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Background Esophageal atresia (EA) is usually accompanied by some form of tracheomalacia. During the early phases in life, excessive dynamic collapse of the trachea can cause a wide spectrum of symptoms ranging from mild complaints to apparent life-threatening events (ALTE’s). Therapeutic strategies for severe tracheomalacia include aortopexy to lift the anterior weakened cartilaginous rings or posterior tracheopexy of the floppy membranous tracheal intrusion. Earlier we have introduced a new approach in which the posterior tracheopexy is performed directly during primary thoracoscopic correction of EA. Methods In the period 2017–2018, all consecutive EA patients (27) underwent a rigid tracheobronchoscopic evaluation during induction of anesthesia prior to the thoracoscopic EA repair. Tracheomalacia was diagnosed in 11 patients. During the subsequent thoracoscopic procedure, the posterior tracheal membrane was fixed to the anterior longitudinal spinal ligament with nonabsorbable sutures. The esophageal ends were then mobilized toward the right hemithorax and anastomosed. Results On preoperative RTB, six patients had a severe (66–99%) mid tracheal collapse and five patients had a moderate (33–66%) collapse. Thoracoscopic posterior tracheopexy with on to three sutures was possible in all 11 patients, prior to the formation of the esophageal anastomosis. Median time per suture was 6 minutes (range: 4–12 minutes). All operative procedures were uneventful. A median follow-up of 10 months (range: 2–22 months) revealed that eight patients recovered without any respiratory symptoms, one patient had respiratory symptoms caused by a suture granuloma that was removed by bronchoscopy, one patient had a respiratory syncytial virus bronchiolitis and one patient had a rhinovirus infection. None of the patients experienced any ALTE’s. Conclusion Eleven patients have been treated by thoracoscopic posterior tracheopexy during primary EA repair. This technique could prevent potentially deleterious sequelae of moderate to severe tracheomalacia that may complicate the lives of EA patients. Also, a second, sometimes complex surgical procedure can be prevented as the posterior tracheopexy is performed during the primary thoracoscopic EA correction.

Background Long-gap esophageal atresia (LGEA) is defined as atresia without distal tracheoesophageal fistula. Preserving the native esophagus is considered superior over intestinal interposition. Thoracoscopic traction technique facilitates lengthening of the esophageal ends, and allows anastomosis within the first weeks of life. The aim of this study was to evaluate the long-term outcome of LGEA patients treated by thoracoscopic traction technique. Methods From 2007 to 2018, 13 consecutive patients with LGEA were treated by thoracoscopic traction technique. During the first operation a bronchoscopy was performed to evaluate the presence of a proximal fistula. Then thoracoscopic traction sutures were placed at both esophageal ends. Initially a gastrostomy was performed. However, nowadays only a gastropexy is performed to prevent the stomach from migrating into the thorax. Approximation of the esophageal ends was evaluated by postoperative X-rays. Thoracoscopic adhesiolysis was performed when necessary. Both ends were anastomosed during the final surgical procedure, usually within a week. Results In 11 patients the anastomosis could be completed by thoracoscopic traction technique. In two patients the elongation procedure failed. In the first patient the sutures tore out. The second patient had an accidental perforation of the proximal pouch by the Replogle tube. Median time on ventilation until after the final anastomosis was 14 days (range 4–34 days). Five patients required chest tube drainage for anastomotic leakage. The median hospitalization time during the first admission was 47 days (range 31–170 days). All patients needed a median of 4 (range 1–16) dilatations for anastomotic stenosis. Ten patients needed a fundoplication within a median time of 8 weeks (range 2–16 weeks) after the esophageal anastomosis. One patient developed an esophago-bronchial fistula. Median weight at age of 2 years was −1.88 SD (range −3.54 – −0.16) and at age of 4 years −1.53 SD (range −2.94–0.66). All patients tolerated full oral feeding. Conclusion LGEA can be treated successfully after elongation by thoracoscopic traction technique. The procedure leads to an earlier anastomosis and shorter initial hospital stay as compared to delayed primary anastomosis. Full oral feeding is possible in all patients. Dilatation for anastomotic strictures and antireflux surgery is necessary in (almost) all patients.