Brain Oxygenation During Thoracoscopic Repair of Long Gap Esophageal Atresia

Abstract

Background: Elongation and repair of long gap esophageal atresia (LGEA) can be performed thoracoscopically, even directly after birth. The effect of thoracoscopic CO2-insufflation on cerebral oxygenation (rScO2) 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 CO2-pneumothorax was installed with a pressure of maximum 5 mmHg and flow of 1 L/min. Parameters influencing rScO2 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 rScO2 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 rScO2 increased after erythrocytes transfusion. Patient 5 also showed a rScO2 of 50% with a Hb <6 mmol/L during all procedures, except for a substantial increase during a high paCO2 of 60 mmHg. Patient 4 had a rScO2 > 85% during the first procedure with a concomitant high FiO2 > 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 rScO2 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.

Conflict of interest statement

The authors have no conflict of interest to declare.

Figures

Fig. 1

Duration of procedures. The entire duration of each procedure is displayed per patient, indicated by the total bar. Of each procedure the gray part with squares indicates the time of insufflation, the black part indicates the duration of surgery without insufflation of CO2 and the striped gray part the duration of induction and emergence of anesthesia, the time where no surgery is performed

Fig. 2

Perioperative vital parameters. Data before, during and after surgery of the vital parameters influencing the cerebral oxygenation: arterial saturation, fraction of inspired oxygen (FiO2), the arterial CO2 (paCO2) and the mean arterial blood pressure (MABP). The dotted line indicates the critical limits

Fig. 3

Intraoperative pH and paCO2. Intraoperative lowest pH and highest paCO2 measured during the consecutive procedures of each patient. The preoperative range of all patients is indicated by the gray bar. The dotted line indicates the paCO2 value of 35 mmHg

Fig. 4

Cerebral oxygenation during consecutive long gap esophageal repair. For each patient the cerebral oxygenation in each procedure is displayed. The black line represents the first procedure, the gray line the second, the dotted gray line the third and the dotted black line the fourth procedure in Patient 2. Data are measured at 10 time periods of 10 min. The circles indicate the significant changes in cerebral oxygenation