy, we need to lift and pull away the muscles to expose the fourth intercostal space. Like dorsal minithoracotomy, this incision can also prevent breast deformity in female neonates-a dreaded complication of some thoracic incisions performed before puberty.[7]

CONCLUSION

The modified posterior thoracotomy is a safe, and a quick approach with satisfactory operative exposure, good functional, and cosmetic results.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.