Thoracoscopic Mobilization and Intraoperative Internal Traction—A Novel Approach for Treatment of Long-gap Type C Esophageal Atresia with Distal Carinal Fistula

Introduction: Long-gap esophageal atresia (LGEA) is challenging due to the substantial distance between the proximal and distal esophageal pouches. Traditionally, it includes Gross types A and B, while inclusion of long-gap type C cases remains debated. In type C esophageal atresia (EA), the distal tracheoesophageal fistula (TEF) varies in location; when situated at the carina, the effective pouch distance may be markedly increased, making it one of the most complex anatomical subtypes. Introduction: We hypothesized that early primary anastomosis in type C with carinal fistula (TEFC) is feasible using thoracoscopic mobilization and intraoperative internal traction, and aimed to compare outcomes with type C cases where the TEF is higher on the tracheal wall (TEFT). Materials and Methods: We analyzed 134 EA patients treated thoracoscopically at the Wilhelmina Children's Hospital in Utrecht between 2012 and 2024, including 25 TEFC and 109 TEFT patients. TEF location was determined by perioperative tracheobronchoscopy, and the surgical approach was tailored accordingly. TEFC patients underwent thoracoscopic esophageal mobilization with intraoperative internal traction, while TEFT patients received conventional primary thoracoscopic anastomosis. Primary outcomes were early successful anastomosis, preservation of the native esophagus, and anastomotic leakage. Secondary outcomes included postoperative morbidity and clinical results during childhood. Results: All patients underwent successful thoracoscopic repair shortly after birth, without requiring esophageal replacement. In the TEFC group, single-stage anastomosis was achieved in 23 patients; two required temporary external traction followed by delayed repair. TEFC patients showed higher rates of anastomotic leakage (40% vs. 20.2%), recurrent stenosis (24% vs. 10.1%), and need for anti-reflux surgery (26.1% vs. 11.3%). Early feeding difficulties affected weight gain in both groups, with 10 to 20% underweight at 6 to 12 months and no significant group difference. By 5.5 years, growth improved markedly, with no TEFC patients and 8.6% of TEFT patients remaining underweight. Conclusion: Although TEFC represents a more complex subgroup with higher complication rates, early thoracoscopic anastomosis with preservation of the native esophagus is achievable in these long-gap type C patients. Routine tracheobronchoscopy may support accurate classification and optimized surgical planning.