From
StayCurrentMD
EA/TEF Discussion & Technique: Difficult Cases
With Dr. David Vanderzee & Dr. Jeff Blair
Chapter 1 of 5 · Surgical Management
Partial division technique
Yama's Partial Fistula Division Technique
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Host summaries · secondary, not cited in answers
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
For thoracoscopic EA/TEF repair, the gap between proximal and distal esophagus should be assessed preoperatively using X-ray with a nasogastric tube and bronchoscope positioned at the fistula orifice.
Leaving one-quarter of the fistula uncut during initial dissection prevents cranial retraction of the distal esophagus and facilitates anastomosis.
Leaving one-fifth to one-quarter of the proximal esophageal tip uncut provides a 'cap' for atraumatic grasping during anastomosis, avoiding damage to the anastomotic site.
When there is a 1-2 to 3 vertebral body gap, the assistant can pull the proximal esophagus caudally using the uncut cap.
The first anastomotic stitch should be placed in the middle of the posterior wall rather than at the edge.
6-0 PDS suture is used for the esophageal anastomosis.
The mucosa of both proximal and distal esophagus must be included in the anastomotic stitches to prevent postoperative stenosis.
The tracheoesophageal fistula is divided completely after 1-2 anastomotic stitches are placed.
The uncut cap of the proximal esophagus is divided after 2-3 anastomotic stitches are placed.
A transfixing suture can be used to close the fistula to ensure it does not come off.
Clips can hook behind sutures during anastomosis, which is a reason some surgeons avoid using them.
For type C EA/TEF with considerable length, two sutures can be placed and made into sliding knots to slowly bring the ends together, dividing tension between the two ends of the esophagus.
Finding the fistula laparoscopically is easier than other approaches, allowing better appreciation of how much esophagus to leave without leaving excess on the tracheal side.
Dissecting the upper segment of the esophagus is difficult, particularly in terms of handling the esophagus without damaging the wall needed for anastomosis.
In thoracoscopic EA/TEF repair, the dissection phase feels advantageous, but the anastomosis phase is technically challenging.
Clips have been implicated in erosion into the esophagus in some cases.
Metal clips are used by some surgeons for fistula closure.
Weck Hema lock clips are larger and the applier reduces visualization compared to metal clip appliers.
Weck Hema lock clips are difficult to reposition once applied.
Clipping the fistula too tightly will crush the esophageal muscle and cause erosion, leading to fistula recurrence; clips should be applied to oppose rather than crush.
A technique from Atlanta involves placing a stitch through the chest wall, through the proximal esophageal end, through the distal end, and back out through the chest wall, holding it up during anastomosis.
Steve Rothenberg, who has the largest experience with clips in EA/TEF repair, has never had a clip erode.