# Esophageal Atresia and Tracheoesophageal Fistula — GCMD Library living collection Updated: n/a · 17 episodes · 294 cited statements ## Episodes ### Thoracoscopic repair - [Thoracoscopic Esophageal Atresia Repair Tips & Tricks: Update Course 2018](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355) — video · 23:14 · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355.md) - [Rothenberg Thoracoscopic Technique Video: EA/TEF](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074) — video · 9:19 · [machine version](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074.md) - [Tips and Tricks: EA & TEF](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075) — video · 9:27 · [machine version](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075.md) - [Thoracoscopic Repair of a Type 3 Tracheoesophageal Fistula in a 2.6 kg Infant](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923) — video · 19:36 · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923.md) - [Thoracoscopic Tracheoesophageal Fistula Repair: Upper Pouch Mobilization and Anastomosis](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922) — video · 2:05 · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922.md) - [Thoracoscopic Tracheoesophageal Fistula Repair](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-11967) — video · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-11967.md) - [QUAD #10 Pt.1: History of Thoracoscopic Repair of Esophageal Atresia (EA) & Tracheoesophageal Fistula (TEF) with Dr. Steve Rothenberg](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702) — video · 6:27 · [machine version](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702.md) - [QUAD #10 Pt.2: Surgical Technique for Thoracoscopic Repair of Tracheoesophageal Fistula (TEF) with Dr. Steve Rothenberg](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704) — video · [machine version](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704.md) - [QUAD #10 Pt.3: Advantages of Thoracoscopic Repair of Esophageal Atresia with Dr. Steve Rothenberg](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703) — video · [machine version](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703.md) - [TEF 2015](https://library.globalcastmd.com/watch/tef-2015-11968) — article · [machine version](https://library.globalcastmd.com/watch/tef-2015-11968.md) - [TEF akron 2018](https://library.globalcastmd.com/watch/tef-akron-2018-11969) — article · [machine version](https://library.globalcastmd.com/watch/tef-akron-2018-11969.md) ### Long-gap atresia - [Long Gap Esophageal Atresia – How I Do It: Update Course 2018](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354) — video · 38:56 · [machine version](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354.md) - [Long Gap Technique Videos: EA & TEF](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078) — video · 17:51 · [machine version](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078.md) - [Thoracoscopic Long-Gap Esophageal Atresia Repair](https://library.globalcastmd.com/watch/thoracoscopic-long-gap-esophageal-atresia-repair-11987) — video · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-long-gap-esophageal-atresia-repair-11987.md) - [Update Course 2021: MAGNET THERAPY FOR ESOPHAGEAL ATRESIA](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416) — video · [machine version](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416.md) ### H-type and recurrent fistula - [VATS H-Type Fistula Repair - Technique](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749) — video · 4:36 · [machine version](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749.md) - [IPEG 2018 - RIGHT THORACOSCOPIC REPAIR OF AN H-TYPE TRACHEOESOPHAGEAL FISTULA](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890) — video · 3:52 · [machine version](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890.md) ## Chapters - [0:00](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=0) Introduction and Gap Assessment Methods (Ep 12) - [5:00](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=300) Timing and Initial Management Approaches (Ep 12) - [10:50](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=650) Traction Techniques and Mobilization (Ep 12) - [17:30](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1050) Anastomotic Leak Management (Ep 12) - [27:30](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1650) Recurrent Fistulas and Endoscopic Management (Ep 12) - [34:30](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=2070) Right-Sided Aortic Arch and Special Considerations (Ep 12) - [0:00](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=0) Evolution of Technique and Patient Positioning (Ep 1) - [3:48](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=228) Trocar Placement and Azygos Division (Ep 1) - [6:30](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=390) Fistula Identification and Ligation (Ep 1) - [10:15](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=615) Upper Pouch Mobilization and Nerve Preservation (Ep 1) - [14:51](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=891) Anastomosis Technique (Ep 1) - [20:10](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1210) Postoperative Management and Outcomes (Ep 1) - [0:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=0) Case presentation and patient positioning (Ep 16) - [1:30](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=90) Initial dissection and plane development (Ep 16) - [3:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=180) Fistula mobilization and stapler division (Ep 16) - [4:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=240) Closure and postoperative result (Ep 16) - [0:00](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=0) Patient positioning and anesthesia setup for thoracoscopic EA/TEF repair (Ep 2) - [2:29](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=149) Surgical steps and anastomotic technique (Ep 2) - [3:37](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=217) Video demonstration with technical discussion (Ep 2) - [8:44](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=524) Panel discussion on feeding tube placement (Ep 2) - [0:00](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=0) Feeding tube placement across anastomosis (Ep 3) - [0:49](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=49) Safe dissection of upper pouch from membranous trachea (Ep 3) - [2:19](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=139) Suture technique and knot tying considerations (Ep 3) - [3:19](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=199) Prevention of recurrent fistula with tissue interposition (Ep 3) - [5:01](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=301) Management of long-gap type C esophageal atresia (Ep 3) - [7:09](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=429) Azygos vein management and fistula ligation technique (Ep 3) - [0:00](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=0) Initial Management and Gastrostomy Placement Techniques (Ep 13) - [0:36](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=36) Gap Measurement Techniques: Endoscopic versus Blind Methods (Ep 13) - [8:24](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=504) Thoracoscopic Repair Technique for Long-Gap EA (Ep 13) - [14:36](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=876) Alternative Gap Measurement with Dynamometry (Ep 13) - [0:04](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=4) Case presentation and diagnosis (Ep 17) - [1:30](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=90) Patient positioning and port placement (Ep 17) - [2:30](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=150) Surgical dissection and fistula identification (Ep 17) - [3:30](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=210) Fistula transection and closure (Ep 17) - [0:00](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=0) Introduction and Clinical Scenario Poll (Ep 15) - [2:41](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=161) Magnet Device Overview and Published Experience (Ep 15) - [8:58](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=538) Complication Case: Broncho-Esophageal Fistula and Re-Division (Ep 15) - [17:57](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1077) Panel Discussion: Appropriate Patient Selection and Center Criteria (Ep 15) - [0:01](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=1) Introduction to the Quad Conference and Dr. Rothenberg (Ep 7) - [0:58](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=58) Rationale for Minimally Invasive Approach and Early Experience (Ep 7) ## Statements Every statement is attributed, typed, and timestamped; the link is the citation. - For thoracoscopic H-type fistula repair, the patient is placed in modified lateral decubitus position rolled prone approximately 45 degrees. (clinical) [Ep 16 · 1:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=60) - Three ports were used: one 4 mm port (later advanced to 5 mm) and two 3 mm ports. (clinical) [Ep 16 · 1:30](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=90) - A 4 mm 30-degree lens was used for the procedure and placed behind the tip of the scapula. (clinical) [Ep 16 · 1:45](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=105) - The procedure starts in the apex using a 3 mm vessel sealer for dissection and to open the pleura. (clinical) [Ep 16 · 2:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=120) - Developing a plane between esophagus and trachea below the level of the fistula is an important maneuver to help safely separate the two structures before encountering the very adherent area. (clinical) [Ep 16 · 2:30](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=150) - Placing a catheter across the H-type fistula can occasionally be helpful for identification, though it was not used in this case. (opinion) [Ep 16 · 3:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=180) - A 3 mm hook cautery was used to pull on fibers and separate them away from critical structures. (clinical) [Ep 16 · 3:15](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=195) - Dissection is carried out above the fistula so that a retro-fistula plane can be developed. (clinical) [Ep 16 · 3:30](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=210) - An instrument is passed around behind the fistula, taking care not to injure the esophagus or membranous portion of the trachea. (clinical) [Ep 16 · 3:45](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=225) - A 2-0 silk suture is passed around the fistula to help with retraction. (clinical) [Ep 16 · 4:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=240) - Previously, the technique involved dividing the fistula and then oversewing the two ends. (clinical) [Ep 16 · 4:15](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=255) - In this case, with the child large enough and availability of a 5 mm stapler, a decision was made to use the stapler to divide the fistula. (clinical) [Ep 16 · 4:30](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=270) - Care must be taken to ensure the recurrent laryngeal nerve and other important structures are not within the field of dissection. (clinical) [Ep 16 · 4:45](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=285) - The lower port in the posterior axillary line was enlarged to 5 mm to accommodate the stapler. (clinical) [Ep 16 · 5:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=300) - A single application of the 5 mm stapler divided the fistula, placing two rows of staples on either side. (clinical) [Ep 16 · 5:15](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=315) - Apical fat is taken and sewn down to cover the esophageal end of the staple line to help separate the two staple lines and prevent recurrent fistulization. (clinical) [Ep 16 · 5:30](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=330) - The pleura is closed over the divided fistula so that any leak would remain contained. (clinical) [Ep 16 · 5:45](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=345) - The lung was re-expanded and no chest tube was left. (clinical) [Ep 16 · 6:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=360) - Spitz uses a 6 French feeding tube (not a Replogle) across the anastomosis to feed the baby for the first few days after operation. — Spitz (clinical) [Ep 3 · 0:04](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=4) - Jack leaves a 5 French feeding tube across the anastomosis, both for feeding and to protect the back wall during the anastomosis. — Jack (clinical) [Ep 3 · 0:18](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=18) - Using cautery to dissect the plane between the membranous trachea and the medial wall of the upper esophageal pouch can result in holes in the membranous trachea, leading to an acquired tracheoesophageal fistula that is very difficult to fix. (clinical) [Ep 3 · 1:35](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=95) - Sharp dissection is the only safe way to dissect the upper pouch off the membranous trachea; cautery should never be used in that particular plane. (clinical) [Ep 3 · 1:35](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=95) - Steve uses blunt and sharp dissection when separating the upper pouch from the membranous trachea, only using cautery when he can clearly see the tissues and knows he is not injuring the membranous trachea. — Steve (clinical) [Ep 3 · 1:10](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=70) - It is very hard to tie an extracorporeal knot with Vicryl suture. — Steve (clinical) [Ep 3 · 2:41](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=161) - If tying extracorporeally, PDS should be used instead of Vicryl because it slides better. — Steve (clinical) [Ep 3 · 2:41](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=161) - When there is an anastomosis under tension and concern about a leak, it is a good idea to get some tissue between the two suture lines to prevent development of a recurrent fistula. (clinical) [Ep 3 · 3:19](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=199) - A pleural flap or pericardial flap can be used to place vascularized tissue between suture lines. (clinical) [Ep 3 · 3:19](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=199) - In a baby, a thick pleural flap can be created that incorporates some of the muscle of the intercostal spaces and some fat. (clinical) [Ep 3 · 3:19](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=199) - The thing that causes most recurrent fistulas is a leak, and the thing that causes most leaks is too much tension on the anastomosis. (clinical) [Ep 3 · 3:19](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=199) - In premature infants with very small upper pouch and fistula, Steve's approach is to ligate the fistula thoracoscopically, mobilize the upper pouch if possible, and if unable to achieve anastomosis, place an internal stitch in the upper pouch under tension and return in 4-6 weeks for anastomosis. — Steve (clinical) [Ep 3 · 5:52](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=352) - The advantage of thoracoscopic approach is that without a big thoracotomy incision, the surgeon can go in, evaluate, and decide whether anastomosis is achievable. — Steve (clinical) [Ep 3 · 5:52](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=352) - Holger shares the experience that in premature infants, if only the fistula is ligated without dissection and the surgeon waits 4-8 weeks for spontaneous growth, the anastomosis can be performed later successfully. (clinical) [Ep 3 · 6:48](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=408) - If the azygos vein is ligated, the distal end can be opened and plastered onto the tracheal or esophageal suture line as tissue interposition. — Spitz (clinical) [Ep 3 · 7:50](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=470) - Jack had a case where he placed only a clip on a fistula in a preemie without dividing it, and 3 weeks later the fistula recurred (recanalized). — Jack (clinical) [Ep 3 · 8:26](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=506) - If clipping a fistula, it must be divided; just putting a clip on can lead to recanalization. — Steve (clinical) [Ep 3 · 8:41](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=521) - When performing fistula division or ligation in a case where the two ends cannot be anastomosed, the distal segment should be tacked to the vertebral body (prevertebral fascia) with a stitch to prevent it from shrinking down. — Spitz (clinical) [Ep 3 · 8:57](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=537) - H-type TEFs are very rare and represent about 4% of all TEFs (epidemiological) [Ep 17 · 1:00](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=60) - H-type TEFs are usually diagnosed later in infancy when the patient presents with difficulty swallowing, aspiration, and recurrent pneumonias (clinical) [Ep 17 · 1:10](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=70) - The procedure was performed using 3 ports: a camera port behind the tip of the scapula at approximately the 4th intercostal space, a working port directly below the camera port, and another one anterior to it at the mid-axillary line (clinical) [Ep 17 · 1:50](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=110) - The parietal pleura at the groove of the esophagus and the trachea was opened using a combination of blunt dissection and a bipolar energy device (clinical) [Ep 17 · 2:30](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=150) - A 5 millimeter stapler was used to transect the tracheoesophageal fistula (clinical) [Ep 17 · 3:15](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=195) - A pleural flap was placed between the staple lines to help avoid a recurrent fistula (clinical) [Ep 17 · 3:25](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=205) - The patient had a swallow study on post-op day 2 that was negative for a leak (clinical) [Ep 17 · 3:35](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=215) - Advantages to a thoracoscopic H-type TEF repair are direct and magnified visualization between the esophagus and the trachea (opinion) [Ep 17 · 3:42](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=222) - Thoracoscopic approach allows visualization of the vagus nerve and avoidance of injury to the recurrent laryngeal nerve (opinion) [Ep 17 · 3:46](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=226) - Thoracoscopic approach avoids a neck incision (opinion) [Ep 17 · 3:49](https://library.globalcastmd.com/watch/ipeg-2018-right-thoracoscopic-repair-of-an-h-type-tracheoesophageal-fistula-3890?t=229) - Some surgeons choose to leave the azygos vein intact during this portion of the dissection (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - Leaving the azygos vein intact means the gap is much larger (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - An endoscopic clip provides atraumatic tissue handling during dissection (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - Extensive dissection of the upper pouch is performed to achieve adequate length for anastomosis (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - This case involves a longer gap than is routine for a type 3 fistula (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - The back wall and corners of the anastomosis are sutured first, using 4 to 5 sutures (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - The nasogastric or orogastric tube is advanced by the anesthesiologist after the back wall is completed (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - Three anterior wall sutures are sufficient to complete the anastomosis in this case (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - Close coordination with the anesthesiologist is extremely important to achieve adequate visualization throughout the procedure (clinical) [Ep 5 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-tracheoesophageal-fistula-repair-upper-pouch-mobilization-and-anas-11922?t=0) - The azygos vein in this case was approximately 4 millimeters in diameter and was sealed proximally and distally with the 3 mm sealer before sharp division. (clinical) [Ep 4 · 3:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=180) - Lung collapse was achieved by insufflating CO2 at a pressure of 4 at a flow of approximately 1 liter per minute, without main stem intubation. (clinical) [Ep 4 · 5:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=300) - The fistula entered the carina right at the bifurcation, described as a trifurcation fistula, meaning the gap was much larger than initially thought because of the low entrance at the bifurcation. (clinical) [Ep 4 · 6:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=360) - The gap appeared to be approximately 4 vertebral bodies. (clinical) [Ep 4 · 9:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=540) - The sealer provides excellent hemostasis with little risk of bleeding or other issues when dividing the azygos vein. (opinion) [Ep 4 · 3:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=210) - A 5 millimeter endoscopic clip was used to secure the fistula, which the surgeon prefers to suture ligation as it provides a very atraumatic and quick way to secure the fistula. (opinion) [Ep 4 · 7:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=420) - Dissection between the membranous wall of the trachea and the esophageal pouch is often difficult due to dense connective tissue in this area. (clinical) [Ep 4 · 10:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=600) - This portion of the dissection is much safer with the sealer than with a hook cautery as previously used. (opinion) [Ep 4 · 11:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=660) - The sealer allows dissection well up into the thoracic inlet and neck, with the dissection in this case extending well up into the neck. (clinical) [Ep 4 · 11:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=690) - The lower pouch tends to retract once the fistula is divided, making it more difficult to find, so division is delayed until ready to perform the anastomosis. (clinical) [Ep 4 · 12:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=750) - The anterior and posterior vagus nerves are carefully dissected off the esophagus during lower pouch mobilization to prevent injury to these structures. (clinical) [Ep 4 · 13:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=810) - The tip of the upper pouch is generally completely amputated to ensure a good ostium for the anastomosis. (clinical) [Ep 4 · 14:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=870) - The initial back wall stitch is placed using a knot pusher because of the significant tension on the two ends. (clinical) [Ep 4 · 15:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=930) - The back row sutures are placed going from inside out on the upper pouch to outside in on the lower pouch, with 4 to 5 stitches typically used. (clinical) [Ep 4 · 16:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=960) - The rest of the sutures after the initial stitch are tied intracorporeally to minimize pulling or stress on the soft esophageal walls. (clinical) [Ep 4 · 16:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=990) - Generally 4 to 5 throws are placed to secure an adequate knot. (clinical) [Ep 4 · 17:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1020) - The true key to this operation is mobilization of the upper pouch, and the use of the sealer allows very safe dissection well up into the neck. (opinion) [Ep 4 · 17:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1050) - The surgeon easily doubled the length of the upper pouch available by doing extensive dissection up into the neck in this case. (clinical) [Ep 4 · 17:50](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1070) - The visualization of the upper pouch dissection thoracoscopically is much greater than when trying to perform this through an open thoracotomy. (opinion) [Ep 4 · 18:10](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1090) - The nasogastric tube is left for 4 to 5 days and removed on the 4th postoperative day when a contrast study is obtained to ensure there is no leak. (clinical) [Ep 4 · 19:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1140) - This procedure took 75 minutes and the child tolerated the surgery extremely well. (clinical) [Ep 4 · 19:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1140) - The child had no other congenital anomalies. (clinical) [Ep 4 · 19:10](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1150) - A contrast study obtained on the 4th postoperative day showed no evidence of leak and feeds were started. (clinical) [Ep 4 · 19:15](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1155) - The child was on full feeds by the 8th postoperative day. (clinical) [Ep 4 · 19:25](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1165) - The child maintained saturations in the mid-90s throughout the procedure with end-tidal CO2s around 40. (clinical) [Ep 4 · 19:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1170) - The child did not have single lung ventilation but had a tracheal intubation which was well tolerated. (clinical) [Ep 4 · 19:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-a-type-3-tracheoesophageal-fistula-in-a-2-6-kg-infant-11923?t=1170) - Single lung ventilation is not required for thoracoscopic TEF repair; CO2 insufflation is used to collapse the lung. — Steven Rothenberg (clinical) [Ep 8 · 1:06](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=66) - All babies will desaturate when initially insufflating the chest and collapsing the lung, but almost all recover. — Steven Rothenberg (clinical) [Ep 8 · 1:18](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=78) - Patient positioning was modified from left lateral decubitus to 60-degree prone tilt because the lung would get in the way in lateral position. — Steven Rothenberg (clinical) [Ep 8 · 2:16](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=136) - Initially making only a slit in the upper pouch (rather than complete amputation) resulted in a higher stricture rate. — Steven Rothenberg (clinical) [Ep 8 · 3:29](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=209) - The upper pouch is now completely amputated except in cases of really long gaps. — Steven Rothenberg (clinical) [Ep 8 · 3:29](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=209) - A single layer anastomosis of 4-0 or 5-0 PDS is used (Vicryl or other sutures are also acceptable). — Steven Rothenberg (clinical) [Ep 8 · 3:29](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=209) - Thoracoscopic visualization of the fistula entering the trachea is much better than with open surgery. — Steven Rothenberg (opinion) [Ep 8 · 4:12](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=252) - A simple clip is used most of the time to ligate the fistula; suture ligation is used if the patient is under 2 kilograms. — Steven Rothenberg (clinical) [Ep 8 · 4:28](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=268) - The degree of magnification and visualization during upper pouch mobilization cannot be achieved through a thoracotomy to this degree. — Steven Rothenberg (opinion) [Ep 8 · 4:55](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=295) - The fistula is no longer divided immediately after ligation; it is kept intact until ready to place sutures to avoid losing it and having to chase it down. — Steven Rothenberg (clinical) [Ep 8 · 5:00](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=300) - The lower fistula is mobilized as far as necessary, but the hiatus is never breached because doing so creates a giant hiatal hernia with its own set of issues. — Steven Rothenberg (clinical) [Ep 8 · 5:18](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=318) - The entire thoracoscopic TEF repair operation is performed in a 2 square centimeter space. — Steven Rothenberg (clinical) [Ep 8 · 5:55](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=355) - A chest drain is left in selected cases but almost never anymore, unless there is concern about the anastomosis or in cases of really long gaps with significant tension. — Steven Rothenberg (clinical) [Ep 8 · 6:12](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=372) - Transanastomotic tubes are no longer left in place because they have been shown to result in a higher stricture rate. — Steven Rothenberg (clinical) [Ep 8 · 6:30](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=390) - A contrast study is obtained on day four postoperatively, and feeds are started if everything is okay. — Steven Rothenberg (clinical) [Ep 8 · 6:30](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=390) - Thoracoscopic TEF repair results in nearly no scars, no chest wall deformity, and no scoliosis. — Steven Rothenberg (clinical) [Ep 8 · 6:48](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=408) - There has been no mortality directly related to TEF repair at Rocky Mountain Hospital, though some patients have died of comorbidities. — Steven Rothenberg (epidemiological) [Ep 8 · 7:41](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=461) - Recurrent TEF can be repaired thoracoscopically, though these are tough operations requiring thorough understanding of the anatomy. — Steven Rothenberg (clinical) [Ep 8 · 7:41](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=461) - Open surgery for TEF creates some of the tracheomalacia that patients develop because surgeons crank on the trachea during dissection. — Steven Rothenberg (clinical) [Ep 9 · 0:48](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=48) - Residual esophageal pouches after open fistula ligation are more common than recognized, occurring when the fistula is ligated below the proper level. — Steven Rothenberg (clinical) [Ep 9 · 1:30](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=90) - Thoracoscopic repair allows elevation of the esophagus and direct visualization of where the fistula enters the membranous portion of the trachea. — Steven Rothenberg (clinical) [Ep 9 · 1:50](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=110) - Thoracoscopic dissection of residual esophageal pouches can be performed using a stapler. — Steven Rothenberg (clinical) [Ep 9 · 2:15](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=135) - According to Dr. Rothenberg, the key to achieving anastomosis in long-gap cases is gaining length through extensive upper pouch mobilization. — Steven Rothenberg (clinical) [Ep 9 · 2:30](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=150) - Thoracoscopic technique allows dissection all the way up to the posterior oropharynx under direct vision. — Steven Rothenberg (clinical) [Ep 9 · 2:35](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=155) - At Rocky Mountain Hospital for Children, they have never been unable to achieve primary repair of a type C fistula. — Steven Rothenberg (clinical) [Ep 9 · 3:05](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=185) - The staged repair technique involves gastrostomy tube placement, allowing growth for 3-8 weeks with bolus feeds to toughen up the lower pouch, obtaining a gap study, then performing thoracoscopic repair. — Steven Rothenberg (clinical) [Ep 9 · 3:25](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=205) - Extensive upper pouch mobilization can bring down a pouch that initially was at the thoracic inlet, allowing anastomosis in the lower third of the chest even with a six vertebral body gap. — Steven Rothenberg (clinical) [Ep 9 · 3:50](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=230) - Operative time for long-gap repairs ranges from 50 minutes to a little over 2 hours. — Steven Rothenberg (clinical) [Ep 9 · 4:20](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=260) - Documented anastomotic leaks after thoracoscopic repair were all treated successfully with conservative therapy. — Steven Rothenberg (clinical) [Ep 9 · 4:30](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=270) - All H-type fistulas are located in the same place, at the thoracic inlet. — Steven Rothenberg (clinical) [Ep 9 · 4:45](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=285) - Thoracoscopic approach to H-type fistulas allows direct visualization of the vagus and recurrent laryngeal nerves, potentially avoiding injury better than neck dissection. — Steven Rothenberg (clinical) [Ep 9 · 4:55](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=295) - Thoracoscopic approach avoids cranking on the trachea and retracting it out of the way, allowing dissection under direct vision. — Steven Rothenberg (clinical) [Ep 9 · 5:05](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=305) - A stapler can be used to divide H-type fistulas thoracoscopically, with tissue interposition placed between the divided ends. — Steven Rothenberg (clinical) [Ep 9 · 5:10](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=310) - Thoracotomy is the most morbid incision performed in pediatric surgery. — Steven Rothenberg (clinical) [Ep 7 · 0:58](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=58) - When performing thoracotomy in a newborn, infant, or small child, there is a 30 to 40% chance the child will develop some degree of shoulder girdle weakness, chest wall asymmetry, and scoliosis. — Steven Rothenberg (epidemiological) [Ep 7 · 1:30](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=90) - Thoracoscopic PDA ligation was first described in 1995 by Labour in Paris. — Steven Rothenberg (clinical) [Ep 7 · 2:30](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=150) - The PDA ligation procedure looks similar to ligating the fistula in a TEF repair when entering the left chest. — Steven Rothenberg (clinical) [Ep 7 · 2:45](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=165) - The first thoracoscopic pure esophageal atresia repair was performed at the 1999 IPEC meeting in Berlin. — Steven Rothenberg (clinical) [Ep 7 · 3:00](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=180) - For the Berlin case, the patient had been taken to the OR every other day with metal bougies placed in upper and lower pouches to stretch them until they overlapped on X-ray. — Steven Rothenberg (clinical) [Ep 7 · 3:30](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=210) - In the Berlin case, approximately 2 hours were spent attempting to achieve single lung anesthesia, ultimately using a Fogarty catheter placed down the endotracheal tube into the right main stem bronchus to block it. — Steven Rothenberg (clinical) [Ep 7 · 3:50](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=230) - Single-lung blockade with a Fogarty catheter is a technique no longer used or needed for thoracoscopic EA repair. — Steven Rothenberg (clinical) [Ep 7 · 4:10](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=250) - The Berlin pure EA patient developed a stricture post-operatively that was dilated a few times but went on without significant problems. — Steven Rothenberg (clinical) [Ep 7 · 4:20](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=260) - The first thoracoscopic type C esophageal atresia with TEF repair was performed in Denver four days before the 2000 IPEC meeting on a 3.2 kg full-term male with no other congenital anomalies. — Steven Rothenberg (clinical) [Ep 7 · 4:30](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=270) - The first thoracoscopic TEF repair surgery was performed in the evening after other staff had left, without prior IRB approval, following a practice of asking forgiveness afterwards rather than permission beforehand. — Steven Rothenberg (opinion) [Ep 7 · 4:50](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=290) - Connor, the first thoracoscopic TEF repair patient, never required dilation and his esophagram one week post-surgery looked great. — Steven Rothenberg (clinical) [Ep 7 · 5:05](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=305) - Connor has graduated from engineering school and is doing great. — Steven Rothenberg (clinical) [Ep 7 · 5:20](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=320) - The Flourish device is an FDA-approved commercially available device under humanitarian device exception from Cook Medical. — Bethany Slater (clinical) [Ep 15 · 4:47](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=287) - The Flourish device uses compression anastomosis by causing ischemia of tissue between two magnets, which then sloughs off to create the anastomosis. — Bethany Slater (clinical) [Ep 15 · 4:59](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=299) - The Flourish device tapers down to a 10 French coupling surface. — Bethany Slater (clinical) [Ep 15 · 5:40](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=340) - In a retrospective study of 13 patients over 17 years using Flourish magnets, all patients achieved anastomosis but all developed strictures post-operatively. — Bethany Slater (epidemiological) [Ep 15 · 7:00](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=420) - Two of 13 patients in the retrospective Flourish series required surgery for recalcitrant strictures after magnet placement. — Bethany Slater (epidemiological) [Ep 15 · 7:30](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=450) - Flourish device eligibility requires gap length less than 4 centimeters; if lengths are greater, magnets will not attract one another. — Bethany Slater (clinical) [Ep 15 · 8:00](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=480) - Flourish device requires either absent fistula (pure EA) or previously repaired fistula. — Bethany Slater (clinical) [Ep 15 · 8:15](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=495) - Flourish device requires gastrostomy that can accommodate 18 French catheter (diameter of gastric portion). — Bethany Slater (clinical) [Ep 15 · 8:25](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=505) - In the presented case, a full-term male with pure EA had gap study at 3 months showing 2.6 cm gap, and Flourish device was placed. — Steven Rothenberg (clinical) [Ep 15 · 10:00](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=600) - The patient was heavily sedated for 12 days during magnet treatment. — Steven Rothenberg (clinical) [Ep 15 · 11:20](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=680) - Four days after esophageal ends came together, patient had acute decompensation and was transferred to another hospital where large fistula between esophagus and left main stem bronchus was identified. — Steven Rothenberg (clinical) [Ep 15 · 11:40](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=700) - At emergency surgery, the surgeon found severe inflammation, divided the fistula, and divided the esophagus again, resulting in a 5 cm gap. — Steven Rothenberg (clinical) [Ep 15 · 12:20](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=740) - Subsequent workup revealed an upper pouch fistula that had not been previously diagnosed, which is a contraindication to using the Flourish device. — Steven Rothenberg (clinical) [Ep 15 · 14:10](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=850) - By International group classification, a gap of 4 centimeters or more is required to be considered long gap esophageal atresia. — Steven Rothenberg (guideline) [Ep 15 · 17:20](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1040) - Dr. Rothenberg's opinion: a patient with less than 4 cm gap should be amenable to primary anastomosis, which he would do thoracoscopically with maybe 20% stricture rate. — Steven Rothenberg (opinion) [Ep 15 · 17:35](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1055) - Dr. Slater agrees that not everyone with 2 cm gap should get a magnet; it can be used in select patients with cardiac disease or previous operations that increase anesthetic risk. — Bethany Slater (opinion) [Ep 15 · 18:40](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1120) - Magnets have been used as staged procedure: surgically approximate ends, then use magnet just for anastomosis portion rather than internal traction sutures. — Bethany Slater (clinical) [Ep 15 · 19:12](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1152) - Dr. Ponsky's experience: used magnets post-operatively in patient with complex airway reconstruction and median sternotomy where suture brought ends together but anastomosis was too tight, avoiding difficult reoperation. — Todd Ponsky (clinical) [Ep 15 · 20:40](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1240) - Dr. Von Allmen's single magnet case worked but resulted in dense stricture requiring lots of dilation and G-tube feeds for long time, though avoided reoperation. — Daniel von Allmen (clinical) [Ep 15 · 21:07](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1267) - Dr. Rothenberg describes potential magnet candidate: 23-week premature infant, 340 grams at birth, pure atresia, who decompensates for two weeks after each thoracoscopic attempt to approximate ends. — Steven Rothenberg (clinical) [Ep 15 · 21:28](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1288) - Dr. Rothenberg's opinion: if a surgeon cannot sew together a 2-3 cm gap, the patient should be sent to a center that can, as that is the best outcome for the child. — Steven Rothenberg (opinion) [Ep 15 · 22:20](https://library.globalcastmd.com/watch/update-course-2021-magnet-therapy-for-esophageal-atresia-5416?t=1340) - In Utrecht, they perform traction technique in the first week after birth without gastrostomy or gap measurement, achieving success in bringing ends together within 4-5 days in all cases — Dave Vanderzee (clinical) [Ep 12 · 3:13](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=193) - Even when the distal pouch is at the level of the hiatus, traction sutures can achieve approximation in 4-5 days — Dave Vanderzee (clinical) [Ep 12 · 3:48](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=228) - Non-stress contrast study of the lower segment is always performed because the lower segment is not always normal and may have duplications or congenital strictures — Rusty (clinical) [Ep 12 · 5:37](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=337) - EGD is performed prior to surgery to understand the lower segment anatomy — Rusty (clinical) [Ep 12 · 6:04](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=364) - Waiting 4-6 weeks with bolus feeds thickens the lower pouch, providing more tissue integrity for anastomosis — Steve (clinical) [Ep 12 · 8:51](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=531) - The baby grows but the esophagus may not grow during waiting periods, potentially making the gap longer to overcome — Steve (opinion) [Ep 12 · 9:53](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=593) - The critical technique in Foker traction is to put sutures in with some traction and then not touch them anymore, rather than continuously increasing traction — Dave Vanderzee (clinical) [Ep 12 · 9:23](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=563) - Manipulation with bougies can cause perforations or micro-perforations leading to esophageal fibrosis that prevents movement — Rusty (clinical) [Ep 12 · 10:29](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=629) - With extensive mobilization of the upper pouch all the way to the thoracic inlet, gaps up to 8 vertebral bodies can be closed in one procedure — Steve (clinical) [Ep 12 · 15:18](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=918) - The distal pouch should be mobilized to the diaphragm but not through the hiatus to avoid severe hiatal hernia — Steve (clinical) [Ep 12 · 15:57](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=957) - Flexing the neck and spine creates thoracic kyphosis which can provide the last centimeter needed for difficult anastomoses — Rusty (clinical) [Ep 12 · 16:51](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1011) - Thoracoscopic approach may result in less gap than open approach because the chest is not opened and the spine is not elongated — Steve (opinion) [Ep 12 · 17:14](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1034) - Treatment approaches are local and situational - gastric pull-up may be appropriate in settings without prolonged ICU capability — Rusty (opinion) [Ep 12 · 18:29](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1109) - Taking very small bites with fine sutures in traction technique risks approximating only the muscularis while the mucosa stays behind — Dave Vanderzee (clinical) [Ep 12 · 11:23](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=683) - For anastomosis, sutures must get deep enough to include submucosa without penetrating the mucosa to avoid leaks — Rusty (clinical) [Ep 12 · 12:00](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=720) - A scope can be placed in the esophagus during traction suture placement to ensure sutures are positioned precisely — Rusty (clinical) [Ep 12 · 12:07](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=727) - Tubes are left through the cricopharyngeus but no farther to avoid causing leaks — Rusty (clinical) [Ep 12 · 13:08](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=788) - Seprafilm is placed in the thorax to reduce adhesions, making re-operation easier — Rusty (clinical) [Ep 12 · 14:39](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=879) - Rotor knots are used for traction sutures so they can be tightened at subsequent operations — Rusty (clinical) [Ep 12 · 14:54](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=894) - For anastomotic leaks, vacuum sponge therapy involves placing a sponge with central drainage tube across the leak under fluoroscopy at 120 cm water suction — Rusty (clinical) [Ep 12 · 20:26](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1226) - Vacuum sponges are left in place for 5-7 days maximum to avoid difficulty with removal — Rusty (clinical) [Ep 12 · 21:20](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1280) - The sponge is soaked in contrast before placement so it can be visualized fluoroscopically — Rusty (clinical) [Ep 12 · 23:15](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1395) - Vacuum sponge technique has been used successfully even for high-tension anastomoses prophylactically — Rusty (clinical) [Ep 12 · 25:22](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1522) - Chest tubes must be placed at least 1 centimeter away from the esophageal anastomosis to prevent erosion — Rusty (clinical) [Ep 12 · 20:10](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1210) - Trans-anastomotic feeding tubes increase leak rates and should be avoided — Rusty (opinion) [Ep 12 · 20:16](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1216) - Getting a small amount of mucosa in the anastomotic sutures prevents trans-anastomotic mucosal layer formation which delays healing — Rusty (clinical) [Ep 12 · 19:52](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1192) - Contained leaks less than 1 centimeter (small diverticula) will likely resolve without intervention by avoiding high intraesophageal pressure — Rusty (clinical) [Ep 12 · 26:35](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1595) - Free leaks into the pleura require immediate control to prevent sepsis and empyema — Rusty (clinical) [Ep 12 · 26:51](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1611) - For recurrent tracheoesophageal fistulas, TCA ablation after creating mucosal injury with cautery and brush has over 50% success rate with a couple of treatments — Steve (clinical) [Ep 12 · 29:17](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1757) - Placing a scope in the esophagus during fistula ablation ensures complete treatment of the entire tract without burning past it — von Alman (clinical) [Ep 12 · 31:11](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1871) - An endotracheal tube balloon can be inflated at the fistula level to maintain apposition of epithelialized surfaces for several days — von Alman (clinical) [Ep 12 · 31:58](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1918) - TCA treatment is limited to patients without tracheomalacia and with long oblique fistula tracts, not appropriate for flat acquired fistulas — Rusty (clinical) [Ep 12 · 35:16](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=2116) - Performing posterior tracheopexy at the time of TEF repair eliminates recurrences in over 100 consecutive cases — Rusty (clinical) [Ep 12 · 34:58](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=2098) - For recurrent TEF with tracheomalacia, open repair with fistula takedown flush with trachea under bronchoscopic view plus posterior tracheopexy is preferred — Rusty (clinical) [Ep 12 · 34:41](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=2081) - Single-lung ventilation is not required for thoracoscopic EA/TEF repair; CO2 insufflation can be used to collapse the lung and achieve exposure. (clinical) [Ep 2 · 0:23](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=23) - CO2 insufflation pressure starts at 4-8 mmHg, usually requires 8 mmHg initially, then can be reduced to 4 mmHg once the lung is collapsed, with flow of 1-2 L/min. (clinical) [Ep 2 · 0:45](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=45) - Modified prone position with right side elevated 30 degrees is preferred over lateral decubitus because the collapsed lung falls away by gravity, eliminating the need for lung retraction. (clinical) [Ep 2 · 1:03](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=63) - The procedure uses three ports: one for camera and two for operating instruments, without need for lung retraction. (clinical) [Ep 2 · 1:20](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=80) - Camera port (3 or 4 mm) should be placed posterior to the tip of the scapula, slightly below scapula level, to look down on the fistula and operating hands. (clinical) [Ep 2 · 1:35](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=95) - Right-hand operating port is placed in the axilla; left port is more posterior to achieve 90-degree angle triangulation at the anastomosis site. (clinical) [Ep 2 · 1:56](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=116) - The azygous vein is divided using hook cautery. (clinical) [Ep 2 · 2:37](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=157) - Fistula ligation is performed with a clip because it is the fastest method. (clinical) [Ep 2 · 2:43](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=163) - Clip migration into the trachea or esophagus has been reported by some surgeons, though the speaker has not experienced this complication. (clinical) [Ep 2 · 2:48](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=168) - A single-layer anastomosis is performed using 5-0 PDS or Vicryl suture. (clinical) [Ep 2 · 3:15](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=195) - Back-row sutures are tied intraluminally, then a replogle tube is placed, followed by front-wall sutures tied extraluminally. (clinical) [Ep 2 · 3:20](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=200) - The azygous vein is divided with hook cautery by burning it first, then dividing with scissors rather than cauterizing completely through with the hook. (clinical) [Ep 2 · 4:14](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=254) - The fistula can be followed all the way down to the membranous trachea, allowing very close ligation at the back wall of the trachea. (clinical) [Ep 2 · 4:31](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=271) - The fistula is not divided immediately after clipping to prevent retraction and difficulty finding it; it is divided after upper pouch dissection. (clinical) [Ep 2 · 5:34](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=334) - The plane between trachea and esophagus can be visualized well and dissected with combination of blunt and sharp dissection, extending up to the thoracic inlet and neck if needed for length. (clinical) [Ep 2 · 6:30](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=390) - The technique leaves a very minimal pouch on the trachea; large residual pouches can cause problems with mucus and bacteria accumulation requiring reoperation. (clinical) [Ep 2 · 6:52](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=412) - The first suture is placed in the middle of the back (medial) wall using PDS suture with no tension. (clinical) [Ep 2 · 7:07](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=427) - A TF (tracheoesophageal fistula) needle is used, which is very small; either 4-0 or 5-0 suture can be used. (clinical) [Ep 2 · 7:27](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=447) - Four or five stitches are placed in the back row. (clinical) [Ep 2 · 7:44](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=464) - At the corner stitch, the technique switches from intraluminal to extraluminal knot tying. (clinical) [Ep 2 · 7:57](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=477) - A 10 French replogle tube is passed down into the stomach before completing the front row. (clinical) [Ep 2 · 8:11](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=491) - The front row consists of about four sutures. (clinical) [Ep 2 · 8:25](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=505) - The replogle tube prevents catching the back wall during front-row suturing. (clinical) [Ep 2 · 8:27](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=507) - Dr. Spitz uses a 6 French feeding tube (not a replogle) for feeding in the first few days after esophageal repair. — Spitz (clinical) [Ep 2 · 8:56](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=536) - Jack leaves a 5 French feeding tube for feeding and to protect the back wall during anastomosis. — Jack (clinical) [Ep 2 · 9:12](https://library.globalcastmd.com/watch/rothenberg-thoracoscopic-technique-video-ea-tef-1074?t=552) - The first thoracoscopic TEF Type C repair was performed in 2000. (clinical) [Ep 1 · 0:16](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=16) - Single-lung ventilation is not required for thoracoscopic TEF repair; CO₂ insufflation at low flow (1 L) and low pressure (4–6 mmHg) is sufficient. (clinical) [Ep 1 · 1:02](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=62) - End-tidal CO₂ increases during thoracoscopic TEF repair, and anesthesiologists must accept CO₂ levels in the high 40s to low 50s mmHg. (clinical) [Ep 1 · 1:19](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=79) - Anesthesiologists should increase ventilation rate rather than tidal volume or peak inspiratory pressure to manage elevated CO₂, as increased pressures will re-expand the lung and obstruct the surgical field. (clinical) [Ep 1 · 1:29](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=89) - All babies desaturate initially when the lung is collapsed, but most recover within a couple of minutes. (clinical) [Ep 1 · 1:47](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=107) - Babies with congenital heart disease require specific cardiac anesthesia for thoracoscopic TEF repair. (clinical) [Ep 1 · 1:56](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=116) - Modified patient positioning at 45° prone (rather than full lateral) allows gravity to retract the lung, which is the biggest obstacle in thoracoscopic TEF repair. (clinical) [Ep 1 · 2:15](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=135) - 99% of thoracoscopic TEF repairs can be performed using only ports without additional incisions. (clinical) [Ep 1 · 2:54](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=174) - The scope should be positioned far enough posterior to look down into the posterior mediastinum rather than up over the horizon, reproducing the view of an open thoracotomy. (clinical) [Ep 1 · 2:57](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=177) - The smallest patient operated on thoracoscopically for TEF repair was 1 kg, requiring modified port placement. (clinical) [Ep 1 · 3:30](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=210) - The scope port should be positioned just below and behind the tip of the scapula, with the left hand port just below and slightly behind the scope port so that right and left hands are at 90° during the critical anastomosis portion. (clinical) [Ep 1 · 3:38](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=218) - A 30° scope is used for thoracoscopic TEF repair. (clinical) [Ep 1 · 4:30](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=270) - The azygos vein is divided using vessel sealing devices to prevent bleeding during suturing, though some surgeons preserve it believing it may reduce stricture rates. (clinical) [Ep 1 · 5:34](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=334) - Vessel sealing devices are safer than monopolar cautery for dissection because there is no energy spread and less risk of surrounding tissue injury. (clinical) [Ep 1 · 6:02](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=362) - The vagus nerve should be preserved during fistula dissection. (clinical) [Ep 1 · 6:11](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=371) - Trifurcation fistulas (entering at the carina) tend to create longer gaps than typical Type C fistulas. (clinical) [Ep 1 · 8:51](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=531) - Type C esophageal atresias are not considered long-gap defects. (clinical) [Ep 1 · 8:58](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=538) - The plane between the esophageal pouch and membranous trachea is easier to visualize thoracoscopically than through open thoracotomy. (opinion) [Ep 1 · 9:07](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=547) - When the upper pouch is densely adherent to the trachea, dissecting higher on the esophageal pouch makes the plane between esophagus and trachea more apparent. (clinical) [Ep 1 · 9:33](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=573) - Upper pouch fistulas, when present, are identified during bronchoscopy performed before pure esophageal atresia repairs. (clinical) [Ep 1 · 9:56](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=596) - The membranous tracheal wall cannot be visualized as well through open thoracotomy even with loupes as it can be seen thoracoscopically. (opinion) [Ep 1 · 10:26](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=626) - In thoracoscopic TEF repair, the most difficult part is avoiding injury to the membranous trachea, as there is sometimes almost a common wall between the pouch and trachea. (clinical) [Ep 1 · 10:57](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=657) - The tip of the upper pouch is where it is most adherent to the trachea, with almost no real plane present; the plane becomes easier to identify higher up on the pouch. (clinical) [Ep 1 · 11:25](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=685) - At the point where the upper pouch and trachea share a common wall, the safest dissection plane is submucosal on the esophagus to avoid entering the trachea. — Rusty (clinical) [Ep 1 · 11:58](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=718) - Pediatric surgeons have an incredibly high rate of recurrent laryngeal nerve injuries. — Rusty (epidemiological) [Ep 1 · 12:11](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=731) - The left recurrent laryngeal nerve is located just on the other side of the esophagus-trachea junction and should be identified and pushed away; it is closer to the esophagus than the trachea, especially higher up. — Rusty (clinical) [Ep 1 · 12:11](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=731) - The magnified thoracoscopic view allows easier identification of the recurrent laryngeal nerve compared to open surgery. (opinion) [Ep 1 · 12:31](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=751) - All H-type fistulas are now repaired thoracoscopically because the nerve can be better identified than through a neck incision with blunt dissection. (clinical) [Ep 1 · 12:54](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=774) - With blunt dissection, there is minimal danger of damaging the recurrent laryngeal nerve. — David (clinical) [Ep 1 · 12:58](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=778) - The fistula is not divided immediately but left in place until ready for ligation, because dividing it early leads to difficulty finding it later. (clinical) [Ep 1 · 15:10](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=910) - In longer-gap repairs, the distal fistula is mobilized all the way down to the diaphragm without breaching the hiatus. (clinical) [Ep 1 · 15:20](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=920) - The tip of the upper pouch is completely amputated rather than just slit to create a good full-thickness opening, which may reduce stricture rates. (clinical) [Ep 1 · 15:33](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=933) - A bucket handle of tissue may be left on the upper pouch to provide a grasping point during suturing without injuring the tracheal wall. (clinical) [Ep 1 · 15:46](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=946) - The anastomosis is performed with a single layer of 5-0 PDS sutures on a TF needle, with the back wall sewn first starting with a middle stitch. (clinical) [Ep 1 · 16:11](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=971) - Large full-thickness bites including all layers are taken during anastomosis. (clinical) [Ep 1 · 16:29](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=989) - The entire anastomosis takes place in approximately a 2 square centimeter area. (clinical) [Ep 1 · 16:42](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1002) - When the gap is minimal, all knots are tied intracorporeally; for longer gaps, extracorporeal ties with a knot pusher allow watching the ends come together to ensure no tearing. (clinical) [Ep 1 · 16:56](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1016) - The back row of anastomotic sutures is placed intraluminally, typically consisting of 3 or 4 sutures. (clinical) [Ep 1 · 17:38](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1058) - Approximately 80% of surgeons can acquire the skill set to perform thoracoscopic TEF repair. (opinion) [Ep 1 · 18:12](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1092) - All surgeons in the speaker's practice perform thoracoscopic TEF repair after going through a training process. (clinical) [Ep 1 · 18:17](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1097) - Almost all surgeons can perform thoracoscopic TEF repair, though perhaps not to the highest technical level; the challenge is implementing training in an institution for a procedure that is not electively scheduled and does not occur frequently. (opinion) [Ep 1 · 18:37](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1117) - Training surgeons to perform thoracoscopic TEF repair requires commitment from experienced surgeons to operate with those learning, with very few contraindications to the approach except possibly patients on oscillators or with severe cardiac issues. (clinical) [Ep 1 · 19:05](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1145) - Three junior faculty members were trained to perform thoracoscopic TEF repair over approximately 3 years. (clinical) [Ep 1 · 19:51](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1191) - An NG tube is placed down about one-third of the way into the anastomosis as an internal stent to allow placement of the front row of sutures without closing off the lumen. (clinical) [Ep 1 · 19:57](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1197) - Five knots are thrown when using PDS suture for the anastomosis. (clinical) [Ep 1 · 20:19](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1219) - 5-0 Vicryl can be used instead of PDS for the anastomosis and may be easier to teach. (clinical) [Ep 1 · 20:22](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1222) - PDS is preferred over Vicryl because it does not become wet and limp, maintains a more rigid tip for easier grasping in small spaces, and is a monofilament that does not soften as much as braided Vicryl. (opinion) [Ep 1 · 20:34](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1234) - NG tubes are no longer routinely left postoperatively based on discussion in the Midwest Consortium study, unless there is concern about anastomotic integrity requiring a stent. (clinical) [Ep 1 · 21:04](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1264) - Contrast studies are still performed on day 4 before starting feeds in the speaker's practice. (clinical) [Ep 1 · 21:48](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1308) - At 6-7 months postoperatively, thoracoscopic TEF repair results in three small 3-4 mm incisions with no chest wall deformity or musculoskeletal problems. (clinical) [Ep 1 · 21:55](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1315) - In the speaker's personal series, the leak rate is 3.5-4%, with no leaks requiring reoperation. (clinical) [Ep 1 · 22:19](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1339) - There has been one recurrent fistula in the speaker's series. (clinical) [Ep 1 · 22:30](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1350) - The stricture rate for Type C repairs is 14%, defined as strictures requiring intervention such as dilation. (clinical) [Ep 1 · 22:32](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1352) - The stricture rate in long-gap repairs is approximately 50%. (clinical) [Ep 1 · 22:34](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1354) - About 25% of patients undergoing thoracoscopic TEF repair eventually require fundoplication, with the rate being approximately 50% in pure esophageal atresia cases. (clinical) [Ep 1 · 22:41](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1361) - Only two aortopexies have been required in the speaker's series of thoracoscopic TEF repairs. (clinical) [Ep 1 · 22:50](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1370) - Clip ligation of the fistula is the fastest method to restore ventilation, as anesthesiologists have difficulty ventilating patients until the fistula is controlled due to significant tidal volume loss through large fistulas. (clinical) [Ep 1 · 7:42](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=462) - In very small patients where a 5 mm clip cannot be used, the fistula is suture-ligated instead. (clinical) [Ep 1 · 7:32](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=452) - The front row of anastomotic sutures is placed extraluminally. (clinical) [Ep 1 · 5:03](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=303) - Gastrostomy is performed in the first 24 hours of life for long-gap esophageal atresia without fistula — Corn (clinical) [Ep 13 · 0:07](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=7) - The stomach is diminutive in these patients, and gastrostomy tubes have been mistakenly placed into the transverse colon because the stomach and transverse colon appear almost the same size — Corn (clinical) [Ep 13 · 0:19](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=19) - After gastrostomy placement, patients are left alone for at least 3 weeks before gap measurement — Corn (clinical) [Ep 13 · 0:28](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=28) - At 3 weeks when the gastrostomy site is matured, gap measurement is performed in the fluoroscopy suite using a neonatal scope inserted into the stomach to find the GE junction — Corn (clinical) [Ep 13 · 0:36](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=36) - The GE junction in these babies is very small and easy to miss with blind Hagar or Bates dilator insertion, leading to incorrect gap measurements — Corn (clinical) [Ep 13 · 0:51](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=51) - Gap is measured in terms of vertebral bodies, and if the gap is less than 2 centimeter vertebral bodies, the operation is considered within the next couple of weeks — Corn (clinical) [Ep 13 · 1:26](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=86) - Interventional radiology can place gastrostomy tubes instead of surgical laparotomy with good results (clinical) [Ep 13 · 1:56](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=116) - Damage to the stomach is a problem with surgical gastrostomy placement; over the years there have been a number of children who had leaks around the gastrostomy tube when placed surgically (clinical) [Ep 13 · 2:05](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=125) - For interventional radiology gastrostomy placement, the stomach is filled with air using a fine needle through the left lobe of the liver under ultrasound guidance, then standard technique is used once the stomach is inflated (clinical) [Ep 13 · 2:35](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=155) - This interventional radiology gastrostomy technique was written up about 10 years ago and is in the literature (clinical) [Ep 13 · 2:50](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=170) - The stomach takes about 3 weeks to get to normal size in pure long gap esophageal atresia with gastrostomy feedings — Corn (clinical) [Ep 13 · 2:58](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=178) - Peter Chait, who invented the Chait button, developed the interventional radiology gastrostomy technique (clinical) [Ep 13 · 3:29](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=209) - Dr. Corn's philosophy has changed regarding conduit use; they would probably wait longer or use a different paradigm to achieve complete primary repair, which they accomplish in over 99% of these patients — Corn (opinion) [Ep 13 · 8:24](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=504) - Gap measurement is performed with G-tube placement followed by initial contrast study, then repeated at 4 to 6 weeks if it looks like a long gap, with surgery generally at 4 to 6 weeks (range 3 to 6 weeks) — Steve (clinical) [Ep 13 · 9:19](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=559) - One advantage of thoracoscopic approach is that you can see much higher, dissecting all the way up to the thoracic inlet near or beyond the tip of the lower lobe of the thyroid — Steve (clinical) [Ep 13 · 10:29](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=629) - For long-gap repairs, slit incisions are made in both upper and lower pouches rather than resecting anything, to preserve as much tissue as possible — Steve (clinical) [Ep 13 · 11:08](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=668) - 40 PDS suture on small TF needle is used with full thickness bites for the anastomosis — Steve (clinical) [Ep 13 · 11:22](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=682) - One disadvantage of thoracoscopic repair is that you can only do one stitch at a time, creating significant tension at each stitch with risk of tearing — Steve (clinical) [Ep 13 · 11:53](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=713) - The back wall is done first in a series of interrupted stitches — Steve (clinical) [Ep 13 · 12:20](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=740) - The case presented was a 5.5 vertebral body gap successfully repaired thoracoscopically — Steve (clinical) [Ep 13 · 12:40](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=760) - Dr. Corn uses almost exactly the same approach as the thoracoscopic technique but performs it open — Corn (clinical) [Ep 13 · 13:46](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=826) - One advantage of open approach is putting several sutures in first and sliding them up before tying, which reduces tension on the first stitch — Corn (clinical) [Ep 13 · 13:52](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=832) - Stitches are placed with knots on the inside posteriorly and knots on the outside anteriorly — Corn (clinical) [Ep 13 · 14:19](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=859) - Vicryl or PDS can be used for sutures and it doesn't make a bit of difference; it's no different than using silk 30 years ago — Corn (opinion) [Ep 13 · 14:24](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=864) - If there is any kind of distal nub of real substance to the distal esophagus, you will eventually be able to get the ends together — Corn (opinion) [Ep 13 · 14:36](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=876) - When there is a gastric diverticulum for the esophagus (which histologically is not really even esophageal tissue) as the only distal esophagus, primary repair cannot be achieved no matter what techniques are used — Corn (opinion) [Ep 13 · 14:55](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=895) - Using dynamometry with Hagar dilator, a gap that appears to be 7 vertebral bodies without pressure can be reduced to less than 2 vertebral bodies with 250-300 grams of pressure — Bhaglan (clinical) [Ep 13 · 16:02](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=962) - Dynamometry provides an objective and measurable method to compare results between different centers and institutions by measuring the pressure applied — Bhaglan (opinion) [Ep 13 · 16:57](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=1017) ## Host summaries Recaps by a host of what the experts said — not the host's own clinical position. - The patient was a 3-month-old infant with multiple medical issues who had recurrent aspiration. — The host summarizing a resource [Ep 16 · 0:00](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=0) - Upper GI study showed an H-type tracheoesophageal fistula. — The host summarizing a resource [Ep 16 · 0:30](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=30) - There were 2 prior attempts at endoluminal ablation before this thoracoscopic repair. — The host summarizing a resource [Ep 16 · 0:45](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=45) - The patient was examined at 2 weeks postoperatively and the fistula was assessed at 3 months. — The host summarizing a resource [Ep 16 · 4:36](https://library.globalcastmd.com/watch/vats-h-type-fistula-repair-technique-749?t=276) - More than 50% of long-gap EA cases are type C. — The host summarizing the discussion [Ep 3 · 5:01](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=301) - A paper by Upadhaya in the European Journal of Pediatric Surgery reported that ligating the azygos vein is associated with an increased rate of pneumonia. — The host summarizing the discussion [Ep 3 · 7:09](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=429) - David Vander says he never ligates the azygos vein. — The host summarizing the discussion [Ep 3 · 7:09](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=429) - For thoracoscopic TEF repair, the surgeon should stand at the patient's front to view in line directly at the fistula for better visualization and ergonomics. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 1:47](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=107) - Three ports are used for thoracoscopic TEF repair with the scope placed more posterior behind the tip of the scapula to look down into the posterior mediastinum. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 2:39](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=159) - The azygos vein is divided to avoid inadvertently sticking a needle in it during suturing, though it can be left alone if preferred. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 3:51](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=231) - Mobilizing the upper pouch is the key part of the operation where all the length is gained. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 4:38](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=278) - Full thickness bites are very important for the anastomosis, with posterior row knots placed intraluminally. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 5:27](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=327) - An OG tube is slid down across the gap during the anterior row to ensure the lumen is not closed, but is now removed rather than left in place. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 5:45](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=345) - At Rocky Mountain Hospital, the leak rate for thoracoscopic TEF repair is about 3%, representing significant leaks that altered treatment but none requiring reoperation. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 7:08](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=428) - There has been just one recurrent fistula in the Rocky Mountain Hospital series. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 7:28](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=448) - The stricture rate is about 16%, defined as requiring dilation even one time. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 7:28](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=448) - About 25% of patients undergo fundoplication because of reflux, with a relatively low aortopexy rate. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 7:28](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=448) - For recurrent TEF repair, perpendicular visualization allows better viewing of the area, enabling dissection of the trachea off the esophagus, suturing of the recurrent fistula, and placement of a pleural patch between them. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 8 · 8:05](https://library.globalcastmd.com/watch/quad-10-pt-2-surgical-technique-for-thoracoscopic-repair-of-tracheoesophageal-fi-8704?t=485) - Thoracoscopic approach causes less iatrogenic tracheomalacia compared to open surgery. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 9 · 5:20](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=320) - Thoracoscopic techniques offer significant advantages over open surgery in treating tracheoesophageal fistulas, including precise dissection and reduced complications like tracheomalacia. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 9 · 5:40](https://library.globalcastmd.com/watch/quad-10-pt-3-advantages-of-thoracoscopic-repair-of-esophageal-atresia-with-dr-st-8703?t=340) - Dr. Rothenberg pioneered thoracoscopic repair for EA/TEF cases to shift management towards less invasive methods. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 7 · 5:30](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=330) - Thoracoscopic repair is a minimally invasive alternative to traditional thoracotomy for esophageal atresia, reducing post-surgical complications like scoliosis and shoulder girdle weakness in children. — Em Gootee summarizes what Dr. Steven Rothenberg said [Ep 7 · 5:30](https://library.globalcastmd.com/watch/quad-10-pt-1-history-of-thoracoscopic-repair-of-esophageal-atresia-tracheoesopha-8702?t=330) - Louis Spitz stated that the esophagus stops growing at 12 weeks — The host summarizing the discussion [Ep 12 · 7:41](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=461) - In India, Dr. Gupta teaches primary gastric pull-up in the neonatal period for long-gap esophageal atresia — Rusty summarizing the discussion [Ep 12 · 17:56](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=1076) - Most panelists approach right-sided aortic arch cases from the right side thoracoscopically without difficulty — The host summarizing the discussion [Ep 12 · 36:09](https://library.globalcastmd.com/watch/long-gap-esophageal-atresia-how-i-do-it-update-course-2018-354?t=2169) - Chest drains are no longer routinely placed after thoracoscopic TEF repair if the repair is good and there are no concerns, based on experience from Great Ormond Street Hospital where contrast studies are not obtained, patients are fed on day 2, and chest drains are never left. — The host summarizing the discussion [Ep 1 · 21:32](https://library.globalcastmd.com/watch/thoracoscopic-esophageal-atresia-repair-tips-tricks-update-course-2018-355?t=1292) - Blind insertion of rigid Hagar dilator can miss the distal esophageal pouch and inadvertently distend the cardia, leading to a falsely narrow measurement of gap — The host summarizing a resource [Ep 13 · 6:26](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=386) - With Hagar dilator technique, the gap appeared to be 2 vertebral bodies, but with endoscopic visualization the gap was actually between 4 and 5 vertebral bodies — The host summarizing a resource [Ep 13 · 6:20](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=380) - If the gap at measurement is greater than 3 to 4 vertebral bodies, the patient will require an esophageal conduit; if smaller than 3 to 4 vertebral bodies, the patient is eligible for primary repair — The host summarizing a resource [Ep 13 · 8:02](https://library.globalcastmd.com/watch/long-gap-technique-videos-ea-tef-1078?t=482) --- Educational content from recorded physician discussions — not medical advice. 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