Brain Oxygenation During Thoracoscopic Repair of Long Gap Esophageal Atresia

BACKGROUND: Elongation and repair of long gap esophageal atresia (LGEA) can be performed thoracoscopically, even directly after birth. The effect of thoracoscopic CO(2)-insufflation on cerebral oxygenation (rScO(2)) during the consecutive thoracoscopic procedures in repair of LGEA was evaluated. METHODS: Prospective case series of five infants, with in total 16 repetitive thoracoscopic procedures. A CO(2)-pneumothorax was installed with a pressure of maximum 5 mmHg and flow of 1 L/min. Parameters influencing rScO(2) were monitored. For analysis 10 time periods of 10’ during surgery and in the perioperative period were selected. RESULTS: Median gestational age was 35+3 [range 33+4 to 39+6] weeks; postnatal age at time of first procedure 4 [2–53] days and time of insufflation 127[22–425] min. Median rScO(2) varied between 55 and 90%. Transient outliers in cerebral oxygenation were observed in three patients. In Patient 2 oxygenation values below 55% occurred during a low MABP and Hb < 6 mmol/L. The rScO(2) increased after erythrocytes transfusion. Patient 5 also showed a rScO(2) of 50% with a Hb <6 mmol/L during all procedures, except for a substantial increase during a high paCO(2) of 60 mmHg. Patient 4 had a rScO(2) > 85% during the first procedure with a concomitant high FiO(2) > 45%. All parameters recovered during the surgical course. CONCLUSIONS: This prospective case series of NIRS during consecutive thoracoscopic repair of LGEA showed that cerebral oxygenation remained stable. Transient outliers in rScO(2) occurred during changes in hemodynamic or respiratory parameters and normalized after interventions of the anesthesiologist. This study underlines the importance of perioperative neuromonitoring and the close collaboration between pediatric surgeon, anesthesiologist and neonatologist. ELECTRONIC SUPPLEMENTARY MATERIAL: The online version of this article (doi:10.1007/s00268-016-3853-y) contains supplementary material, which is available to authorized users.