Background: Esophageal atresia (EA) is a rare congenital malformation of the esophagus. Surgical treatment is required to restore the continuity of the esophagus. This can be performed through thoracotomy. However, an increasing number of hospitals is performing minimal invasive surgery (MIS). In this article, we describe the technique of thoracoscopic repair of EA in neonates in more detail and show the outcome of a patient cohort operated by young pediatric surgeons in training. Methods: Between 2014 and 2019 correction was performed in 64 EA type C patients at the UMC Utrecht, Wilhelmina Children's Hospital, mainly by young pediatric surgeons in training. Results: All patients were corrected through MIS, 3 days after birth. The median operation duration was 181 (127–334) minutes. Nasogastric tube feeding was started on the first postoperative day, and oral feeding 6 days postop. Postoperative complications included leakage (14.1%), stenosis (51.1%), and recurrent tracheoesophageal fistula (7.8%). Conclusion: Thoracoscopic repair of EA can be performed safely, with good outcome and all the benefits of MIS. However, it remains a challenging procedure and should be performed only in pediatric centers with a vast experience in MIS, especially when training young pediatric surgeons. These centers must have access to a multidisciplinary team of neonatologists, pediatric anesthesiologists, surgeons, and ENT specialists to ensure the best possible care in hemodynamic, respiratory, and cerebral monitoring and gastrointestinal and developmental outcome.

Background:Esophageal atresia (EA) is often accompanied by tracheomalacia (TM). TM can lead to severe respiratory complaints requiring invasive treatment. This study aims to evaluate if thoracoscopic primary posterior tracheopexy (PPT) can prevent the potential sequelae of TM in patients with EA.Methods:A cohort study including all consecutive EA patients treated between 2014 and July 2019 at the Wilhelmina Children's Hospital was conducted. Two groups were distinguished: (group 1) all EA patients born between January 2014 and December 2016 and (group 2) all EA patients born between January 2017 and July 2019, after introduction of PPT. In the latter group, PPT was performed in EA patients with moderate (33–66%) or severe (67–100%) tracheomalacia, seen during preoperative bronchoscopy. Group differences were assessed using the Fisher's exact test for bivariate variables and the Mann–WhitneyU-test for continuous variables.Results:A total of 64 patients were included in this study (28 patients in group 1; 36 patients in group 2). In group 2, PPT was performed in 14 patients. Respiratory tract infections (RTIs) requiring antibiotics within the first year of life occurred significantly less in group 2 (61 vs. 25%,p= 0.004). Brief resolved unexplained events (BRUEs) seemed to diminish in group 2 compared to group 1 (39 vs. 19%,p= 0.09).Conclusion:Thoracoscopic primary posterior tracheopexy decreases the number of respiratory tract infections in EA patients. The clinical impact of reducing RTIs combined with the minimal additional operating time and safety of PPT outweighs the risk of overtreatment.

Thoracoscopic external traction technique (TTT) is a relatively new surgical intervention for patients with long-gap esophageal atresia (LGEA) that preserves the native esophagus. The major accomplishment with TTT is that esophageal repair can be achieved within days after birth. This study evaluates the childhood outcome in LGEA patients treated with TTT, including gastrointestinal outcome, nutritional status and Health-Related Quality of Life (HRQoL). A cohort study including all LGEA patients that underwent TTT between 2006-2017 was conducted. Patients and/or their parents were invited to fill out questionnaires regarding reflux symptoms and HRQoL. TTT was successful in 11/13 patients (85%). Esophageal anastomosis was accomplished at a median age of 12 days (range 7-138), first oral feeding was started at a median of 16 days postoperatively (range 5-37). All patients required multiple dilatations and 10 patients required anti-reflux surgery. At median follow-up of seven years, five patients reported mild and one moderate reflux complaints. All patients but one reached age-appropriate oral diet. Most patients (80%) were within normal growth range. Overall HRQoL was comparable to healthy controls. TTT provides acceptable results in childhood. Oral feeding can be started as soon as two weeks postoperatively. Almost all patients are able to eat an age-appropriate oral diet. Overall HRQoL was comparable to healthy controls.

Recurrent Tracheoesophageal Fistula (rTEF) is a complication of Esophageal Atresia (EA) that can lead to severe respiratory symptoms. RTEF can be corrected via endotracheal treatment (ET) or surgical treatment (ST). The efficacy of these techniques varies in literature. This study presents the outcome of rTEF treatment after EA correction at the Wilhelmina Children's Hospital in Utrecht. From 2000 until 2023, patients with EA (n = 251) underwent thoracoscopic EA correction by using the native esophagus at the Wilhelmina Children's Hospital in Utrecht. All EA patients who had developed rTEF (n = 19) were evaluated. Success rates, number of treatment attempts, and complication rates of ET and ST were collected in our EA database. Data was expressed as medians with interquartile ranges (IQR). In total, 19/251 (8 %) patients had developed an rTEF after EA correction. For 10/19 (53 %) patients, primary ET was performed, with a median number of 2 procedures per patient [range 1-3]. In 8/10 patients, ET failed, therefore, these eight patients underwent secondary ST. For 9/19 (47 %) patients, primary ST was performed, with a median number of 1 procedure per patient [range 1-3]. In all patients, primary ST was performed via thoracoscopy with a success rate (absence of recurrence after 1 procedure) of 78 % (7/9) and no conversions. The complication rate was 10 % for primary ET and 44 % for primary ST, and 75 % for secondary ST. All complications were classified as minor. Thoracoscopic correction of rTEF has a high success rate. Similar to previous studies, the Utrecht success rate of ET for rTEF treatment is poor. Retrospective cohort study. IV.

Introduction Tracheomalacia (TM) often occurs in children with oesophageal atresia (OA), leading to recurrent respiratory symptoms and in severe cases to blue spells or ultimately respiratory arrest. In some patients, a secondary posterior tracheopexy may then be indicated. This secondary surgery, as well as respiratory morbidity, may be prevented by performing a primary posterior tracheopexy (PPT) concurrent with primary OA correction. The aim of this trial is to determine if a PPT can decrease—or prevent—tracheal collapse in newborns with OA and TM. Additionally, the trial aims to determine whether the potential observed effect of PPT on tracheal stability is sustained over time. Methods and analysis This is an international multicentre double-blind randomised controlled trial. Seventy-eight children with OA type C will be randomised 1:1 into the no-PPT group or PPT group. Randomisation will be stratified by centre. The degree and location of TM are assessed during preoperative, intraoperative and two postoperative tracheobronchoscopies. The occurrence of TM will be evaluated during three routine follow-up consultations until the age of 6 months. The primary outcome is the degree of collapse of the tracheal wall during the intraoperative tracheobronchoscopy (after performing the PPT/no-PPT), measured in percentages. The difference in the mean degree of collapse will be compared between the no-PPT and the PPT groups using linear regression, adjusting for centre and the preoperative degree of tracheal collapse at baseline. The adjusted mean difference will be reported as effect size together with its 95% CI. Ethics and dissemination Patients will be included after written parental informed consent. The risks and burden associated with the trial are minimal. The institutional review board of the University Medical Center Utrecht has approved this protocol (METC-number 23-256/A). Results will be shared in a peer-reviewed scientific journal and presented at international conferences. Trial registration number NCT06335862.

Tracheomalacia (TM) is a common comorbidity in children with esophageal atresia (EA), reported in up to 87 % of patients. Around 30 % of EA patients develop severe TM associated with recurrent respiratory morbidity. In such cases, surgical intervention may be required. Traditionally, treatment involved secondary procedures such as aortopexy or posterior tracheopexy. More recently, primary posterior tracheopexy (PPT) has been adopted in an increasing number of centers. The evolution of the surgical treatment of TM from secondary to primary intervention is described. A single-center cohort is evaluated, including 38 EA patients, 14 of whom underwent PPT. Compared with historical controls, PPT reduced brief resolved unexplained events (39 % vs. 19 %, p = 0.09) and significantly decreased respiratory infections (61 % vs. 25 %, p = 0.004). Cost analysis showed lower respiratory-related admissions after excluding outliers. These findings established the TEACHER project, an international framework for training and dissemination, which in turn laid the foundation for the PORTRAIT trial, a multicenter randomized controlled study designed to randomize 78 neonates with TM to PPT versus standard repair. Early data suggest PPT reduces respiratory morbidity and may lower healthcare costs. The PORTRAIT trial aims to provide high-level evidence to determine whether PPT should be adopted as standard treatment during EA repair or avoided to prevent overtreatment.