Tips and Tricks: EA & TEF

Spitz uses a 6 French feeding tube (not a Replogle) for feeding in the first few days after esophageal atresia repair.

Jack leaves a 5 French feeding tube, both for feeding and to protect the back wall during the anastomosis.

Steve uses a 10 French Replogle across the anastomosis.

When separating the upper pouch from the membranous trachea, Steve uses blunt and sharp dissection; he only uses cautery if he can clearly see the tissues and knows he is not injuring the membranous trachea.

Surgeons have created holes in the membranous trachea during dissection of the plane between the membranous trachea and the medial wall of the upper pouch, resulting in acquired tracheoesophageal fistula that is very difficult to fix.

Cautery should never be used to dissect the upper pouch off the membranous trachea; sharp dissection is the only safe way.

For extracorporeal knots on the first couple of stitches, Vicryl should not be used because it is very hard to tie an extracorporeal knot with it.

If tying extracorporeally, PDS should be used because it slides better than Vicryl.

When there is an anastomosis under tension and concern about a leak, it is advisable to get some tissue between the two suture lines to prevent development of a recurrent fistula.

A pleural flap or pericardial flap can be used to place vascularized tissue between the two suture lines.

In a baby, a thick pleural flap can incorporate some of the muscle of the intercostal spaces and some fat.

The thing that causes most recurrent fistulas is a leak; the thing that causes most leaks is too much tension on the anastomosis.

For premature infants with a very small upper pouch and a fistula, Steve has ligated the fistula thoracoscopically and, if the baby is doing well, mobilized the upper pouch; if unable to get it together, he places an internal stitch in the upper pouch under tension and returns in 4 to 6 weeks to do the anastomosis.

The advantage of doing the procedure thoracoscopically is that there is no big thoracotomy incision, allowing evaluation and decision-making about whether the anastomosis can be performed.

For premature infants, if only the fistula is ligated (maybe without dissecting so it does not slip back) and waiting 4 to 6 to 8 weeks for spontaneous growth, the anastomosis can be done later.

If the azygos vein is ligated, the distal end can be opened and placed over the tracheal or esophageal suture line.

Jack placed a clip on a fistula in a preemie without dividing it, and 3 weeks later the fistula recurred.

If clipping the fistula, it must be divided; just putting a clip on can lead to recanalization.

When doing just a fistula division or ligation and it is clear the two ends cannot be put together, the distal segment should be tacked up to the vertebral body (prevertebral fascia) to keep it from shrinking down.