Esophageal Atresia/Tracheoesophageal Fistula Bronchoscopy and Surgical Technique

At Cincinnati Children's Hospital, ENT colleagues perform rigid bronchoscopy for every TEF case as part of the protocol.

Pre-operative bronchoscopy provides information about the degree of airway compression, expected tracheomalacia, and fistula location, which helps determine tension on the anastomosis.

During rigid bronchoscopy for TEF, the team attempts to find and cannulate the fistula using a 3 French Bugby cautery as a probe, which is skinny, blunt-ended, and can have its tip bent if needed.

Rigid bronchoscopy is preferred over flexible bronchoscopy for initial TEF evaluation because pulmonary specialists are not reliable at diagnosing laryngeal clefts with flexible bronchoscopy, as they cannot adequately visualize the posterior glottis.

Subsequent follow-up bronchoscopies are typically performed as a combination procedure with both ENT and pulmonology.

A Hopkins rod endoscope is typically used for rigid bronchoscopy in TEF cases, often with an endotracheal tube loaded on it to allow precise placement of the tube tip proximal or distal to the fistula.

For proximal fistulas, a ventilating tracheoscope (which lacks side ports) can be used to ventilate the child even when upper ports are above the larynx; this can be purchased or made by taping up the side ports of a standard bronchoscope.

The esophagus is located in the posterior mediastinum, followed by the vagus nerve, and the azygous vein is the target landmark for locating the distal fistula in a type C TEF.

The thoracoscopic approach to TEF repair is less traumatic than open thoracotomy and provides better exposure, particularly for mobilizing the proximal pouch.

Clips used to ligate the distal fistula can be knocked off; alternative techniques include hook cautery or energy devices.

Bakes dilators are used to identify and manipulate the proximal pouch during thoracoscopic TEF repair.

During proximal pouch dissection, it is critical to stay on the esophageal wall of the common wall between esophagus and trachea, as it is easy to inadvertently enter the trachea; this is similar to the common wall dissection in anorectal malformations.

During proximal pouch dissection, there is concern for recurrent laryngeal nerve injury from traction or cautery.

One technique is to leave the fistula partially attached until the first anastomotic stitch is placed, then cut it completely.

When using clips to ligate the fistula, the surgeon should attempt to be flush with the trachea and avoid leaving a stump, which is easier to achieve with thoracoscopic visualization.

If possible, a piece of tissue (pleura, azygous flap, or fat) should be placed between the tracheal and esophageal suture lines to minimize the risk of recurrence.

For high-tension anastomoses, the surgeon can place traction sutures and return after 3 days to complete the repair.

Magnet-assisted anastomosis is performed by GI colleagues at Cincinnati Children's Hospital, with Dr. Phil Putnam being particularly skilled with flexible esophagoscopy for this technique.