Median sternotomy approach for the repair of esophageal atresia: a case report

During the operation for esophageal atresia, when the upper pouch of the esophagus is located to the left of the trachea or in a very high position, identification, and dissection of the upper esophagus through the right thoracic cavity may be difficult. Furthermore, when the right aberrant subclavian artery is involved, as in our case, it obstructs the visual field, complicating surgical manipulation. Owing to these conditions in the current case, we performed the operation through a median sternotomy, which allowed easy manipulation with an unobstructed operative visual field. Normally, the left brachiocephalic vein is located in front of the trachea during a median sternotomy. However, in this case, owing to a persistent left superior vena cava, only the brachiocephalic artery was present in that position, which simplified the approach.

In previous cases, a cervical incision was used when the upper esophagus and TEF were located at a higher position than normal [2]. However, in cases where the upper esophagus and TEF were located near the thoracic inlet and dorsal to the sternum, a cervical incision is likely to provide a poor operative field, and a median sternotomy, as in the present case, is a better alternative. The median sternotomy approach is a far better option than the cervical approach in terms of the visual field. As this was the first time this approach was used for esophageal atresia, we performed a total sternotomy; however, a partial sternotomy may also be adequate.

Recently, CT has been proposed for newborns with esophageal atresia to identify the position of the TEF and anomalies of the aortic arch [3]. However, experience with the use of these diagnostic tools in the preoperative evaluation of neonates with esophageal atresia is very limited, and concerns have been raised about neonatal transport to the radiology department, the need for sedation, and CT-related radiation injury [4].

We routinely perform preoperative contrast-enhanced CT when the patient's condition permits. In the present case, the preoperative CT images allowed us to visualize the route to the upper esophagus and TEF, as well as the anastomotic maneuver. Contrast-enhanced CT provides detailed information on the location of the upper esophagus and TEF, as well as anomalies in the vasculature, which can be useful in performing surgery.

The median sternotomy approach may be indicated in particular cases, such as when the upper esophagus is extremely high (at the level of the thoracic inlet) and located to the left of the trachea. Moreover, the presence of a right aberrant subclavian artery complicated the approach from the right thoracic cavity. The disadvantages of a median sternotomy approach for esophageal atresia compared to a thoracic approach are cosmetic inferiority and the possibility of severe mediastinitis due to anastomosis leakage.

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