Tracheoesophageal Fistula

Tracheoesophageal fistula (TEF) repair remains a defining procedure in pediatric surgery, with persistent challenges including long-gap atresia, recurrent fistulas, and strictures. Preoperative assessment centers on echocardiography to identify right-sided aortic arch and cardiac anomalies, while bronchoscopy documents fistula location and rules out laryngeal cleft—a frequently missed diagnosis in referred patients with multiple prior thoracotomies. Surgical approach varies: right thoracotomy remains standard, though right-sided arch can be successfully repaired from either side. Thoracoscopic repair offers superior visualization for proximal pouch mobilization and is feasible in approximately 75% of cases, though the anastomosis remains technically demanding. Extensive proximal pouch mobilization—not distal esophageal preservation—is critical for tension-free anastomosis; the historical teaching against distal mobilization is unfounded, as extensive dissection causes no significant bleeding and reduces leak risk. Postoperative management prioritizes early extubation when feasible, avoids transanastomotic tubes (associated with 2.72× higher stricture rates), and reserves dilation for symptomatic strictures rather than radiographic narrowing. Long-term follow-up remains inadequate; virtually all patients have reflux, and recurrent strictures warrant fundoplication after 2–3 dilations.