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Tracheoesophageal Fistula with Dr. Daniel von Allmen
With Dr. Daniel von Allmen · hosted by Dr. Todd Ponsky & Dr. Avi Schlager
Chapter 1 of 10 · Fundamentals
Center overview
Introduction and Multidisciplinary Center Structure
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Cincinnati Children's has a multidisciplinary aerodigestive center that includes ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians.
Physical examination findings in esophageal atresia include assessment of abdominal contour (scaphoid vs. distended) and respiratory status.
Personal confirmation of NG tube passage is important because some patients started on treatment for esophageal atresia were subsequently found to have tubes that passed normally.
Injecting air into the NG tube and obtaining a plain film helps visualize distention of the proximal esophageal pouch.
Lack of visible proximal pouch distention raises concern for either incorrect diagnosis or presence of a proximal fistula allowing pouch decompression.
Preoperative echocardiogram is essential to assess cardiac anatomy and identify right-sided aortic arch.
Renal ultrasound and spine evaluation for tethered cord are needed but are not necessary before addressing esophageal atresia.
Conventional wisdom suggests left thoracotomy for right-sided aortic arch, though the operation is somewhat more difficult with the heart more in the way.
If right-sided arch is discovered intraoperatively during right thoracotomy, it is possible to complete the operation from that side, though some reports suggest higher incidence of swallowing problems.
In a stable, larger baby not requiring intubation, it is reasonable to wait until full resources are available (Sunday or Monday) rather than operating emergently on Saturday.
Prolonged delay risks colonization of the GI tract and soiling of the lungs.
Oscillator ventilation has not been found to make a significant difference in managing infants with large fistulas and abdominal distention.
Air preferentially entering the GI tract rather than lungs is a bigger problem in more premature infants with poor lung compliance.
Treating with surfactant and improving lung compliance helps as much as changing ventilator type in managing fistula-related ventilation problems.
One risk in managing the deteriorating infant with TEF is waiting too long to make a decision, which can lead to an emergency situation with inability to ventilate.
Bronchoscopic placement of Fogarty balloon in the fistula is difficult unless expertise and equipment are immediately available.
G-tube decompression may paradoxically worsen ventilation by creating even lower resistance pathway, allowing more air to flow from trachea to GI tract rather than to lungs.
Laparotomy with vessel loop around gastroesophageal junction with gentle traction (Rommel tourniquet technique) can be used to stabilize critically ill infant, with G-tube placement and delayed definitive repair after several days.
In esophageal atresia with associated duodenal atresia, if the child is stable, consider fixing duodenal atresia first to avoid repairing esophagus upstream from an obstruction.
Both esophageal and duodenal atresia can potentially be repaired in the same operative setting if the child is stable enough.
Routine intraoperative bronchoscopy documents fistula location, assesses for proximal fistula, and most importantly identifies laryngeal clefts that are easily missed.
Laryngeal clefts have been seen many times in referred patients who had multiple thoracotomies but never had bronchoscopy.
The rate of missed second fistula is approximately 1%.
High fistulas exist on a spectrum from essentially a trifurcation of the carina to fistulas high enough to be approachable through the neck.
Endotracheal tube positioning depends on fistula location: for fistula at carina (trifurcation), tube should be placed higher; for high fistula, tube should be placed distal to fistula but not into the fistula itself.
Extrapleural approach offers the advantage of potentially limiting soilage of pleural space if there is a postoperative leak.
Dividing the azygos vein has no morbidity, gives better access, and frequently guides to the fistula location.
For open repair, the azygos is typically ligated and divided with suture.
Thoracoscopically, the azygos can be divided with energy devices or clips; hook cautery can be used if applied slowly up and down rather than all at once.
The 3mm Just Right surgical sealer is an ideal device for dividing the azygos in this size patient.
To establish extrapleural plane, place heel of right angle on ribs and spread to nicely show the plane, then mobilize pleura posteriorly to expose azygos.
Mobilizing pleura up around apex of lung is important to allow access for proximal pouch mobilization.
Distal esophageal segment is controlled with vessel loop, allowing proximal dissection to identify the fistula site.
Contrary to standard teaching that distal esophagus should not be mobilized, it can be mobilized extensively especially laterally, all the way to the diaphragm.
Medial mobilization of distal esophagus requires more caution due to blood supply concerns.
Extensive proximal pouch mobilization provides the most important length gain for anastomosis.
Proximal pouch dissection is similar to separating rectum and vagina—making two planes out of one with no great natural separation.
For proximal dissection, blade cautery with light buzz followed by mostly blunt dissection with flat end of blade, staying right on the thickened esophagus, is preferred; better to enter esophagus than trachea high in chest.
For large tracheal injury, sleeve resection is possible given tracheal mobility; pericardium or autologous tissue should be interposed between trachea and esophageal repair.
5-0 PDS (absorbable monofilament) is the preferred suture for esophageal anastomosis; silk is not favored.
Myotomies are not favored because they potentially create even more dysfunctional esophageal segment; motility is already abnormal in esophageal atresia.
For long-gap atresia when ends cannot be brought together, approach is to ligate distal end after dividing fistula, tack both ends on tension to prevertebral fascia, close, allow patient to grow 2-3 weeks, then return for anastomosis.
Traction or pressure is a strong stimulus to growth throughout the body including cardiovascular system and lungs.
For thoracoscopic Foker technique, traction sutures are placed in proximal and distal ends, brought out through trocar sites above and below (crossed), tensioned, with return to OR within a week for anastomosis.
Internal Foker (tacking ends to prevertebral fascia) is preferred over classic Foker with prolonged paralysis and sequential tensioning.
Bob Perry has performed 5-6 Foker procedures with excellent outcomes and minimal stricture formation.
For thoracoscopic TEF repair, patient is rotated past 90 degrees to allow gravity to move lungs away, with standard port placement: camera center, posterior port inferiorly, anterior port superiorly.
3mm instruments are used for thoracoscopic TEF repair.
Thoracoscopic visualization is very helpful for mobilizing the proximal pouch.
The anastomosis is the most difficult part of thoracoscopic TEF repair and requires significant minimally invasive experience.
Simulation courses for thoracoscopic TEF repair will be a great advantage for trainees given the infrequency of these cases.
For thoracoscopic anastomosis, Vicryl ties down nicely but cannot be used with knot pusher as it will tear through esophagus under tension; monofilament is needed for knot pusher technique.
For intracorporeal knot tying, braided suture is safe and preferred.
When clipping the fistula thoracoscopically, do not divide the esophagus distally until ready to place first stitch, preventing it from dropping toward diaphragm.
The hanging stitch helps release tension as first stitches are placed, providing some degree of approximation before throwing down initial stitches.
Every stitch must incorporate mucosa, which requires good visualization; the hanging stitch helps visualize lumens of both proximal and distal ends.
Ventilator management during thoracoscopy depends more on anesthesiologist comfort and attention than ventilator type (oscillator vs. conventional).
Endotracheal tube can be positioned to selectively ventilate left lung during thoracoscopy, aided by preoperative bronchoscopy.
A little CO2 insufflation with time will collapse the lung as long as anesthesiologist is not fighting with positive pressure; anesthesiologists can get scared by initial shunting but things settle down.
Early extubation is preferred when patient had good lung function preoperatively and operation went smoothly, even potentially in the operating room, to avoid positive pressure on tracheal repair and instead have negative intratracheal pressure with spontaneous breathing.