# Esophageal Atresia — GCMD Library living collection Updated: n/a · 8 episodes · 189 cited statements ## Episodes ### Tools ### High-Yield Summaries - [Esophageal Atresia](https://library.globalcastmd.com/watch/esophageal-atresia-627) — video · 39:30 · [machine version](https://library.globalcastmd.com/watch/esophageal-atresia-627.md) ### In-depth Review - [Tracheoesophageal Fistula with Dr. Daniel von Allmen](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300) — podcast · 45:21 · [machine version](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300.md) - [Esophageal Atresia/Tracheoesophageal Fistula Bronchoscopy and Surgical Technique](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895) — video · 16:54 · [machine version](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895.md) - [Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791) — podcast · 10:56 · [machine version](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791.md) ### Work-up and Treatment ### Technique Videos/OP Notes - [Neonatal Open Repair of Esophageal Atresia & Tracheo-esophageal Fistula EA_TEF. Dr Tamer Ashraf](https://library.globalcastmd.com/watch/neonatal-open-repair-of-esophageal-atresia-tracheo-esophageal-fistula-ea-tef-dr-tamer-ashraf-3937) — video · [machine version](https://library.globalcastmd.com/watch/neonatal-open-repair-of-esophageal-atresia-tracheo-esophageal-fistula-ea-tef-dr-tamer-ashraf-3937.md) - [IPEG Academy: Thoracoscopic Esophageal Atresia Repair](https://library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-esophageal-atresia-repair-4140) — video · [machine version](https://library.globalcastmd.com/watch/ipeg-academy-thoracoscopic-esophageal-atresia-repair-4140.md) ### Updates - [Thoracoscopic Repair of Esophageal Atresia](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-esophageal-atresia-7311) — video · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-esophageal-atresia-7311.md) - [Update Course Rewind: Magnet Therapy for Esophageal Atresia](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763) — podcast · 10:25 · [machine version](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763.md) ## Chapters - [0:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=0) Introduction and Multidisciplinary Center Structure (Ep 2) - [3:17](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=197) Initial Assessment and Preoperative Workup (Ep 2) - [7:08](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=428) Right-Sided Arch Management and Timing of Surgery (Ep 2) - [11:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=681) Emergency Management of Severe Abdominal Distention (Ep 2) - [14:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=870) Intraoperative Bronchoscopy and Open Technique (Ep 2) - [19:25](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1165) Mobilization Techniques and Tracheal Injury Management (Ep 2) - [23:53](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1433) Anastomotic Technique and Long-Gap Management (Ep 2) - [29:06](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1746) Thoracoscopic Approach and Port Placement (Ep 2) - [35:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2120) Postoperative Management and Extubation (Ep 2) - [38:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2303) Stricture Management and Dilation Protocol (Ep 2) - [43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2606) Fundoplication Indications and Pure Atresia Approach (Ep 2) - [0:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=0) Introduction and Initial Workup of Esophageal Atresia (Ep 1) - [7:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=420) Surgical Approach: Right vs. Left Thoracotomy and Aortic Arch Position (Ep 1) - [15:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=900) Role of Preoperative Bronchoscopy (Ep 1) - [22:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1320) Open Repair Technique and Suture Material (Ep 1) - [28:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1680) Thoracoscopic Repair: Indications, Technique, and Training Challenges (Ep 1) - [35:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2100) Long-Gap Atresia Management and Esophageal Replacement (Ep 1) - [0:00](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=0) Case presentation and traditional surgical approaches for 3cm gap esophageal atresia (Ep 8) - [1:54](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=114) Flourish device mechanism, eligibility criteria, and patient selection (Ep 8) - [4:44](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=284) Complication case: undiagnosed fistula and treatment failure (Ep 8) - [7:36](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=456) Clinical guidance on appropriate use and referral patterns (Ep 8) - [0:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=0) Introduction and Gap Measurement Protocol (Ep 4) - [1:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=68) Esophageal Elongation Techniques (Ep 4) - [3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) Foker Technique Outcomes and Morbidity (Ep 4) - [4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276) Esophageal Replacement Options and Colonic Interposition Technique (Ep 4) - [8:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=480) Complications and Advantages of Colonic Interposition (Ep 4) - [9:56](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=596) Growth vs Stretch Mechanism Discussion (Ep 4) - [0:00](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=0) Introduction and Case Presentation Setup (Ep 3) - [1:23](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=83) Case Presentation and Diagnosis (Ep 3) - [2:29](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=149) Pre-operative Rigid Bronchoscopy Protocol (Ep 3) - [6:05](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=365) Thoracoscopic Surgical Technique and Approach (Ep 3) - [10:33](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=633) Technical Considerations and Long-Gap Management (Ep 3) - [16:16](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=976) Closing Remarks (Ep 3) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - At Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology. — Daniel von Allmen (clinical) [Ep 4 · 0:46](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=46) - Stretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero. — Daniel von Allmen (clinical) [Ep 4 · 2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130) - The philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together. — Daniel von Allmen (clinical) [Ep 4 · 2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130) - The colon can be used as an interposition for esophageal replacement. — Daniel von Allmen (clinical) [Ep 4 · 4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276) - Common problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm. — Daniel von Allmen (clinical) [Ep 4 · 8:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=480) - Von Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true. — Daniel von Allmen (opinion) [Ep 4 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497) - Von Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach. — Daniel von Allmen (clinical) [Ep 4 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497) - Colonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well. — Daniel von Allmen (opinion) [Ep 4 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497) - You can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up. — Daniel von Allmen (clinical) [Ep 4 · 9:03](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=543) - Von Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science. — Daniel von Allmen (opinion) [Ep 4 · 9:56](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=596) - Cincinnati Children's has a multidisciplinary aerodigestive center including ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians — Daniel von Allmen (clinical) [Ep 2 · 2:01](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=121) - The aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway arms — Daniel von Allmen (clinical) [Ep 2 · 2:46](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=166) - Physical examination should assess for scaphoid versus full or distended abdomen and respiratory distress — Daniel von Allmen (clinical) [Ep 2 · 3:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=235) - The surgeon should personally attempt to pass the NG tube rather than relying on nursing reports, as tubes reported as not passing sometimes pass easily — Daniel von Allmen (clinical) [Ep 2 · 4:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=260) - Injecting air into the NG tube and obtaining a plain film helps visualize proximal pouch distention and assess distal GI gas pattern — Daniel von Allmen (clinical) [Ep 2 · 4:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=295) - Lack of visible distended proximal pouch raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression — Daniel von Allmen (clinical) [Ep 2 · 5:01](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=301) - Contrast studies can be performed if there is high suspicion of unusual anatomy, as long as the radiologist knows the esophagus may be obstructed — Daniel von Allmen (clinical) [Ep 2 · 5:42](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=342) - Echocardiogram is the most important preoperative study to assess cardiac anatomy and rule out right-sided aortic arch — Daniel von Allmen (clinical) [Ep 2 · 6:25](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=385) - Renal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia — Daniel von Allmen (clinical) [Ep 2 · 6:54](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=414) - Conventional wisdom is to perform left thoracotomy for right-sided aortic arch — Daniel von Allmen (guideline) [Ep 2 · 7:27](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=447) - Left thoracotomy for right-sided arch is somewhat more difficult with the heart more in the way and harder proximal pouch mobilization — Daniel von Allmen (clinical) [Ep 2 · 7:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=471) - It is possible to complete the repair from the right side if right-sided arch is discovered intraoperatively, though some reports suggest higher incidence of swallowing problems — Daniel von Allmen (clinical) [Ep 2 · 8:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=500) - In a stable larger baby not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting 1-2 days — Daniel von Allmen (clinical) [Ep 2 · 9:31](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=571) - Should not wait a long time before repair due to risk of colonizing GI tract and soiling lungs — Daniel von Allmen (clinical) [Ep 2 · 9:56](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=596) - Oscillator ventilation does not make a significant difference in managing large fistulas with abdominal distention — Daniel von Allmen (opinion) [Ep 2 · 10:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=615) - Large fistula with distention tends to be a bigger problem in more premature infants with significant lung disease, where poor lung compliance drives air into GI tract — Daniel von Allmen (clinical) [Ep 2 · 10:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=615) - Treating with surfactant and improving lung compliance helps as much as changing ventilator type — Daniel von Allmen (clinical) [Ep 2 · 10:56](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=656) - Risk of waiting too long to make a decision in worsening distention can lead to emergency situation where child cannot be ventilated — Daniel von Allmen (clinical) [Ep 2 · 11:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=681) - For reasonably stable but worsening distention, would take child urgently to OR for right thoracotomy and fistula ligation — Daniel von Allmen (clinical) [Ep 2 · 12:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=720) - Bronchoscopic Fogarty balloon placement sounds good but is difficult unless expertise and equipment are immediately available — Daniel von Allmen (opinion) [Ep 2 · 12:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=720) - G-tube decompression may paradoxically worsen ventilation by making stomach lower resistance, allowing more air to go there instead of lungs — Daniel von Allmen (clinical) [Ep 2 · 12:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=720) - Laparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize severe cases, leaving in place for several days before definitive repair — Daniel von Allmen (clinical) [Ep 2 · 12:50](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=770) - For associated duodenal atresia in stable child, would potentially fix duodenal atresia first to avoid fixing esophagus upstream from obstruction — Daniel von Allmen (clinical) [Ep 2 · 13:36](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=816) - Both duodenal and esophageal atresia could potentially be fixed at same time if child is old enough and stable enough — Daniel von Allmen (clinical) [Ep 2 · 14:05](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=845) - Von Allmen changed practice to always perform intraoperative bronchoscopy after exposure to Cincinnati's complex patient population — Daniel von Allmen (clinical) [Ep 2 · 14:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=875) - Bronchoscopy documents fistula location, assesses for proximal fistula, and most importantly rules out laryngeal cleft which is easily missed — Daniel von Allmen (clinical) [Ep 2 · 14:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=875) - Many referred patients with multiple thoracotomies never had bronchoscopy and actually have laryngeal cleft — Daniel von Allmen (clinical) [Ep 2 · 14:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=875) - Second fistula occurs in approximately 1% of cases and can be very difficult to diagnose — Daniel von Allmen (epidemiological) [Ep 2 · 15:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=935) - High fistulas can range from trifurcation of carina (suggesting difficulty getting ends together) to very high fistulas potentially approachable through neck — Daniel von Allmen (clinical) [Ep 2 · 15:52](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=952) - Bronchoscopy allows guidance of ET tube placement by anesthesiologist based on fistula location — Daniel von Allmen (clinical) [Ep 2 · 16:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=995) - For fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula but not into the fistula itself — Daniel von Allmen (clinical) [Ep 2 · 16:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=995) - Extrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak — Daniel von Allmen (clinical) [Ep 2 · 17:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1039) - Dividing azygos has no morbidity, gives better access, and frequently guides to the fistula — Daniel von Allmen (clinical) [Ep 2 · 17:41](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1061) - Open azygos division is done by ligation and division; thoracoscopically can use energy devices or clips — Daniel von Allmen (clinical) [Ep 2 · 17:59](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1079) - Hook cautery can safely divide vessels if done slowly going up and down to ensure coagulation, learned from robotic Nissen experience dividing short gastrics — Daniel von Allmen (clinical) [Ep 2 · 18:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1131) - 3mm surgical sealer is ideal device for this size patient and vessel — Daniel von Allmen (opinion) [Ep 2 · 18:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1131) - Spreading heel of right angle on ribs nicely shows extrapleural plane when going through intercostal muscles — Daniel von Allmen (clinical) [Ep 2 · 19:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1175) - Important to mobilize pleura up around apex of lung to have access for proximal pouch mobilization — Daniel von Allmen (clinical) [Ep 2 · 19:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1175) - After azygos division, identify distal esophagus and control with vessel loop, then dissect proximally to identify fistula site — Daniel von Allmen (clinical) [Ep 2 · 19:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1175) - Muscle-sparing thoracotomy can make exposure more difficult; has not seen significant morbidity from standard posterolateral thoracotomy — Daniel von Allmen (opinion) [Ep 2 · 20:28](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1228) - Standard teaching has been not to mobilize distal esophagus, but can actually mobilize it significantly especially laterally all the way to diaphragm — Daniel von Allmen (clinical) [Ep 2 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1270) - Must be careful with medial mobilization of distal esophagus due to blood supply concerns — Daniel von Allmen (clinical) [Ep 2 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1270) - Extensive proximal pouch mobilization gives the most length to get ends together — Daniel von Allmen (clinical) [Ep 2 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1270) - Thoracoscopic approach advantage is clearer visualization for proximal pouch mobilization — Daniel von Allmen (opinion) [Ep 2 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1270) - Proximal pouch dissection is similar to separating rectum and vagina - making two planes out of one without great natural separation — Todd Ponsky (clinical) [Ep 2 · 22:03](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1323) - Risk of entering trachea during proximal dissection; must be very careful using blade cautery with light buzz and mostly blunt dissection with flat end of blade — Daniel von Allmen (clinical) [Ep 2 · 22:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1340) - Better to be in esophagus than trachea during high chest dissection; esophagus is thickened from obstruction — Daniel von Allmen (clinical) [Ep 2 · 22:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1340) - For significant tracheal defect, could perform sleeve resection as trachea is incredibly mobile, then place pericardium or autologous tissue between trachea and esophageal repair — Daniel von Allmen (clinical) [Ep 2 · 23:01](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1381) - Personal preference is 5-0 PDS - absorbable monofilament suture; not a fan of silk — Daniel von Allmen (opinion) [Ep 2 · 23:59](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1439) - Not a fan of myotomies as they potentially create even more dysfunctional esophageal segment; motility is already clearly abnormal in esophageal atresia — Daniel von Allmen (opinion) [Ep 2 · 24:42](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1482) - For cases too tight for primary repair, would ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for couple weeks, then return to put together — Daniel von Allmen (clinical) [Ep 2 · 24:42](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1482) - Traction or pressure is very strong stimulus to growth throughout cardiovascular system and lungs — Daniel von Allmen (clinical) [Ep 2 · 25:38](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1538) - For thoracoscopic approach, can place traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing return within a week for anastomosis — Daniel von Allmen (clinical) [Ep 2 · 26:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1570) - Would not do classic Foker technique with prolonged paralysis and sequential suture tensioning — Daniel von Allmen (opinion) [Ep 2 · 26:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1570) - Rusty Jennings and Foker published series in JPS showing 98% success getting ends together in primary atresia versus only 67% in secondary approaches after previous surgeries — Daniel von Allmen (epidemiological) [Ep 2 · 27:38](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1658) - Foker technique requires patients intubated and paralyzed spending weeks in ICU, which is probably worth it if you get good result — Daniel von Allmen (clinical) [Ep 2 · 27:38](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1658) - For thoracoscopic procedure, rotate patient past 90 degrees to allow gravity to move lungs out of way — Daniel von Allmen (clinical) [Ep 2 · 29:18](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1758) - Standard port placement: camera in center, posterior port inferiorly, anterior port superiorly — Daniel von Allmen (clinical) [Ep 2 · 29:18](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1758) - Uses 3mm instruments for thoracoscopic TEF repair — Daniel von Allmen (clinical) [Ep 2 · 29:52](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1792) - Important to do same quality operation thoracoscopically as would do open — Daniel von Allmen (opinion) [Ep 2 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810) - Sewing the anastomosis is one of the challenges with thoracoscopic TEF repair and requires most experience with minimally invasive techniques — Daniel von Allmen (clinical) [Ep 2 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810) - Would use clips for dividing fistula thoracoscopically, less worried about them falling off esophagus than blood vessel — Daniel von Allmen (opinion) [Ep 2 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810) - Thoracoscopic visualization is very helpful for mobilizing proximal pouch — Daniel von Allmen (opinion) [Ep 2 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810) - Simulation courses for TEF repair will be great advantage for trainees as these cases are not done often enough to get practice — Daniel von Allmen (opinion) [Ep 2 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810) - Marcelo Martinez Ferro's 'spaghetti trick' - grabbing and twirling tip of proximal pouch shows the dissection plane nicely — Todd Ponsky (clinical) [Ep 2 · 31:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1881) - Vicryl ties down nice and tight but cannot use knot pusher for first stitch under tension as it will tear through esophagus; need monofilament for extracorporeal knots — Todd Ponsky (clinical) [Ep 2 · 32:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1930) - Braided suture is safe for all intracorporeal technique — Todd Ponsky (clinical) [Ep 2 · 32:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1930) - After clipping fistula, do not divide it completely until ready to place first stitch so distal esophagus doesn't drop toward diaphragm — Todd Ponsky (clinical) [Ep 2 · 32:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1965) - Hanging stitch helps let go of some tension as first couple stitches are placed, providing some degree of approximation before throwing down first stitches — Avi Schlager (clinical) [Ep 2 · 33:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2001) - Must be able to see and incorporate mucosa on every stitch; hanging stitch helps visualize lumen of both proximal and distal ends — Todd Ponsky (clinical) [Ep 2 · 33:54](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2034) - Thoracoscopic ventilation management depends more on anesthesiologist than ventilator type; need anesthesiologist comfortable with procedure who pays attention during operation — Daniel von Allmen (clinical) [Ep 2 · 34:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2070) - Can position ET tube after bronchoscopy to selectively ventilate left lung — Todd Ponsky (clinical) [Ep 2 · 34:48](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2088) - Little CO2 insufflation with some time will collapse lung as long as anesthesiologist isn't fighting with positive pressure — Daniel von Allmen (clinical) [Ep 2 · 35:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2120) - Anesthesiologists can get scared seeing initial shunting but things settle down if they wait — Daniel von Allmen (clinical) [Ep 2 · 35:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2120) - Concern about reintubation exists, but equally concerned that positive pressure puts pressure on tracheal repair — Daniel von Allmen (clinical) [Ep 2 · 36:05](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2165) - Prefer spontaneous breathing with negative pressure in trachea rather than positive pressure — Daniel von Allmen (opinion) [Ep 2 · 36:05](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2165) - If patient had good lung function preoperatively and operation went smoothly, advocate extubating as soon as possible, even conceivably in operating room — Daniel von Allmen (clinical) [Ep 2 · 36:05](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2165) - Gets contrast study at 5-7 days before pulling chest drain, timing depends on avoiding weekends — Daniel von Allmen (clinical) [Ep 2 · 36:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2195) - Uses small TLS drain rather than formal chest tube, especially for open extrapleural approach — Daniel von Allmen (clinical) [Ep 2 · 36:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2195) - Does not use transanastomotic tube based on Midwest Pediatric Surgical Consortium study showing much higher stricture and leak rate with transanastomotic tubes — Daniel von Allmen (clinical) [Ep 2 · 37:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2240) - Midwest consortium study was presented at APSA and should be published in JPS soon — Daniel von Allmen (clinical) [Ep 2 · 37:37](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2257) - Unless incredibly tight stricture risking complete obstruction, would wait several weeks before first dilation — Daniel von Allmen (clinical) [Ep 2 · 37:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2275) - Always appears to be narrowing at anastomosis because proximal pouch is dilated; as long as patent with free contrast flow distally, would hold off on dilation — Daniel von Allmen (clinical) [Ep 2 · 37:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2275) - Fairly aggressive with dilations: dilate, wait 1-2 weeks, restudy, potentially dilate again — Daniel von Allmen (clinical) [Ep 2 · 38:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2303) - Huge spectrum from very tight strictures requiring many dilations to kids fine after one dilation — Daniel von Allmen (clinical) [Ep 2 · 38:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2303) - If case goes well and post-op study looks great, does not get routine follow-up esophagrams; studies based on clinical symptoms suggesting stricture — Daniel von Allmen (clinical) [Ep 2 · 38:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2303) - Balloon or radial dilation is less traumatic for tissue than bougie dilators — Daniel von Allmen (clinical) [Ep 2 · 39:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2359) - Dilations done with GI colleagues in aerodigestive center for bigger kids or with interventional radiologists — Daniel von Allmen (clinical) [Ep 2 · 39:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2359) - For small leak with child not sick, would absolutely wait and do nothing, leaving drain in; vast majority close — Daniel von Allmen (clinical) [Ep 2 · 39:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2391) - Leak increases risk of postoperative stricture — Todd Ponsky (clinical) [Ep 2 · 40:04](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2404) - Would only go to OR for leak if child getting sicker, wide open leak, or large uncontrollable pneumothorax — Daniel von Allmen (clinical) [Ep 2 · 40:09](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2409) - Even reasonably significant leaks will heal, then can deal with stricture postoperatively — Daniel von Allmen (clinical) [Ep 2 · 40:09](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2409) - Usually waits one week between esophagrams for leak; if child continues to do well, restudies — Daniel von Allmen (clinical) [Ep 2 · 40:34](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2434) - Sometimes little outpouching where leak happened makes it unclear if still leaking; if nothing from tube and nothing goes further, leak probably healed and would remove tube — Daniel von Allmen (clinical) [Ep 2 · 40:34](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2434) - Pediatric surgeons don't do fantastic job of long-term follow-up with TEF patients — Todd Ponsky (opinion) [Ep 2 · 41:09](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2469) - International esophageal atresia meeting occurs every 2 years and is multidisciplinary including patients — Daniel von Allmen (clinical) [Ep 2 · 41:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2479) - Patients in their 20s-40s at international meeting discuss long-term issues; surgeons tend to follow until eating well or age 18 then never see them again — Daniel von Allmen (clinical) [Ep 2 · 41:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2479) - Have a lot to learn about long-term complications; personally follows patients for at least couple years which is probably not long enough — Daniel von Allmen (opinion) [Ep 2 · 41:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2479) - Biggest challenges in long-term follow-up are reflux and recurrent strictures — Daniel von Allmen (clinical) [Ep 2 · 42:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2535) - More concerning are patients with ongoing reflux due to unknown long-term impact on Barrett's esophagus and potential malignant change — Daniel von Allmen (clinical) [Ep 2 · 42:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2535) - If patient has stricture dilated 2-3 times, next move would be to address reflux — Daniel von Allmen (clinical) [Ep 2 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2565) - Most patients left on anti-reflux medications when discharged from hospital — Daniel von Allmen (clinical) [Ep 2 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2565) - Virtually all patients have some degree of gastroesophageal reflux — Daniel von Allmen (clinical) [Ep 2 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2565) - Very aggressive about fundoplication for strictures not responsive to dilations (dilates easily then restrictures) — Daniel von Allmen (clinical) [Ep 2 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2565) - Does Nissen fundoplication in patients with poor esophageal motility but makes them loose and short, using 2 or at most 3 stitches — Daniel von Allmen (clinical) [Ep 2 · 43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2606) - For pure esophageal atresia, approach is G-tube placement with calibration of gap length using distal catheter pushed up and NG tube in proximal pouch — Daniel von Allmen (clinical) [Ep 2 · 43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2606) - Would wait 4-6 weeks to see how close ends come together, then attempt primary repair once within 2 vertebral bodies — Daniel von Allmen (clinical) [Ep 2 · 43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2606) - Less than half of esophageal atresia cases are detected antenatally, typically by small stomach and polyhydramnios. (epidemiological) [Ep 1 · 1:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=60) - Echocardiography is performed preoperatively to rule out congenital heart defects and determine aortic arch sidedness (right vs. left). (clinical) [Ep 1 · 2:12](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=132) - VACTERL workup (renal ultrasound, vertebral X-rays, anorectal exam) can be completed electively after initial repair. (clinical) [Ep 1 · 2:31](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=151) - Right-sided aortic arch does not necessarily require left thoracotomy; multiple surgeons report successful repairs from the right side despite right arch. (clinical) [Ep 1 · 9:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=540) - Echocardiography may misidentify aortic arch sidedness; one surgeon encountered a double arch after echo reported right arch. (clinical) [Ep 1 · 10:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=600) - Preoperative bronchoscopy can identify double fistulas and predict gap length: fistula at mid-trachea suggests shorter gap, fistula at carina suggests longer gap. (clinical) [Ep 1 · 13:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=780) - For thoracoscopic repair, bronchoscopy helps the surgeon understand fistula location and anticipate gap distance. (clinical) [Ep 1 · 14:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=840) - Standard open approach uses right posterolateral thoracotomy, extrapleural dissection to vertebral bodies, with azygos vein as landmark for fistula location. (clinical) [Ep 1 · 17:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1020) - For uncomplicated EA, tissue interposition between trachea and esophagus is not routinely used because adequate tissue is difficult to find. (clinical) [Ep 1 · 17:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1050) - Chest tube is placed in extrapleural space on water seal (not suction) and removed after postoperative contrast study confirms no leak. (clinical) [Ep 1 · 18:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1080) - Retrospective study of ~100 patients found no difference in complications between Vicryl and silk suture for EA repair. (clinical) [Ep 1 · 21:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1260) - For thoracoscopic repair using knot-pusher technique, PDS must be used for the first stitch to avoid sawing through tissue; Vicryl can be used for intracorporeal ties. (clinical) [Ep 1 · 21:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1290) - Approximately 75% of EA/TEF patients are candidates for thoracoscopic repair; complicated congenital heart disease may preclude thoracoscopic approach due to longer operative time. (clinical) [Ep 1 · 23:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1380) - If the two esophageal ends cannot be approximated thoracoscopically, conversion to open is appropriate—surgeons get one good chance at primary repair. (opinion) [Ep 1 · 23:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1410) - Babies under 2 kg are more difficult for thoracoscopic repair due to limited space for lung retraction and intracorporeal suturing. (clinical) [Ep 1 · 26:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1560) - In US training programs, fellows typically perform 4-8 EA repairs during fellowship, raising questions about adequate thoracoscopic training volume. (epidemiological) [Ep 1 · 27:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1620) - For thoracoscopic repair, ports should be spaced widely and staggered, with patient positioned more prone than lateral since esophagus is posterior mediastinal. (clinical) [Ep 1 · 29:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1740) - High-frequency oscillatory ventilation in the OR keeps the lung collapsed during thoracoscopic repair; disadvantage is the baby shaking, but hypercarbia is avoided. (clinical) [Ep 1 · 30:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1800) - C1 or TF needles (5-0 PDS) are preferred for thoracoscopic EA repair due to appropriate curve and ability to pass through 5-6mm trocars without tip damage. (clinical) [Ep 1 · 34:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2040) - Starting the anastomosis at the lateral (far) corner is most common; some start with a middle back-row stitch tied intracorporeally. (clinical) [Ep 1 · 34:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2070) - The first anastomotic stitch does not need to be tied tight; subsequent stitches are tightened once approximation is confirmed. (clinical) [Ep 1 · 35:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2130) - Exteriorizing the first stitch through the chest wall with a hemostat can help bring the gap closer before placing subsequent sutures. (clinical) [Ep 1 · 36:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2160) - For long-gap atresia (pure EA with gasless abdomen), G-tube placement allows gap assessment; if gap is ≤2 vertebral bodies, primary repair is attempted. (clinical) [Ep 1 · 37:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2250) - Interventional radiology can pass a wire and catheter up the distal esophagus via G-tube to define the gastroesophageal junction and measure gap accurately. (clinical) [Ep 1 · 38:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2280) - Cervical esophagostomy commits the patient to esophageal replacement; most surgeons avoid it and attempt delayed primary anastomosis. (opinion) [Ep 1 · 38:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2310) - For long-gap EA, waiting up to 3 months with G-tube feeds (advancing to bolus feeds to encourage distal esophageal growth) is reasonable before declaring the gap irreparable. (clinical) [Ep 1 · 39:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2340) - Routine bougienage of the proximal pouch does not reliably promote esophageal growth; growth occurs spontaneously over time. (opinion) [Ep 1 · 39:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2340) - Magnets have been used for many years for esophageal atresia as a non-surgical alternative for esophageal anastomosis, promoting lengthening and approximation of the proximal and distal ends. — Bethany Slater (clinical) [Ep 8 · 1:54](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=114) - The Flourish device is an FDA-approved commercially available catheter-based magnet system for esophageal atresia. — Bethany Slater (clinical) [Ep 8 · 1:54](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=114) - Magnets placed in the proximal and distal esophagus attract one another and cause the esophagus to lengthen, then compression anastomosis occurs through ischemia in the tissue at the two ends once magnets are nearly together. — Bethany Slater (clinical) [Ep 8 · 2:22](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=142) - The Flourish device has esophageal and gastric catheters with inner bullet-shaped magnets on each end, tapering down to a 10 French luminal surface. — Bethany Slater (clinical) [Ep 8 · 2:41](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=161) - The proximal catheter has a suction port for suctioning saliva and the gastric port has a portion for feeds. — Bethany Slater (clinical) [Ep 8 · 2:41](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=161) - For Flourish device eligibility, gap length must be less than 4 centimeters because at greater lengths the magnets will not attract one another. — Bethany Slater (clinical) [Ep 8 · 3:11](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=191) - There should be no fistula for Flourish device use, or if there is a fistula it must be repaired first. — Bethany Slater (clinical) [Ep 8 · 3:11](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=191) - Patients require a gastrostomy that can accommodate an 18 French catheter, which is the diameter of the gastric portion of the Flourish catheter. — Bethany Slater (clinical) [Ep 8 · 3:11](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=191) - Magnet therapy is not to replace esophageal atresia repair but is another tool in the armamentarium, particularly for patients with cardiac disease or previous operations that make them higher risk for reoperative surgery or anesthesia. (opinion) [Ep 8 · 3:39](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=219) - One contraindication for using the Flourish device is the presence of a fistula. — Steven Rothenberg (clinical) [Ep 8 · 4:59](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=299) - Dr. Rothenberg ligates all upper pouch fistulas and H-type fistulas thoracoscopically because the view is excellent and provides good control. — Steven Rothenberg (clinical) [Ep 8 · 6:06](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=366) - By classification of the International Esophageal Atresia Group, a gap must be at least 4 centimeters to be considered a long gap. — Steven Rothenberg (guideline) [Ep 8 · 6:54](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=414) - The indications for the magnet require a gap of less than 4 centimeters, and there is an incredibly high stricture rate with multiple strictures. — Steven Rothenberg (clinical) [Ep 8 · 6:54](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=414) - A patient with less than a 4 centimeter gap should be amenable to a primary anastomosis, which Dr. Rothenberg would do thoracoscopically. — Steven Rothenberg (opinion) [Ep 8 · 6:54](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=414) - Magnets have been used sometimes for a staged repair rather than using internal traction sutures. — Bethany Slater (clinical) [Ep 8 · 7:51](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=471) - There is a possibility of trying to get the two ends together closer surgically and then using a magnet just for the anastomosis portion. — Bethany Slater (clinical) [Ep 8 · 7:51](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=471) - Dr. Ponsky would try to go in and do surgical repair for a 3cm gap, and if unable to get the two ends together after dissection, would then do an internal lengthening procedure like the Vanderzee procedure. — Todd Ponsky (opinion) [Ep 8 · 1:13](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=73) - You don't lose anything by trying to go in and do the dissection to see if you can get the esophageal ends together. — Todd Ponsky (opinion) [Ep 8 · 1:33](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=93) - Dr. Harmon considers 3 centimeters overcomeable and would try thoracoscopic repair to get the two ends together. — Matt Harmon (opinion) [Ep 8 · 1:39](https://library.globalcastmd.com/watch/update-course-rewind-magnet-therapy-for-esophageal-atresia-4763?t=99) - The protocol at Cincinnati Children's includes rigid bronchoscopy performed by ENT colleagues for every TEF case. — Aaron Garrison (clinical) [Ep 3 · 1:56](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=116) - Pre-operative bronchoscopy provides information about the degree of airway compression, expected tracheomalacia, and fistula location, which helps determine tension on the anastomosis. — Aaron Garrison (clinical) [Ep 3 · 2:29](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=149) - During rigid bronchoscopy, the team attempts to find and cannulate the fistula using a 3 French bugby cautery as a probe, which is skinny, blunt-ended, and can have its tip bent if needed. — Michael Rutter (clinical) [Ep 3 · 2:53](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=173) - Rigid bronchoscopy is used to probe for laryngeal clefts, which are not reliably diagnosable with flexible bronchoscopy because pulmonary specialists are not good at looking at the posterior glottis. — Michael Rutter (clinical) [Ep 3 · 3:26](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=206) - A Hopkins rod endoscope is typically used for the rigid bronchoscopy, often with an endotracheal tube loaded on it to place the tip proximal or distal to the TEF, which helps anesthesia know exactly where the tube tip is. — Michael Rutter (clinical) [Ep 3 · 4:47](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=287) - For proximal fistulas, a ventilating tracheoscope (which lacks side ports) can be used to ventilate the child even when upper ports are above the larynx; this can be purchased or made by taping up the side ports of a standard bronchoscope. — Michael Rutter (clinical) [Ep 3 · 4:47](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=287) - Doctor Rothenberg has refined the thoracoscopic approach, with the most important technical point being that the baby must be positioned semi-prone, more prone than surgeons initially think. — Aaron Garrison (clinical) [Ep 3 · 6:05](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=365) - The esophagus is in the posterior mediastinum followed by the vagus nerve, and the azygous vein is the target landmark for locating the distal fistula in a type C TEF. — Aaron Garrison (clinical) [Ep 3 · 6:05](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=365) - Thoracoscopic dissection feels less traumatic than open thoracotomy, and mobilizing the proximal pouch is easier with the scope. — Aaron Garrison (opinion) [Ep 3 · 6:53](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=413) - The distal fistula can be taken with clips, though some surgeons prefer hook cautery or other energy devices because clips can be knocked off. — Aaron Garrison (clinical) [Ep 3 · 7:37](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=457) - Bakes dilators are used to identify and manipulate the proximal pouch during dissection. — Aaron Garrison (clinical) [Ep 3 · 7:58](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=478) - During proximal pouch dissection, surgeons must stay on the esophagus on the common wall (similar to anorectal malformations where one wall must be made into two), as it is easy to get too close to the trachea and enter it inadvertently. — Aaron Garrison (clinical) [Ep 3 · 8:15](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=495) - The recurrent laryngeal nerves are at risk during proximal pouch dissection from traction, cautery injury, or other mechanisms. — Daniel von Allmen (clinical) [Ep 3 · 8:39](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=519) - One surgical approach is to leave a small portion of the fistula attached until ready to place the first stitch, then place the stitch and cut the fistula, rather than completely dissecting it early. — Todd Ponsky (clinical) [Ep 3 · 9:03](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=543) - A suspensory stitch can be used during the repair, though the speaker is uncertain whether they prefer this technique. — Aaron Garrison (opinion) [Ep 3 · 9:25](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=565) - When placing clips to ligate the fistula, surgeons should avoid leaving a stump and should be flush with the trachea to prevent recanalization. — Aaron Garrison (clinical) [Ep 3 · 10:34](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=634) - The thoracoscopic approach provides clear visualization to ensure the fistula ligation is flush against the trachea. — Aaron Garrison (clinical) [Ep 3 · 10:34](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=634) - During dissection of the common wall between esophagus and trachea, surgeons must stay on the esophagus and away from the trachea because this is a dangerous part of the dissection. — Aaron Garrison (clinical) [Ep 3 · 11:26](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=686) - If possible, surgeons should place tissue (pleura, azygous flap, or fat) between the suture lines to minimize the risk of recurrence. — Aaron Garrison (clinical) [Ep 3 · 11:41](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=701) - Posterior tracheopexy can isolate and protect the tracheal closure from the esophageal anastomosis by pexing the trachea posteriorly. — Aaron Garrison (clinical) [Ep 3 · 11:41](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=701) - For the anastomosis, sutures can be placed to cross and bring down tension on the repair. — Aaron Garrison (clinical) [Ep 3 · 11:41](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=701) - An alternative technique from Doctor Vanderzee's group involves putting sutures in and sliding the ends together with gentle traction, pulling until they are as close as possible. — Daniel von Allmen (clinical) [Ep 3 · 12:48](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=768) - After placing the ends on as much tension as they will tolerate, surgeons can wait and come back when there is less tension to perform the anastomosis. — Daniel von Allmen (clinical) [Ep 3 · 12:48](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=768) - The delayed anastomosis approach involves bringing the ends together with prolene sutures and returning after 3 days to complete the repair. — Daniel von Allmen (clinical) [Ep 3 · 13:44](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=824) - Magnets can be used to approximate the esophageal ends in long-gap cases, with much of this work performed by GI colleagues using flexible esophagoscopy. — Michael Rutter (clinical) [Ep 3 · 14:07](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=847) - Subsequent follow-up bronchoscopies are usually performed as a combination procedure with both ENT and pulmonology. — Michael Rutter (clinical) [Ep 3 · 4:20](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=260) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - In the Foker technique, the surgeon ties sutures to either end of the esophagus through an open incision, brings them out through the chest wall, ties them together in a knot, and places spacers underneath periodically (about every day) until the ends come together for primary anastomosis. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 4 · 1:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=68) - The van der Zee technique uses the same concept as Foker but is done thoracoscopically with no external sutures, so all tension is inside the thorax. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 4 · 2:39](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=159) - The Kimura technique involves creating a spit fistula and periodically moving it down the chest wall over time to stretch the proximal pouch closer to the distal pouch, but is not used all that often anymore. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 4 · 2:39](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=159) - In the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients. — Daniel von Allmen summarizing a resource [Ep 4 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - In the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed. — Daniel von Allmen summarizing a resource [Ep 4 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - In the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition. — Daniel von Allmen summarizing a resource [Ep 4 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195) - The surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum. — Daniel von Allmen summarizing a resource [Ep 4 · 4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276) - In colonic interposition, the piece of colon chosen is based on the blood supply and the diameter needed. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 4 · 5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308) - In colonic interposition, a pyloroplasty is performed to help with gastric emptying. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 4 · 5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308) - The short interval between time of traction and anastomosis (less than five days) raises the question of whether the mechanism is stretching or growth, which will impact results and likely reflects on complications. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 4 · 9:27](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=567) - TEF is a defining procedure of pediatric surgery with challenges including long gap atresia, recurrent fistulas, and strictures — The host summarizes what Dr. Daniel von Allmen said [Ep 2 · 0:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=0) - Atlanta group uses stay stitch between two ends brought out of chest to hold anastomosis up for subsequent stitches, similar to duodenal atresia technique — Daniel von Allmen summarizing a resource [Ep 2 · 31:37](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1897) - Early thoracoscopic series (2008-2010) showed lower stricture rates with thoracoscopic vs. open repair, but more recent data show equivalent stricture rates. — The host summarizing the discussion [Ep 1 · 25:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1500) - Average US attending surgeon performs 1-2 TEF repairs per year, making advanced thoracoscopic technique acquisition challenging. — The host summarizing the discussion [Ep 1 · 27:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1650) - Low-cost training models for EA repair are available and should be used at society meetings (IPEG, APSA) to address low case volume. — The host summarizing the discussion [Ep 1 · 31:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1860) - Marcello reports doing all EA repairs thoracoscopically for over 10 years after performing ~150 open repairs, finding the approach natural and comfortable. — The host summarizing the discussion [Ep 1 · 31:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1890) - Wet clips are a fast and reliable method for dividing the TEF during thoracoscopic repair. — The host summarizing the discussion [Ep 1 · 32:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1920) - Yama's technique: divide only 3/4 of the fistula initially, leaving partial attachment as traction to facilitate anastomosis, then complete division. — The host summarizing the discussion [Ep 1 · 33:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1980) - Passing a transanastomotic feeding tube after back-row sutures provides volume to help guide the needle through the anterior wall. — The host summarizing the discussion [Ep 1 · 35:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2100) - Minimal dissection of the distal esophagus preserves blood supply and reduces trauma, even in long-gap cases. — The host summarizing the discussion [Ep 1 · 36:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2190) - Ligating the azygous vein is not always necessary, but most of the time it provides better exposure to the distal pouch or distal fistula. — Rod Gerardo summarizing the discussion [Ep 3 · 9:46](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=586) - If a long fistula stump is accidentally left behind, it can create a third trifurcation remnant that can soil the lungs, cause pneumonia, or form an air-fluid level and abscess cavity. — Rod Gerardo summarizing the discussion [Ep 3 · 11:01](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-bronchoscopy-and-surgical-technique-6895?t=661) --- Educational content from recorded physician discussions — not medical advice. 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