From
Grand Rounds
Esophageal Replacement with Dr. Dan von Allmen
With Dr. Daniel von Allmen · hosted by Dr. Em Gootee
Chapter 1 of 5 · Fundamentals
EA terminology & epidemiology
Terminology, Epidemiology, and Initial Evaluation of Esophageal Atresia
Expert statements on this page
No expert statements were drawn from this page.
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.
Video
Esophageal Atresia
39 min · Published Nov 2018
Video
Tracheoesophageal Fistula with Dr. Daniel von Allmen
Dr. Todd Ponsky · 45 min · Published Dec 2016
Video
Posterior Tracheopexy For Severe Tracheomalacia
Dr. Todd Ponsky · 2 min · Published Feb 2018
Video
Esophageal Atresia/Tracheoesophageal Fistula Bronchoscopy and Surgical Technique
Dr. Todd Ponsky · 16 min · Published Nov 2021
Video
QUAD #2 Thoracoscopic Tracheopexy with Dr. Aaron Garrison
CCHMC Pediatric Surgery · 7 min · Published Jan 2024
Podcast
Journal of Pediatric Surgery Article Review: December 2021
16 min · Published Jan 2022
Podcast
Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement
10 min · Published Jan 2022
Video
7th Annual Pediatric Surgery Update Course 2019 - FULL SHOW
285 min · Published Jul 2020
Podcast
Neuroblastoma
56 min · Published Aug 2019
Video
Aerodigestive & Esophageal Surgery - The Unsalvageable Esophagus & Cases
CCHMC Pediatric Surgery · 101 min · Published Nov 2018
Video
Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula
Dr. Todd Ponsky · 120 min · Published Nov 2018
Video
Abdominal Wall Defects
37 min · Published Nov 2018
Video
GYN #4 Management of Tubal Torsion: When to Consider Salpingectomy with Dr. Lesley Breech
CCHMC Pediatric Surgery · Published Oct 2024
Podcast
Pyloric Stenosis with Dr. Alex Bondoc
16 min · Published Jun 2024
Video
GYN #3 Management of an Adnexal Torsion with a Healthy Appearing Ovary with Dr. Lesley Breech
CCHMC Pediatric Surgery · Published May 2024
Video
GYN #2 Oophoropexy in Adnexal Torsion with Dr. Lesley Breech
CCHMC Pediatric Surgery · Published May 2024
Video
GYN #1 Importance of Documenting Reproductive Anatomy with Dr. Lesley Breech
CCHMC Pediatric Surgery · Published Feb 2024
Podcast
Hepatic Infections: Hepatitis, Abscess & Cysts with Dr. Alex Bondoc
15 min · Published Oct 2023
What the experts said
Esophageal atresia incidence is 1 in 4500 in the United States with slight male predominance
Recurrence risk of esophageal atresia among parents who have one affected child is 0.5 to 2%
Prenatal ultrasound detects only about half of esophageal atresia cases, primarily detecting pure atresia due to significant proximal pouch dilation
The most common type of esophageal atresia is proximal atresia with distal fistula
VACTERL is an association, not a syndrome, requiring 3 of the defects for diagnosis
Esophageal atresia associated with significant cardiac anomalies and low birth weight has only 27 to 30% survival rate
In type C fistula with respiratory distress, air continuously goes into the intestine via the low resistance pathway instead of into the lungs, causing increased stomach size and affecting respiratory compliance
G-tube decompression or needle decompression helps temporarily but air still follows the low resistance pathway out of the G-tube instead of going into the lungs
Putting vessel loop around distal esophagus is easier than dividing the fistula when in trouble during surgery
Every child with tracheoesophageal fistula or esophageal atresia needs bronchoscopy due to 10-15% association of airway issues and to help plan surgery
Virtually all kids with esophageal atresia have some element of tracheomalacia, though clinical significance varies
There is growth in the esophagus over time, but once past 4 to 6 weeks there is not going to be any more growth
For significant gap, approach is to support child with enteral bolus feedings to put stretch on the distal esophagus and get sequential gap studies, then take to OR at 6 weeks
For thoracoscopy, patient positioning should be almost 45 degrees from prone, pushed to one side of bed, with camera port looking straight down at esophagus providing better visualization than open surgery
The azygos vein guides to the level of the fistula because the fistula typically occurs right about the level of the azygos vein
When placing clip on fistula, it must be flush with the trachea to avoid leaving a long pouch that can pool secretions and cause problems
Anesthesiologist needs to push down repeatedly to help find the proximal pouch during surgery
It is safer to put a hole in the esophageal pouch than in the trachea during dissection
If CO2 skyrockets on ET tube during thoracoscopy, this indicates a hole in the trachea as CO2 from thoracoscopy goes up the trachea and out the endotracheal tube
Foker procedure uses traction sutures brought out through chest wall with sequential tightening, as traction is a stimulus for esophageal growth
In primary Foker cases, esophagus was successfully brought together 96% of the time, versus only 2/3 of the time in secondary cases after previous operation
Primary Foker cases spent more than 1 month in ICU on average and were paralyzed for more than 2 weeks
Secondary Foker cases spent mean of 110 days in ICU and were paralyzed for more than 1 month
Most common esophageal replacement is gastric pull-up, but other options include reverse gastric tube, colon interposition, and duodenal interposition, with none being clearly better than others
Reverse gastric tube is created from greater curve of stomach and requires preserving gastroepiploic artery when placing initial G-tube, but has many problems
Colon interposition advantage is tremendous length, allowing anastomosis to pharynx in caustic ingestion cases with no remaining esophagus
Biggest challenge with colon interposition is that conduits dilate and elongate over time, with food collecting and not emptying
Colon interposition conduits can be revised despite teaching that revision damages blood supply
In institutional series of first 13 colon interpositions, 12 of 13 patients were NPO at presentation, with no graft loss after initial case
Posterior tracheopexy involves putting sutures into membranous trachea to hold it back for tracheomalacia management
When performing initial repair with field already dissected, placing 3 posterior tracheopexy stitches takes 15 minutes and avoids need to operate through previously operated field later