quiz patient with a right sided aortic arch (intraoperative)

[Ahmed Nabil]

First one with correct answer with justification win.

A four-kg term infant has esophageal atresia with tracheoesophageal fistula (EA/TEF). Echocardiogram shows a left sided aortic arch with no other cardiac abnormalities. The EA/TEF repair is approached using a right thoracotomy and right sided aortic arch is encountered.

At this time the best approach for this patient with a right aortic arch would be

A close the right thoracotomy and perform the entire repair through a left thoracotomy.

B abandon the repair and place a gastrostomy tube.

C close the right thoracotomy and perform the repair through a median sternotomy.

D return in six weeks to perform the operation through a left thoracotomy.

E continue the operation, but convert to a left thoracotomy if the operation becomes difficult to complete.

[Admin]

correct answer
E continue the operation, but convert to a left thoracotomy if the operation becomes difficult to complete.

When a right sided aortic arch (RAA) is known, the approach to a EA/TEF repair is controversial and somewhat surgeon dependent. A left thoracotomy may be a better approach to EA/TEF repair if a RAA is recognized. However, some authors have suggested that if a right thoracotomy is already in place, repair of a standard proximal pouch/distal fistula (i.e. nonlong gap) EA/TEF through a right thoracotomy is possible but challenging. Literature supports going ahead with the repair as long as it is safe but to convert to a left thoracotomy if the operation cannot be completed otherwise.

The standard approach for the thee to five percent of patients with EA/TEF and RAA is through a left thoracotomy due to difficulty of the repair through the right side and significant complications that may ensue through this approach. Recently, authors have noted that transthoracic echocardiography has poor sensitivity (14 to 62%) in detecting RAA. Furthermore, some strongly recommend doing either a computerized tomography (CT) or magnetic resonance (MR) angiogram in children with RAA to define the anatomy of the arch in a more precise way. The two most common anatomic configuration of RAA’s: (1) a mirror image of a left sided arch and (2) RAA with an aberrant takeoff of the left subclavian artery along with a patent ductus arteriosus. The second type creates a complete vascular ring and requires the division of the ductus (left sided) to alleviate difficulties with respiration and swallowing.

Placing a gastrostomy tube is not necessary in this baby. A median sternotomy would not give access to the esophagus and the trachea. Waiting six weeks to perform the operation through the left chest keeps the child in the hospital unnecessarily.

[Secundino López Ibarra]

A or E ... depends on the surgeon's experience

[Sharon]

E

[mughrabi79]

E

[Nicolas]

the structure of the question is not right as there is no single right answer..

[Manal Dhaiban]

E . You would continue with the operation from the right side, you don’t give a patient another thoracotomy with out trying.
the thing is that you may find the esophagus and manage it with some difficulty.
I will do left if it is absolutely necessary and I am doing more harm then good.
there is an option of mobeliizing the esophagus to by pass the Arch if necessay

[Basma Waseem]

E

[Admin]

correct answer
E continue the operation, but convert to a left thoracotomy if the operation becomes difficult to complete.

When a right sided aortic arch (RAA) is known, the approach to a EA/TEF repair is controversial and somewhat surgeon dependent. A left thoracotomy may be a better approach to EA/TEF repair if a RAA is recognized. However, some authors have suggested that if a right thoracotomy is already in place, repair of a standard proximal pouch/distal fistula (i.e. nonlong gap) EA/TEF through a right thoracotomy is possible but challenging. Literature supports going ahead with the repair as long as it is safe but to convert to a left thoracotomy if the operation cannot be completed otherwise.

The standard approach for the thee to five percent of patients with EA/TEF and RAA is through a left thoracotomy due to difficulty of the repair through the right side and significant complications that may ensue through this approach. Recently, authors have noted that transthoracic echocardiography has poor sensitivity (14 to 62%) in detecting RAA. Furthermore, some strongly recommend doing either a computerized tomography (CT) or magnetic resonance (MR) angiogram in children with RAA to define the anatomy of the arch in a more precise way. The two most common anatomic configuration of RAA’s: (1) a mirror image of a left sided arch and (2) RAA with an aberrant takeoff of the left subclavian artery along with a patent ductus arteriosus. The second type creates a complete vascular ring and requires the division of the ductus (left sided) to alleviate difficulties with respiration and swallowing.

Placing a gastrostomy tube is not necessary in this baby. A median sternotomy would not give access to the esophagus and the trachea. Waiting six weeks to perform the operation through the left chest keeps the child in the hospital unnecessarily.