Previously unreported shoulder deformity following right lateral thoracotomy for esophageal atresia

Scoliosis after thoracotomy repair of esophageal atresia: a systematic review

Standard surgical repair of esophageal atresia/tracheoesophageal fistula (EA/TEF) is via a right posterolateral thoracotomy. A recognized complication is the later development of scoliosis. The prevalence and pathogenesis of secondary scoliosis are poorly understood. We, therefore, conducted a systematic review on this topic. All English language articles reporting incidence, outcomes and/or interventions for scoliosis in children after EA repair via thoracotomy were identified. Fourteen relevant articles published between 1969 and 2019 reporting 1338 children were included in the analysis. The aggregate prevalence of scoliosis among 937 children without congenital vertebral anomalies was 13%, but this figure varied widely between studies. Severity of scoliosis was documented in 181 children; eight children had a Cobb angle > 40° and 10 had undergone spinal surgery. The spinal curvature in affected individuals was dominantly or exclusively convex to the left. In conclusion, the reported prevalence of scoliosis varies widely but on average affects about one in eight children after open repair of EA/TEF. Most cases are mild and do not require intervention. It is currently uncertain whether secondary scoliosis is preventable by using meticulous thoracotomy techniques or thoracoscopic repair.Level of evidence IV.

Esophagoesophagopexy technique for assisted fistulization of esophageal atresia

PURPOSE

We describe our experience using a modified suture fistula technique for addressing tension in longer gap esophageal atresia (EA). Esophagoesophagopexy (EEP) is the tacking of the proximal and distal ends of esophageal pouches without formal anastomosis. In this retrospective cohort, we review the outcomes of patients with EA after EEP.

METHODS

We reviewed the operative reports of EA cases treated at our institution from 1997 to 2016 and identified all patients described as having EEP.

RESULTS

Of 129 EA cases, five patients underwent EEP. Formal anastomosis was not done due to patient's instability, prematurity, or long gap. Median birth weight was 1.4 kg (0.6-2.2 kg), and median gestational age at birth was 29 weeks (25-34 weeks). Age at time of EEP ranged 0-5 months. Esophagoesophageal fistula was confirmed in three patients. All three had strictures requiring weekly dilations. One of these patients died. The two surviving patients underwent fundoplication.

CONCLUSION

We describe an alternative technique for esophageal anastomosis in patients for whom a standard anastomosis is not possible. EEP can lead to a functional anastomosis through fistulization and avoid the morbidity of multiple thoracotomies and lengthening procedures. Families should be educated on the potential need for dilations and antireflux procedures.

The great debate: open or thoracoscopic repair for oesophageal atresia or diaphragmatic hernia

Controversy exists over the best method and technique of repair of oesophageal atresia and diaphragmatic hernia. Open surgical repairs have a long established history of over 60 years of experience. Set against this has been a series of successful thoracoscopic repairs of both congenital anomalies reported over the past decade. This review was based upon a four-handed debate on the merits and weaknesses of the two contrasting surgical philosophies and reviews existing literature, techniques, complications, and importantly outcome and results.

Thoracoscopic repair of esophageal atresia and tracheo-esophageal fistula in neonates: the current state of the art

The first thoracoscopic esophageal atresia with tracheo-esophageal fistula (EATEF) repair was performed in March of 2000. This report evaluates the results and evolution of the technique over the last decade. Thoracoscopic esophageal atresia repair has proven to be an effective and safe technique. Initial experience resulted in a higher stricture rate but this improved with experience and changes in technique over the last decade. The outcomes are similar to or superior to that of an open thoracotomy and avoid the musculoskeletal morbidity associated with that technique.

A survey of musculoskeletal and aesthetic abnormalities after thoracotomy in pediatric patients

OBJECTIVE

To study the incidence and type of musculoskeletal and aesthetic abnormalities after thoracotomy in children.

MATERIALS AND METHODS

Children below 12 years of age who had undergone thoracotomy for any condition and have at least 2 years follow up were included in the study. Detailed assessment of the patients included: history and general examination, clinical examination of chest and musculoskeletal system, X-ray chest including bilateral shoulders [antero-posterior (AP), lateral, oblique], X-ray whole spine (AP, lateral, right and left side bending AP view).

RESULTS

Fifty-two pateints were recruited. The incidences of various clinically and radiologically assessed musculoskeletal and aesthetic abnormalities observed were: winging of scapula (5.7%), ipsilateral elevation of shoulder (5.7%), fixation of skin cicatrix to bony thorax (7.7%), maldevelopment of pectoral muscles (11.5%), asymmetry of the level of nipples (1.9%), rib fusion (5.7%), crowding of ribs (9.6%), mediastinal shift (3.8%), decreased space available for lungs (3.8%), Scoliosis with Cobb's angle >10(0) (1.9%).

CONCLUSIONS

The incidences of musculoskeletal and aesthetic abnormalities after posterolateral thoracotomies in children were low. Longer follow up of patients after thoracotomy is needed to pick up these abnormalities as the children grow.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula in neonates, first decade's experience

The first thoracoscopic esophageal atresia with tracheoesophageal fistula (EATEF) repair was performed in March of 2000. This report evaluates the results and evolution of the technique in a single surgeons' experience after the first decade of thoracoscopic EATEF repair. From March 2000 to September 2012, 52 consecutive patients with type 3 EATEF, and an additional nine patients with pure esophageal atresia (EA) were repaired by or under the direct supervision of a single surgeon. Patient weight ranged from 1.2 to 3.8 kg (mean 2.6 kg). Twenty-two patients had significant associated congenital anomalies. The repairs were performed using three ports. The fistula was ligated using a single endoscopic clip, and the anastomosis was performed using a single layer of interrupted sutures. A transanastomotic tube and chest drain were left in all cases. Fifty-one of the 52 procedures were completed successfully thoracoscopically. Operative times ranged from 50 to 120 minutes (average 85 minutes). There were three clinical leaks, one in an EATEF and two in patients with long-gap pure EA, all resolved with conservative therapy. Oral feedings were started on day 5 in all other patients. Twelve of 61 patients required dilations (1-9), and 18 required a Nissen fundoplication for severe reflux. One patient required a thoracoscopic aortopexy for severe tracheomalacia. All patients are currently on full oral feedings. No patient has any evidence of chest wall asymmetry, winged scapula, or clinically significant scoliosis. There have been no recurrent fistulas. Thoracoscopic EA repair has proven to be an effective and safe technique. Initial experience resulted in a higher stricture rate, but this improved with experience and changes in technique. The results are superior to that of documented open series and avoid the morbidity of an open thoracotomy.

Thoracoscopic repair of esophageal atresia and tracheo-esophageal fistula in neonates: evolution of a technique

Advancements in minimally invasive surgical techniques and instruments for neonates have allowed even the most complex neonatal procedures to be endoscopically approached. In 1999, the first successful thoracoscopic repair of an esophageal atresia (EA) was performed in a 2-month-old infant. One year later, the first totally thoracoscopic repair of an atresia with distal fistula (tracheo-esophageal fistula [TEF]) was realized in a newborn. Over the ensuing 10 years, this technique was used and modified by a single surgeon in 49 consecutive patients. Overall, 43 patients with TEF and 6 with pure EA were repaired by using a thoracoscopic approach. An additional 3 patients with H-type TEF were also thoracoscopically treated. Weight ranged from 1.2 to 3.8 kg. Operative time ranged from 50 to 120 minutes. In fact, 48 out of 49 were successfully completed thoracoscopically. There were 2 patients with leaks that resolved with conservative management. Thirty percent of patients required at least one dilatation, but this number dropped to less than 10% in the second half of the series. There were no deaths and no recurrent fistula. Thoracoscopic TEF repair has proved to be an effective and safe technique. Evolution of the technique has resulted in fewer complications while avoiding the significant short- and long-term morbidity associated with thoracotomy in neonates.

The surgical approach to esophageal atresia repair and the management of long-gap atresia: results of a survey

The optimal approach for esophageal atresia (OA) repair and technique used for long-gap OA repair are controversial. There are few data comparing the outcomes of the different approaches and techniques. We performed a survey of current practice of 88 pediatric surgeons and asked experts to provide us with definitions and rationales behind their management strategies. There were no differences between UK and non-UK surgeons. Although the majority of pediatric surgeons perform minimally invasive surgery (68%), only 16% have performed thoracoscopic OA repair; however, 46% are planning to carry out thoracoscopic OA repair. Gastric interposition is the most preferred technique for long-gap OA when primary anastomosis is not possible, with 94% of those surgeons who use the technique satisfied with it. Growth of the esophageal ends by traction is the other major technique used, but only 76% of surgeons who use it are satisfied with it. Most surgeons repair < or =2 patients with long-gap OAs per year. Long-gap OA should be managed by a limited number of surgeons at each center. Even among experts, there is little consensus on the definition of or the optimum technique for repair of long-gap OA.

Thoracoscopic versus open repair of tracheoesophageal fistula and esophageal atresia

BACKGROUND/OBJECTIVE

Recent studies show the minimally invasive approach to the repair of esophageal atresia (EA) and tracheoesophageal fistula (TEF) is feasible. This study aimed to evaluate the efficacy and safety of the thoracoscopic versus open techniques.

METHODS

We performed a retrospective review of EA/TEF cases from June 2000 to July 2006. Patient characteristics, operative time, blood loss, duration of narcotic usage, time to extubation, time to first oral feeding, length of stay, complications, and follow-up were analyzed.

RESULTS

Thirty-five type-C EA/TEF patients were evaluated. Two patients with excessively long gaps who required esophageal "bougienage" stretching were excluded. Twenty-five patients underwent traditional repair through thoracotomy. There were 8 thoracoscopic attempts, 7 of which were successfully completed without a conversion. The mean operative time was 130 minutes (range, 75-240) for the thoracoscopic approach, compared to 123 (range, 82-205) for the thoracotomy; mean duration of narcotic use was 5 days (range, 1-12), as compared to 23 (range, 2-190); the mean time to extubation was 4.6 days (range, 1-12), compared to 19 (range, 3-150); the mean days to per os feeding were 9.8 days (range, 7-17) versus 37 (range, 7-360); and the mean length of stay was 21.8 days (range, 11-38), compared to 66 (range, 8-280). There were no intraoperative complications or deaths in either group. The anastomotic leak rate was 14 versus 20%, whereas the stricture rate was 14 versus 50% for the closed and open techniques, respectively. Of the thoracoscopic group, 87.5% had at least one major associated anomaly, compared with 70% of patients undergoing thoracotomy. Follow-up for the thoracoscopic and open groups were 18 and 28 months, respectively.

CONCLUSION

Our results suggest that the outcomes of the thoracoscopic technique are comparable to that of the open technique. However, the number is small, and more data are needed to further evaluate the procedure.

The long-term follow-up of patients with a congenital diaphragmatic hernia: a broad spectrum of morbidity

Congenital diaphragmatic hernia (CDH) is a life-threatening anomaly with a mortality rate of approximately 40-50%, depending on case selection. It has been suggested that new therapeutic modalities such as nitric oxide (NO), high frequency oxygenation (HFO) and extracorporal membrane oxygenation (ECMO) might decrease mortality associated with pulmonary hypertension and the sequelae of artificial ventilation. When these new therapies indeed prove to be beneficial, a larger number of children with severe forms of CDH might survive, resulting in an increase of CDH-associated complications and/or consequences. In follow-up studies of infants born with CDH, many complications including pulmonary damage, cardiovascular disease, gastro-intestinal disease, failure to thrive, neurocognitive defects and musculoskeletal abnormalities have been described. Long-term pulmonary morbidity in CDH consists of obstructive and restrictive lung function impairments due to altered lung structure and prolonged ventilatory support. CDH has also been associated with persistent pulmonary vascular abnormalities, resulting in pulmonary hypertension in the neonatal period. Long-term consequences of pulmonary hypertension are unknown. Gastro-esophageal reflux disease (GERD) is also an important contributor to overall morbidity, although the underlying mechanism has not been fully understood yet. In adult CDH survivors incidence of esophagitis is high and even Barrett's esophagus may ensue. Yet, in many CDH patients a clinical history compatible with GERD seems to be lacking, which may result in missing patients with pathologic reflux disease. Prolonged unrecognized GERD may eventually result in failure to thrive. This has been found in many young CDH patients, which may also be caused by insufficient intake due to oral aversion and increased caloric requirements due to pulmonary morbidity. Neurological outcome is determined by an increased risk of perinatal and neonatal hypoxemia in the first days of life of CDH patients. In patients treated with ECMO, the incidence of neurological deficits is even higher, probably reflecting more severe hypoxemia and the risk of ECMO associated complications. Many studies have addressed the substantial impact of the health problems described above, on the overall well-being of CDH patients, but most of them concentrate on the first years after repair and only a few studies focus on the health-related quality of life in CDH patients. Considering the scattered data indicating substantial morbidity in long-term survivors of CDH, follow-up studies that systematically assess long-term sequelae are mandatory. Based on such studies a more focused approach for routine follow-up programs may be established.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: lessons learned

OBJECTIVE

Repair of esophageal atresia and tracheoesophageal fistula has traditionally been performed via thoracotomy. This study aims to evaluate the feasibility and pitfalls of the thoracoscopic approach.

MATERIALS AND METHODS

Six consecutive patients with type C tracheoesophageal fistulae underwent thoracoscopic repair. The operation was approached through the right chest using a three-trocar technique (two 5-mm and one 3-mm) with the patient placed in a three-quarter prone position. Patient characteristics, operative time, duration of narcotic usage, conversion factors, postoperative complications, and long-term follow-up were recorded.

RESULTS

Five of six patients were successfully operated on thoracoscopically. The average operative time was 143 minutes (range, 75-215 minutes) with repair of long-gap defects requiring significantly longer times than short-gap defects (200 vs. 129 minutes, P < 0.05). There were no intraoperative complications. Mean duration of narcotic use was 52 hours (range, 24-72 hours). There were no anastomotic leaks. One patient developed an anastomotic stricture at the third postoperative week, which resolved with two dilations. One patient died on the first postoperative day from respiratory failure.

CONCLUSION

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula is feasible, but is technically challenging. Long-gap defects require more extensive dissection and difficult anastomosis, and are therefore associated with longer operative times. More data are needed for further evaluation of this approach.

Thoracoscopic repair of esophageal atresia and tracheoesophageal fistula: a multi-institutional analysis

OBJECTIVES

For the past 60 years, successful repair of esophageal atresia (EA) and distal tracheoesophageal fistula (TEF) has been performed via a thoracotomy. However, a number of reports have described adverse musculoskeletal sequelae following thoracotomy in infants and young children. Until now, only a few scattered case reports have detailed an individual surgeon's success with thoracoscopic repair of EA/TEF. This multi-institutional review represents the largest experience describing the results with this approach.

METHODS

A cohort of international pediatric surgeons from centers that perform advanced laparoscopic and thoracoscopic operations in infants and children retrospectively reviewed their data on primary thoracoscopic repair in 104 newborns with EA/TEF. Newborns with EA without a distal TEF or those with an isolated TEF without EA were excluded.

RESULTS

In these 104 patients, the mean age at operation was 1.2 days (+/-1.1), the mean weight was 2.6 kg (+/-0.5), the mean operative time was 129.9 minutes (+/-55.5), the mean days of mechanical ventilation were 3.6 (+/-5.8), and the mean days of total hospitalization were 18.1 (+/-18.6). Twelve (11.5%) infants developed an early leak or stricture at the anastomosis and 33 (31.7%) required esophageal dilatation at least once. Five operations (4.8%) were converted to an open thoracotomy and one was staged due to a long gap between the 2 esophageal segments. Twenty-five newborns (24.0%) later required a laparoscopic fundoplication. A recurrent fistula between the esophagus and trachea developed in 2 infants (1.9%). A number of other operations were required in these patients, including imperforate anus repair in 10 patients (7 high, 3 low), aortopexy (7), laparoscopic duodenal atresia repair (4), and various major cardiac operations (5). Three patients died, one related to the EA/TEF on the 20th postoperative day.

CONCLUSIONS

The thoracoscopic repair of EA/TEF represents a natural evolution in the operative correction of this complicated congenital anomaly and can be safely performed by experienced endoscopic surgeons. The results presented are comparable to previous reports of babies undergoing repair through a thoracotomy. Based on the associated musculoskeletal problems following thoracotomy, there will likely be long-term benefits for babies with this anomaly undergoing the thoracoscopic repair.

Extrapleural thoracoscopic repair of esophageal atresia with tracheoesophageal fistula

Traditionally, open repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) required thoracotomy. Innovations in minimal access surgery have created a thoracoscopic technique resulting in violation of the pleural space. Most pediatric surgeons favor an extrapleural approach for open repair. We present a novel minimal access, extrapleural technique for repairing EA with TEF. A 2-day-old infant with EA and distal TEF underwent thoracoscopic extrapleural repair that utilized three ports. Initial creation of the extrapleural space was achieved through one of the port sites and was completed thoracoscopically. A thoracoscopic repair of EA with distal TEF was achieved within the extrapleural space. A small tear in the pleura was inadvertently created during the dissection. The child began feeding normally. At 1 year of age, the patient had dysphagia requiring a single esophageal dilatation. This is the first known report of an extrapleural thoracoscopic repair of EA with TEF. Although thoracoscopic repairs of EA/TEF have been previously reported, these were all done transpleurally. Many pediatric surgeons favor the extrapleural approach for two reasons: (1) containment of a potential leak within the extrapleural space, avoiding an empyema, and (2) easier transpleural access for future thoracic procedures.

Thoracic sequels after thoracotomies in children with congenital cardiac disease

The standard surgical approach for closed heart procedures in small infants and children is to use a posterolateral thoracotomy incision, which results in the division of the latissimus dorsi and serratus anterior muscles. The aim of our study was to determine the frequency and type of musculoskeletal deformities in children undergoing surgery with this approach for congenital cardiac disease. We included 49 children, 28 boys and 21 girls, in the study. Their mean age was 10.2 +/- 4.8 years, the mean age at the time of surgery was 3.8 +/- 4.0 years, and they were evaluated at an average of 6 years after the thoracotomy. Of the patients, 94% had various musculoskeletal deformities. Scoliosis was observed in 15 patients (31%) but only in two patients did the curves exceed 25 degrees. Of these patients, three-fifths had aortic coarctation. Elevation of the shoulder was seen in 61%, winged scapula in 77%; while 14% had asymmetry of the thoracic wall due to the atrophy of the serratus anterior muscle. Deformity of the thoracic cage was observed in 18%; and 63% had asymmetry of the nipples. Thus, we found that musculoskeletal deformities are frequent after thoracotomies in children with congenital cardiac disease. Patients who have undergone such procedures for cardiac or noncardiac surgery should be followed until their skeletal maturation is complete. Techniques sparing the serratus anterior and latissimus dorsi muscles should be preferred. These adverse effects of thoracotomy may be another reason for using interventional procedures in these cases.

Feasibility of thoracoscopic repair of esophageal atresia with distal fistula

BACKGROUND/PURPOSE

Evaluation of the feasibility of thoracoscopic correction of esophageal atresia with distal fistula.

METHODS

Eight consecutive neonates with esophageal atresia and distal fistula were treated thoracoscopically. Mean birth weight was 3,048 g (range, 2,140 to 3,770). The patients were intubated endotracheally and placed in a 3/4 left prone position. Three cannulae were inserted along the inferior tip of the scapula. CO(2) was insufflated at a pressure of 5mm Hg and a flow of 0.5 L/min. The fistula was either clipped or ligated. The proximal esophagus was opened and an anastomosis was made over a 6F or 8F nasogastric tube with interrupted 5-0 Vicryl.

RESULTS

All procedures were completed thoracoscopically without major peroperative complications. The mean operating time was 198 minutes (range, 138 to 250). One patient had a major leak, resulting in a stormy postoperative course, but the leak healed on conservative treatment. This patient and 3 others had stenosis requiring dilatation, respectively, 3, 6, 12, and 1 times. The babies were fed after a median period of 8 days. The median hospital stay was 13 days.

CONCLUSIONS

Thoracoscopic repair of esophageal atresia with distal fistula is feasible. Larger series are needed to determine the exact place of the thoracoscopic approach.

Aesthetics and lateral thoracotomy in the neonate

BACKGROUND

Lateral thoracotomy is a relatively common procedure in the neonate. Early reports on the incidence of shoulder deformity, scoliosis, and winged scapula rapidly led to a muscle-sparing approach. Scar cosmesis, however, received less attention. Better education and increasing sophistication have led to a higher aesthetic expectation by the public.

METHODS

Since 1988 the authors have combined both principles in the high axillary skin crease approach to lateral thoracotomy in 27 children with esophageal atresia and tracheoesophageal fistula and two children with a patent ductus arteriosus.

RESULTS

Access was not restricted, and early healing was uncomplicated by wound breakdown or infection. Scar aesthetics is excellent and is enhanced by the natural tendency of the scar to migrate into the axilla. Long-term morbidity has been singularly absent.

CONCLUSION

Parent appreciation and operator satisfaction have been noteworthy.

Experience with modified posterolateral muscle-sparing thoracotomy in neonates, infants, and children

Between May 1991 and December 1995, a total of 38 posterolateral muscle-sparing thoracotomies were performed in neonates and children. The technique described preserves the serratus anterior and most of the latissimus dorsi muscle. In all except 1 case, excellent exposure of the thoracic cavity was achieved. The muscle-sparing approach is easy to perform with appropriate attention to the anatomy of the chest wall. It has the advantages of minimal anatomic disturbance and trauma to the major chest-wall muscles, and hence is likely to be associated with less postoperative pain and, possibly, improved pulmonary function. A plea for routine use of a muscle-sparing incision for thoracotomy procedures in the pediatric age group is thus justifiable.

Chest wall and spinal deformities in adults with congenital diaphragmatic defects

Between 1948 and 1980, 107 of 164 patients survived after repair of congenital diaphragmatic defects. To study chest wall and spinal deformities among these patients, 60 survivors (mean age, 29.6 +/- 9.0 years) underwent clinical examination, chest and spinal radiography, spirometry, and diffusing capacity measurements. Twenty-seven of these patients also had body pletysmography, xenon 133 radiospirometry, and a test for bronchial hyperreactivity. Chest asymmetry was present in 29 patients (48%). Eleven patients (18%) had pectus excavatum, and one had a pectus carinatum deformity. Anterior asymmetry, pectus deformities, and a flat chest were more common among the patients who initially had a large diaphragmatic defect. Two patients underwent anterior thoracoplasty because of their deformities. Sixteen patients (27%) had significant scoliosis (Cobb angle > or = 10 degrees). Scoliosis was more common in patients with ventilatory impairment than in those with normal lung function. One patient required spinal stabilization, one with severe kyphoscoliosis remains under observation, and a patient with moderate scoliosis was treated with a spinal brace. The results of this study indicate that chest wall deformities and scoliosis are common among adults with repaired congenital diaphragmatic defects. In most patients the deformity is mild, but some will require surgery. Surveillance until adulthood is appropriate.

The muscle-sparing thoracotomy in infants and children

Deformities of the chest wall, breast, shoulder girdle, and spine are well-documented sequelae of major thoracotomies that transect muscles, divide major motor nerves, resect ribs, or cause them to fuse. These deformities are probably aggravated by the growth process. This is why we make a plea for the routine use, in infants and children, of a muscle-sparing thoracotomy that will minimize these sequelae without sacrificing exposure. Major (lateral) thoracotomy by this technique involves these steps: (1) creating a transverse incision below the tip of the scapula, or a vertical axillary incision; (2) elevating the skin flaps to expose the muscles; (3) retracting the latissimus dorsi posteriorly; (4) retracting the serratus anterior and scapula superiorly; (5) disinserting the lower origins of the serratus if required only; (6) opening the desired intercostal space; (7) reapproximating the ribs without crowding, using a pericostal suture that is passed along the inferior rib subperiosteally, to avoid any compression on the neurovascular bundle; and (8) allowing the muscles to fall back into place, reattaching the serratus insertions as indicated. Lessened postoperative pain and improved respiratory function are additional benefits.

Chest wall deformity in patients with repaired esophageal atresia

Chest wall deformities developed after thoracotomy for esophageal atresia, in 77 of 232 patients (33%) who did not have a congenital vertebral anomaly. Anterior chest wall asymmetry was present in 47, scoliosis in 18 and a combination of both in 12 patients. Scoliosis was convex away from the incision in two thirds of those affected. Anterior chest wall deformity was more common in patients greater than 25 years of age, and scoliosis was more common in patients who had had multiple thoracotomies. Breast surgery to minimize inequality was required in three female patients, and spinal surgery in one patient. Twenty-two of 53 patients with a congenital vertebral anomaly developed scoliosis, eight of whom required surgery. The scoliosis was probably the result of the vertebral anomaly in these patients, who are particularly at risk for progressive deformity.

The history of oesophageal atresia and tracheo-oesophageal fistula--1670-1984

The history of oesophageal atresia commenced in the year 1670 with Durston's description of "A narrative of a monstrous birth at Plymouth". However, the most significant contribution in the 17th century was made by Gibson, who clearly described the clinical picture and necropsy findings in a baby with a proximal oesophageal atresia and a distal tracheo-oesophageal fistula. The 18th century was singularly lacking in contributions to the literature, but there were many important presentations during the 19th century. Early in that century Martin in France and Hill in United States of America contributed to the literature; subsequently, many anecdotal references can be found particularly in England, and ultimately a surgical attempt to correct the anomaly was made in 1888 by Steele in London. With this, the pre-surgical era gave way to the surgical era, and at a later stage pre-survival era was to give way to the survival phase. Reference will be made in the text to these various phases in the history and to the many pioneering surgical endeavours which took place in the earlier years of the 20th century. It will be seen that the surgical efforts employed palliative procedures, indirect attacks on the problem and finally direct attacks. The classic successes by indirect methods which were achieved by Ladd and Leven in babies born in 1939 were to be followed by the first successful end-to-end anastomosis which was achieved in Ann Arbor, Michigan, by Cameron Haight. Others had attempted primary anastomosis, and Lanman in particular deserves mention. However, it was Cameron Haight who opened a new era in the history of the treatment of oesophageal atresia; the recent history is largely concerned with increasing experience and refinements in technique. For the future historian many pathways can still be explored, including oesophageal replacement, the unstable trachea, follow-up studies and research projects. This history also included comments on the history of the less frequently encountered anomalies and such aspects as classification and radiology. The history of oesophageal atresia and tracheo-oesophageal fistula is a mini history of surgery - "oesophageal atresia is the epitome of modern surgery".

Morbid musculoskeletal sequelae of thoracotomy for tracheoesophageal fistula

The standard surgical approach for tracheoesophageal fistula (TEF) is right dorso-lateral thoracotomy. The late musculoskeletal consequences of the operation have been evaluated only rarely. Two hundred and seventy-seven patients with TEF were operated upon during the past 16 years, 117 of whom were available for long term (3 to 16 year) study. Twenty-nine of the patients had significant musculoskeletal deformities: (1) Twenty-one patients (23.8%) had prominent elevation of the right shoulder or "winged" scapula secondary to partial paralysis of the latissimus dorsi muscle; (2) Eighteen (20%) had marked asymmetry of the thoracic wall from atrophy of the serratus anterior muscle; (3) Nine (10%) had fusion of the ribs, in one of whom major respiratory dysfunction was a consequence; (4) Seven (7.8%) had severe thoracic scoliosis. The deformity was not of sufficient severity to warrant surgical correction but all patients required physiotherapy; (5) In two children (2.2%), fixation of the skin cicatrix to the bony thorax limited the mobility of the ipsilateral shoulder; (6) And finally, in three girls (3.3%), the thoracotomy scar disfigured the right breast leading to mammary maldevelopment in one adolescent. The latter child required plastic release of the entrapped breast. The dorso-lateral thoracic incision for tracheoesophageal atresia may lead to significant musculoskeletal complications and, since other alternatives are available, should be reevaluated as the recommended surgical approach.