Diseases of the Esophagus (2013) 26, 365–371

DOI: 10.1111/dote.12053

Original article

Thoracotomy for repair of esophageal atresia: not as bad as they

want you to think!

J.-M. Laberge,2 G. K. Blair1

1
British Columbia Children’s Hospital, University of British Columbia, Vancouver, British Columbia and
2
Montréal Children’s Hospital, McGill University, Montreal, Quebec, Canada

SUMMARY. Is it outdated now to do a thoracotomy to repair esophageal atresia (EA)? Our practices and the
literature on the subject of thoracoscopic and open thoracotomy repair of EA were reviewed, seeking answers to
the following questions: Is it correct to compare the new thoracoscopic approach for the repair of EA against the
thoracotomy techniques of 15–30 years ago? Should post-thoracotomy scoliosis/thoracic deformity reported in up
to 56% of patients be a significant current concern? Are the clips used to close the fistula in thoracoscopic repairs
as safe as open suture closures? Is the leak and stricture rate similar with thoracoscopic surgery? Are the anesthesia,
period of ventilation, pain, time to first feeding, and the length of hospital stay significantly different with current
thoracotomy techniques compared with thoracoscopic methods? Is the cosmetic result of a thoracoscopic repair
significantly better? Is the learning curve for EA thoracoscopic repair harming patients for minimal long-term
benefit? These questions were scientifically unanswerable at this time. The limited EA thoracotomies currently
performed have a track record of proven safety and minimal morbidity. The results published by surgeons who are
pioneers in thoracoscopy may not be generalizable, and the complication rate from teams with less experience is
likely underreported. In selected patients and with experienced teams, thoracoscopic EA repair is appropriate.
However, EA repair via thoracotomy should, for now, remain as the ‘gold standard’. Further registry-based,
multicenter, comparative studies on EA repair methodologies and outcomes should provide important answers.
KEY WORDS: esophageal atresia, neonatal surgery, thoracoscopy, thoracotomy, tracheoesophageal fistula.

As surgeons, we often refer to certain procedures and
techniques as the ‘gold standard’ for the treatment
of specified maladies. This, of course, is derived from
the extant monetary system wherein the basic unit
of currency is defined by a stated amount of gold of
fixed purity. Insofar as surgical procedures and tech-
niques are concerned, the gold standard, by analogy,
is that procedure, generally accepted by all as provid-
ing at least a consistency, if not necessarily always the
best, of outcomes against which all other operations
for the same disease are measured. Older surgical
techniques that afford unreliable, extremely variable,
Address correspondence to: Dr Geoffrey K. Blair, MD, FRCSC,
British Columbia Children’s Hospital, Rm K0-106, 4480 Oak
Street, Vancouver V6H 3V4, Canada. Email: gblair@cw.bc.ca
Both authors made substantial contributions to conception
and design, and/or acquisition of data, and/or analysis and
interpretation of data. Each participated in drafting the article or
revising it critically for important intellectual content and gave
final approval of the version to be submitted, and each will
approve any revised version to be published.
© 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
or even reliably bad outcomes are regularly eschewed,
and newer operations are adopted as gold standards
if, and only if, they prove to afford consistently better
results. Furthermore, like currency, the gold standard
operations are therefore eventually adopted by all.
Is it a sin, like disbursing counterfeit or outdated
coinage, to do a thoracotomy to repair esophageal
atresia (EA) now that thoracoscopic repair has
arrived? The purpose of this discussion paper is to
briefly review what we think we know of the pur-
ported advantages of thoracoscopic repair of EA and
whether this indicates the need for us to trash the still
standard open thoracotomy repair of EA.
BACKGROUND
The first thoracoscopic repair of EA was performed in
1999.1 Since then, there have been numerous articles
reporting a burgeoning number of series, mostly
365
366 Diseases of the Esophagus
uni-institutional, documenting surgeons’ experiences
with this new technique. The results reported variably
concluded that thoracoscopic EA repair was in 2002,
‘technically feasible’2 through 2008 ‘comparable to
that of the open technique’3 and in 2009, to ‘may be
regarded as the procedure of choice if performed by
an experienced endoscopic pediatric surgeon’,4 and
finally in 2011, ‘thoracoscopic repair of EA and TEF
seems to be superior to open surgery’.5 The purported
advantages of the new technique include a better
cosmetic result, the avoidance of rib fusion and chest
deformities, shoulder dysfunction, scoliosis, post-
thoracotomy pain, thoracic nerve damage, prolonged
ventilation, and better visualization of the anatomy.3
The evidence presented in the recent literature of ben-
efits of thoracoscopic EA repair deserves perusal.
MUSCULOSKELETAL ISSUES
Practitioners were alerted to the possibility of scolio-
sis developing in post-thoracotomy EA patients
in 1980 after Durning et al.6 reported 18 scoliotic
patients, operated on between 1960 and 1970. The
proportion of EA patients developing this curvature
of the spine was not elucidated, and of the 18 patients
in their study, all had had rib resections at the time of
thoracotomy and six of these patients had multiple
thoracotomies. Despite this, only 9 of the 18 had
more than 10 degrees of spinal deformity. Most
importantly, these 18 patients were studied because
their last available chest radiograph was more than
10 years after EA repair, thereby introducing a selec-
tion bias.
In a large follow-up cohort of 588 EA patients from
Finland treated by thoracotomy between 1947 and
1985, a surprising 56% of them developed scoliosis,
mostly upper thoracic. Yet 45% of the patients had
documented vertebral anomalies as well. The scolio-
sis was described as ‘mild’, most not requiring any
interventions such as bracing or surgery.7 Sistonen
et al. go on to discuss the role that post-thoracotomy
rib fusion supposedly played in the morbidity of their
patients citing rib fusion as being linked to upper
thoracic scoliosis and possibly causative in the pul-
monary restrictive defect seen in 21% of their cases.7
However, they are careful to add that the causes of
pulmonary function abnormalities in their patient
cohort is unclear. Rintala, a co-author of that study,
concluded elsewhere that ‘scoliosis that is associated
with thoracotomy is usually mild and does not cause
symptoms’.8 Wong-Chung et al. corroborates the
notion of rib fusion as a culprit in a 1990 case report.9
The following year Westfelt and Nordwall postulated
that many subtle mechanisms and force interrup-
tions in the costotransverse joints and ligaments
during and following childhood thoracotomy could
lead to scoliosis, even without rib resection or rib
© 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
fusion, but only have two patients with EA in their
series of 20 youth with evidence of post-thoracotomy
scoliosis.10
Arguably, these studies can be labeled as historical
and not necessarily representing modern thorac-
otomy methods for EA repair. More contemporary
results are illustrated by Burford et al.11 who reported
72 EA patients, all repaired by thoracotomy from
1993 to 2008, and only saw two patients with scoliosis,
both secondary to vertebral anomalies and neither
requiring surgery. In a recent quality of care audit in
one of our centers (BC), of our last 203 EA patients
operated on, all via open thoracotomy, between 1984
and 2010, only one patient is documented as being
followed by our scoliosis clinic. (We grant that the
younger patients in our series may not have yet mani-
fested spinal curvature and that perhaps some have
been lost to follow-up or not appropriately referred
for spinal evaluation.) Furthermore, from the same
center, our pediatric spine surgical specialists report
that post-thoracotomy scoliosis is simply not an entity
that they are seeing in any concerning numbers, if at
all! (GB, pers. comm., 2012).
Chetcuti et al. in a large review published in 1989 of
302 EA patients followed long term noted scoliosis in
30 (10%) patients who did not have vertebral anoma-
lies. However, 14 of these 30 patients had two or more
thoracotomies, and 22 of the 30 had rib resections.12
Again, in this regard, perhaps this study is mostly of
historical significance. However, in that same paper,
they reported the post-thoracotomy sequelae of chest
wall deformities in an alarming 33% of their post-
thoracotomy EA patients who did not have concomi-
tant vertebral anomalies. The authors make an
important point that anterior chest wall asymmetry
and deformities, and perhaps also the reported
shoulder deformities that are manifest in post-
thoracotomy patients of that era, which occur likely
because of the ‘partial denervation of the serratus
anterior muscle during thoracotomy’.12 Certainly,
modern teaching of EA repair by thoracotomy indi-
cates that the pliable infant chest affords a good and
adequate view of EA while one minimizes the size of
the incision, absolutely avoiding rib fracture or split-
ting, periosteal stripping, or rib resection. The serra-
tus anterior is simply retracted anteriorly, and no
division of thoracic nerve trunks is necessary. Closure
is by approximation and not by induced fusion of
the rib space entered. Such ‘muscle sparing’ thorac-
otomies for this condition surely help to avoid
much of the pain, deformity, and disability of a full
classic posterolateral thoracotomy.13 Another fre-
quently quoted report of the ‘morbid’ musculoskel-
etal sequelae of thoracotomy describes 277 patients
operated between 1965 and 1981 by 24 different sur-
geons, with a 63% survival, again of historical inter-
est, but unfairly considered to detract against current
neonatal thoracotomy techniques.14

There is little doubt that thoracoscopic repair can
avoid rib fusions and perhaps the possibly harmful
operative rib retraction and potential deleterious
growth effects on the chest wall following repair of
EA. However, although we must be alert to the pos-
sibilities of the adverse long-term musculoskeletal
effects of thoracotomy, we need not be necessarily
convinced that a thoracotomy done with gentleness
and appropriate contemporary muscle and tissue
sparing techniques will cause harm to our delicate
EA patients.
TECHNIQUE ASPECTS
Certainly, one of the clear advantages made evident
at the advent of minimally invasive surgery (MIS)
in the 1980s was the detailed view that one has,
affording the surgeon a true ‘close up’ picture of the
anatomy during the operation. Thoracoscopic enthu-
siasts point out that the visualization of structures is
excellent.4,15,16 Yet, the ‘technical hurdles are many’ as
pointed out by an acknowledged leader in thoraco-
scopic repairs, Steven Rothenberg.17 He cites the dif-
ficulties in suturing within such a small closed space
as a major technical difficulty. In fact, he evidently
regards these technical demands as being so signifi-
cantly challenging that he commented in a 2012 paper
that ‘for this procedure to become more widely
accepted, it may be necessary to develop a mechanical
anastomotic device or self-knotting suture’.18 Rates
of stricture (however, variably, they may be defined)
after thoracoscopic EA have been reported as higher
than one might expect16,17 and in some series respect-
ably low.3,5,15 Leak rates have been significant in some
series17 and in others lower than a compared cohort
of open repairs.3 But by that same token, strictures
have been reported in some open thoracotomy series
as high as well,3,19 as the rates reported of these anas-
tomotic complications may depend on how they are
defined.
Most thoracoscopic repair descriptive papers seem
to indicate that the number of sutures used for the
anastomosis is less than with the open repairs. Vari-
able suture materials are used as well. Rothenberg
described in 2005 how he switched to using absorbable
monofilamentous sutures primarily because of the
difficulties of working with other suture material such
as Ethibond® (Ethicon Corp., Markham, Ontario,
Canada).2,17,18 Others describe using Vicryl® (Ethicon
Corp.) of various sizes20,21 and even silk.15
Although there are descriptions of suture ligations
of the tracheoesophageal fistula (TEF) with thoraco-
scopic repairs, it appears that metallic clips are also
routinely used.18 Recurrent TEF has been reported in
both open and thoracoscopic repairs, and in series of
both techniques, the rate is variable, although unlike
stricture rates, should be more easily defined. Clip-
© 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
Thoracotomy repair of esophageal atresia 367
Fig. 1 Endoscopic view of metal clip in the lumen of a repaired
esophageal atresia. Clips had been placed to divide the azygos
vein.
ping and other techniques in thoracoscopic and open
repairs have been implicated as potentially causative
in recurrent TEF, although Rothenberg discounts
these cases as ‘anecdotal’18,22 (see Fig. 1).
A majority of pediatric surgeons were taught that in
open repairs, it is desirable to perform an extrapleural
anastomosis. Although not preventative of anasto-
motic leakage, an extrapleural dissection, at least
theoretically, avoids the morbidity of a pleural cavity
empyema should an anastomotic leak occur. It also
ensures a ‘virgin’ chest cavity should re-thoracotomy
be required for some reason. Although a technique
for extrapleural thoracoscopic EA repair has been
described,23 it appears that in most instances a trans-
pleural approach is used with the thoracoscope.
The question remains, despite continued compari-
sons, do the technique differences of anastomosis and
TEF ligation demanded of the thoracoscopic surgeon
repairing an EA make a morbid difference in the
anastomotic outcomes?
COSMETIC APPEARANCE
Clearly, it is in the realm of better cosmetic results
that thoracoscopic EA repair is superior when com-
pared with open thoracotomy repair. Yet, there are
still at least three port sites that can pucker and be
unsightly. In very small babies, a port site can be
relatively large, and as they say, the scar tends to
grow with the child. Once again with newer minimal
thoracotomies, the resultant scars seem to those die-
hard thoracotomy advocates to be of little concern.
Lawal et al. in 2009 looked at comparators of thora-
coscopy and thoracotomy in infants and children
who had undergone either technique for the treat-
ment of EA, lobectomy, or pleural surgery, and tried
to address the cosmetic issue. They found statistically
insignificant differences in the satisfaction ratings
368 Diseases of the Esophagus

a b

Fig. 2 (a,b) both represent the same 3-month-old infant who underwent on day 1 of life a difficult open thoracotomy repair of a
long-gap esophageal atresia with an unusual bronchoesophageal fistula. The thoracotomy was muscle-sparing, and the scar is short.
(a) was taken without a flash, (b) with a flash. One should be aware that the photographic technique can potentially hide the true
cosmetic result.

done by parents and no significant difference between
the two groups as per the desire for a scar revision.
However, there was certainly a trend favoring the
cosmetic outcome of thoracoscopy over thoracotomy
scarring.24 Who will do a prospective assessment of
older children and young adults who have had the
modern shorter thoracotomy scars to note their cos-
metic concerns?
We must also be mindful that published pictures
of resultant ‘barely noticeable’ scars may not be the
truly perceived cosmetic result that the patient is
living with. Figure 2 show how a simple change in the
photographic lighting parameters can hide scars from
the readership (Fig. 2).
Scars on the side of the chest are surely not com-
parable with facial or even abdominal scars for their
cosmetic impact. However, we should find out what
our patients’ perceptions and feelings are about their
scars before we assign our importance to them.
In the previously quoted paper by Lawal et al.,
detailed comparative morphometric chest measure-
ments were carried out.24 A statistically significant
difference was found between thoracotomy versus
thoracoscopy in the ratios of transverse diameter as
measured on the operative side divided by the same
measurement of the non-operative side and in the
ratios of nipple to xiphisternum distance of operative
side divided by the non-operative side. Simply put, by
their measurements and analysis, the operative sides
of the thoracotomy patients appear to be smaller
and/or more growth restricted as compared with the
thoracoscopy patients. Although we must be mindful
© 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
of these findings as it may reflect a real effect of
thoracotomy on the operative sides of our patients, it
is unclear at this point if these ‘statistically significant’
millimetric differences will be clinically apparent.
Furthermore, the authors point out that the mean
follow up of these two groups of patients at the time
of measurement was significantly different.24
PAIN CONSIDERATIONS
Whether newborns undergo open thoracotomy or
thoracoscopy for repair of their EA, our inner surgi-
cal rearranging of what they had the misfortune to
be born with is the same – a dissection, a pulling of
esophageal ends, an anastomosis, and if there is one,
a disconnection and closing of a TEF. This demands,
for the most part, a period of postoperative ventila-
tion, no feeding for at least a few days, and other
invasive supportive care. None of this is a comfort
to the baby. In our review of the literature, there
was no convincing evidence that thoracoscopic repair
afforded a speedier or necessarily a more comfortable
recovery. Studying retrospectively the pain scores
and the cumulative postoperative opioid doses
administered to 24 infants undergoing thoracoscopic
EA repair (n = 14) or thoracoscopic congenital dia-
phragmatic hernia (CDH) repair (n = 10) as com-
pared with a matched group of 28 EA and 20 CDH
patients repaired via thoracotomy, Ceelie et al. found
no evidence denoting a difference in postoperative
pain.25 Furthermore, the perception that the MIS

approach leads to a speedier recovery may have led
to precocious extubation and avoidable respiratory
arrest or mortality in at least two reports.3,26
PHYSIOLOGY
Carbon dioxide insufflation used to collapse the right
lung during thoracoscopic EA repair may afford a
less traumatic ‘push’ on the infant’s lung parenchyma
than a retractor but has other possibly significant
physiological effects. Bishay et al. reported an elegant
study of eight infants undergoing thoracoscopic
surgery, six for CDH, and two for EA repair. Their
measurements of absorption of the insufflated CO2
and the effect on cerebral oxygen saturation during
thoracoscopic surgery may be a cause of some con-
cern. Cerebral oxygen saturation fell significantly
during surgery. The absorbed CO2 was associated
with a significant drop in arterial pH as well.27
Insufflation of the chest cavity may compress the
superior vena cava as well. One of the authors (GB)
has been assured by a thoracoscopic EA repair advo-
cate that the insufflation pressures can be increased as
high as 10 mmHg with impunity in one’s effort to see
the EA anatomy and to effect a good anastomosis.
Indeed in the Bishay study, they recorded CO2 insuf-
flation pressures of 5–10 mmHg, which may also
have been a factor in their observed resultant physi-
ological derangements.27 What effect could this have
on venous return to the heart and cardiac output?
Combine that concern with the definite possibility of
any EA child having concomitant minor or major,
recognized, or unrecognized congenital heart disease.
A comparison study between open and thoraco-
scopically repaired EA showed no differences in the
esophageal motor function of the esophagus after-
wards. It had been hoped that thoracoscopic repair
would be beneficial in this regard.28
More physiological studies are required.
LEARNING CURVE
Most of the reports of the last decade on thoraco-
scopic repair of EA cite the experiential factor that we
would call the ‘learning curve’.2–4,15,17,21,28 There is no
doubt that thoracoscopic repairs demand the highest
degree of minimally invasive surgical skill. Most
repairs reported have been performed by experienced
MIS pediatric surgeons working with experienced
teams, and even they report that initially, the tech-
nique was difficult, hard to master, and took signifi-
cantly longer. Holcomb et al. responsibly point out
that some patients are not good candidates for this
MIS approach, being especially difficult in babies less
than 2 kg.16 According to the experts, the learning
curve requires at least 10–20 thoracoscopic EA
© 2013 Wiley Periodicals, Inc. and the International Society for Diseases of the Esophagus
Thoracotomy repair of esophageal atresia 369
repair. While many pediatric surgery centers perform
5–10 EA repair per year, this is often split between
four or five surgeons. A similar learning curve may be
applicable to anesthesiologists, except that they are
in even higher numbers than surgeons. How many
patients will suffer serious, avoidable complications,
or mortality while the teams will go through their
learning curves, mostly to minimize the scar?
CONCLUSIONS
So where does this leave us? Is the average pediatric
surgeon ‘old fashioned’ if he/she does not adopt the
thoracoscopic EA approach? And would he/she do
his patients a good service to just begin with ‘the next
case’ to attempt a thoracoscopic repair? How should
a responsible surgeon effectively learn the new tech-
nique? Is mentoring the way to go as many of us did
in the early 1990’s when we were learning laparo-
scopic surgery? How will our trainees learn? Are there
high-fidelity laboratory simulation models for acquir-
ing the high level of skill required to be competent
at thoracoscopic EA repairs. How shall we define
competence?
Furthermore, is this technique of doing thoraco-
scopically what we have been doing since Haight first
did a primary EA in 1941 truly the way of the future?
Or is there soon going to be a technological ‘skip’,
with perhaps image-guided EA repair using engi-
neered esophageal ‘joiners’? If we anticipate that,
should we be struggling now with hand-sewn thora-
coscopic EA repairs?
Oomen recently published a comparison of EA
thoracoscopic and open repairs by means of a system-
atic review of the literature. His conclusions mirror
the tone of this discussion paper, that there is not,
as yet, any convincing evidence that thoracoscopic
EA repair is superior or inferior to an open thorac-
otomy repair. Along with Holcomb et al. in 2005,
he concludes stating the need for more prospective,
properly designed studies.29 Because randomized,
controlled studies will be very difficult to perform,
perhaps registry-based, multicenter, comparative
studies on EA repair methodologies and outcomes
will provide important answers.
Tovar and Fragoso in their ‘Current Controversies
in the Surgical Treatment of Esophageal Atresia’
paper in 2011 perhaps summarized it best: ‘. . . the
gold standard remains a good anastomosis with sur-
vival, limited sequelae and good quality of life rather
than a successful minimally invasive repair’.30 Our
currency of good surgical technique coupled with the
best possible outcomes for our patients demands
that we continue to search for newer and better ways
to treat diseases like EA through practice, a spirit of
enquiry, ethically conducted collaborative research,
and acting in good conscience.
370 Diseases of the Esophagus
Table 1 Comparison of thoracotomy versus thoracoscopic repair of esophageal atresia
Thoracotomy
Perceived • Easier extrapleural approach
advantages • Technically mastered
• Easier to teach
• Complications well-known
• Less intraoperative physiological
disruption
Perceived • Visible scar
disadvantages • Postoperative pain
• Prolonged ventilation
• Thoracic nerve damage
• Rib fusion
• Chest wall deformity
• Shoulder dysfunction
• Scoliosis
• Breast disfigurement, mammary
maldevelopment
During the Second International Esophageal
Atresia Conference in Montreal in 2012, many par-
ticipants raised their hands when asked if they were
aware of significant anesthetic or surgical compli-
cations related to thoracoscopic EA repair. More
importantly, the mother of a patient testified how
she felt that her baby’s surgeon appeared ‘pressured’
to perform a thoracoscopic repair, which led to a
complicated course. While thoracoscopic repair is
apparently safe and possibly advantageous in some
respects when performed by a handful of experts,
it should not be touted as the ‘gold standard’ to be
utilized by all pediatric surgeons. There are advan-
tages and disadvantages to both techniques, as listed
in Table 1.
We have adopted minimally invasive surgical tech-
niques for many diseases into our practices only once
we believed in our hands that it could offer a real,
significant, and meaningful outcome difference to our
patients that could be safely and reliably realized. In
our view, the good pediatric surgeon will continue to
repair EA and approach the repair in each patient
with what is best for that patient.
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Thoracotomy repair of esophageal atresia 371
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