From
StayCurrentMD
Update Course 2013: EA & TEF
Chapter 1 of 6 · Diagnosis & Workup
Preop workup
Initial presentation and preoperative workup
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.
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What the experts said
Less than half of esophageal atresia cases are diagnosed antenatally, typically identified by small stomach and polyhydramnios
Echocardiogram is obtained preoperatively to rule out congenital heart defects and determine aortic arch sidedness (right vs left)
VACTERL workup (vertebral anomalies, renal ultrasound, evaluation for imperforate anus) is performed on an elective basis postoperatively
Echocardiogram may misidentify arch sidedness; one case had double aortic arch after right arch was reported
Right-sided aortic arch can be successfully repaired via right thoracotomy without converting to left approach
Bronchoscopy helps identify fistula location: mid-tracheal fistula suggests shorter gap, while carinal-level fistula suggests longer gap
Standard open approach uses right posterolateral thoracotomy with extrapleural dissection to vertebral bodies
Azygos vein division provides landmark for fistula location
Retrospective study of approximately 100 patients showed no difference in complications between Vicryl and silk suture material
For thoracoscopic repair using knot pusher technique, PDS must be used for first stitch as Vicryl will saw through tissue
Approximately 75% of EA/TEF patients are candidates for thoracoscopic repair
Complicated congenital heart disease is a relative contraindication to thoracoscopic repair due to longer operative time
Gap distance is the primary determinant of thoracoscopic repair feasibility, assessed after fistula division
Patient weight under 2 kg makes thoracoscopic repair more difficult due to limited space and difficulty retracting lung
In US training programs, typical fellow may perform 4-8 EA/TEF repairs during fellowship, with discontinuity between fellow cohorts
Ports should be spaced widely and staggered, with patient positioned more prone than lateral to optimize esophageal exposure
High-frequency oscillating ventilator in OR keeps lung collapsed during thoracoscopic repair, though causes patient shaking
Thoracoscopic approach is gentler on lungs, resulting in easier postoperative management, less pain, and smoother extubation
For thoracoscopic anastomosis, back-row middle stitch is placed first with knot tied intracorporeally, then transanastomotic feeding tube passed before front-row sutures
Transanastomotic feeding tube provides volume during suturing, making needle passage easier by using tube wall as guide
First anastomotic stitch does not need to be tied tight initially; subsequent stitches are tied down tight once approximation is confirmed
Stay sutures can be exteriorized through chest wall with hemostat to help approximate gap before placing subsequent stitches
Dividing only 3/4 of fistula (leaving 1/4 attached) during anastomosis makes procedure easier by maintaining traction
Minimal dissection of distal esophagus preserves blood supply and reduces trauma
Cervical esophagostomy commits patient to esophageal replacement rather than primary anastomosis
Waiting period of up to 3 months with gastrostomy feeds allows esophageal growth in some long-gap cases
Bougienage of proximal esophagus once weekly does not reliably promote esophageal growth; growth occurs spontaneously during waiting period
Bolus gastrostomy feeds may promote distal esophageal growth in long-gap cases
Polling showed almost everyone (specific percentage not stated) does not perform routine preoperative bronchoscopy
Chest tube is routinely placed in extrapleural space on water seal (not suction) and removed after postoperative contrast study
Recent literature shows no significant difference in outcomes between open and thoracoscopic repair
Average US attending surgeon performs 1-2 TEF repairs per year (Maury Ziegler's data)
Low-cost training models for EA/TEF repair have been developed, including one from Argentina presented at IPEG Beijing
Marcello has performed all EA/TEF repairs thoracoscopically for over 10 years after completing approximately 150 open repairs
Wet clips are fast and reliable for fistula division in thoracoscopic approach
Polling showed 35% perform thoracoscopic repair, 60% perform open repair
Cathy Barsson at Northwestern developed bovine fetal tissue model for TEF repair training, used to train 30 senior fellows
C1 needle with 5-0 PDS is preferred for thoracoscopic anastomosis due to good curve and ability to pass through 5mm trocar
Long-gap atresia is defined as gap greater than 2 vertebral bodies on contrast study through gastrostomy
Most surgeons attempt delayed primary anastomosis for long-gap atresia rather than proceeding directly to esophageal replacement