Cerebral Oxygenation During Thoracoscopic Repair of Esophageal Atresia

Thoracoscopic repair of esophageal atresia is a neonatal emergency procedure. With the increasing use of minimal invasive techniques, thoracoscopy is now commonly done to approach this complex anomaly. Due to CO2 pneumothorax, there is an increase in the CO2 load, over and above, produced by lung retraction during open thoracotomy, leading to hypoxia, hypercarbia, and eventually acidosis. In addition, there is a decrease in the venous return as well as hemodynamic perturbations because of elevated intrathoracic pressure and the anesthetic agents. Many studies have raised concerns regarding the impact of the above cardiorespiratory changes on cerebral oxygenation and subsequent long-term neurological outcome. The measurement of cerebral oxygenation is not feasible with routine hemodynamic monitoring and therefore requires other sophisticated noninvasive modalities to monitor cerebral oxygenation. The commonly used cerebral blood oxygen saturation monitoring methods include measurement of jugular venous oxygen saturation (SjvO2), brain tissue oxygen tension monitoring, transcranial Doppler ultrasonography (TCD), positron emission tomography (PET), and functional magnetic resonance imaging (fMRI). One of the new modalities which measure regional cerebral oxygen saturation (rScO2) includes near-infrared spectroscopy (NIRS), which is used during the surgical procedure to optimize cerebral oxygenation and thereby protect the neonatal brain, and it has been the commonly utilized modality by many studies. This chapter aims to present the available evidence on the effect of CO2 insufflation on cerebral oxygenation, discuss the function and role of NIRS to monitor and assess brain oxygenation intraoperatively during neonatal thoracoscopy, as well understand how further research will help in improving the knowledge base for future favorable outcome.