# Tracheoesophageal Fistula — GCMD Library living collection

Updated: n/a · 23 episodes · 630 cited statements

## Episodes
### Resources
- [Aerodigestive & Esophageal Surgery - Difficult Tracheal Esophageal Fistula](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739) — video · 2:00:59 · [machine version](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739.md)
- [Treatment for Long Gap Esophageal Atresia: Esophageal Elongation and Replacement](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791) — podcast · 10:56 · [machine version](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791.md)
- [Case Based Journal Review: Esophageal Atresia in 2022](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631) — podcast · 17:55 · [machine version](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631.md)
- [Quick Literature Updates Episode 9](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770) — video · [machine version](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770.md)
- [QUAD #6 Slide Tracheoplasty for TEF, Otolaryngology Approach with Dr. Mike Rutter](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114) — video · 7:37 · [machine version](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114.md)
- [QUAD #27 - Multidisciplinary - How Do Teams Enhance Outcomes by the CCHMC ADEC Team](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201) — video · 10:19 · [machine version](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201.md)
- [TEF Presentations (Extended): Aerodigestive & Esophageal Surgery](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037) — video · 1:48:11 · [machine version](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037.md)
- [Dr. Marc Michalsky - Pediatric Robotic-Assisted Surgery – Developing a Programmatic Paradigm](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169) — video · 1:06:48 · [machine version](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169.md)
- [Esophageal Atresia & Tracheoesophageal Fistula (EA/TEF) Types Explained for Pediatric Surgery](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001) — video · 2:11 · [machine version](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001.md)
- [Tracheoesophageal Fistula with Dr. Daniel von Allmen](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300) — podcast · 45:21 · [machine version](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300.md)
- [Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356) — video · 18:17 · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356.md)
- [Thoracoscopic Repair of Tracheo-esophageal Fistula Tricks: Pediatric Surgery...](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424) — video · 19:14 · [machine version](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424.md)
- [Esophageal Atresia](https://library.globalcastmd.com/watch/esophageal-atresia-627) — video · 39:30 · [machine version](https://library.globalcastmd.com/watch/esophageal-atresia-627.md)
- [Tracheoesophageal Fistula with Dr. Daniel von Allmen](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956) — video · 45:21 · [machine version](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956.md)
- [EA/TEF Discussion & Technique: Difficult Cases](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053) — video · 19:33 · [machine version](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053.md)
- [Update Course 2013: EA & TEF](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057) — video · 38:25 · [machine version](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057.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)
- [Introduction and Panel Discussion: EA & TEF](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076) — video · 36:02 · [machine version](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076.md)
- [Long Gap Discussion: EA & TEF](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077) — video · 10:16 · [machine version](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077.md)
- [Leak after Esophageal Atresia Repair / TEF Repair: Discussion of World Experts](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082) — video · 15:25 · [machine version](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082.md)
- [Interesting Case Presentations Part II: EA/TEF](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084) — video · 1:06:11 · [machine version](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084.md)
- [Rigid Bronchoscopy for Diagnosis and Treatment of Proximal Pouch Fistula in...](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230) — video · 4:26 · [machine version](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230.md)
- [Rigid Bronchoscopy for Diagnosis and Treatment of Proximal Pouch Fistula in...](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246) — video · 4:26 · [machine version](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246.md)

## Chapters
- [0:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=0) Introduction and Multidisciplinary Center Structure (Ep 10)
- [3:17](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=197) Initial Assessment and Preoperative Workup (Ep 10)
- [7:08](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=428) Right-Sided Arch Management and Timing of Surgery (Ep 10)
- [11:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=681) Emergency Management of Severe Abdominal Distention (Ep 10)
- [14:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=870) Intraoperative Bronchoscopy and Open Technique (Ep 10)
- [19:25](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1165) Mobilization Techniques and Tracheal Injury Management (Ep 10)
- [23:53](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1433) Anastomotic Technique and Long-Gap Management (Ep 10)
- [29:06](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1746) Thoracoscopic Approach and Port Placement (Ep 10)
- [35:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2120) Postoperative Management and Extubation (Ep 10)
- [38:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2303) Stricture Management and Dilation Protocol (Ep 10)
- [43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2606) Fundoplication Indications and Pure Atresia Approach (Ep 10)
- [0:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=0) Introduction and session framing (Ep 11)
- [0:40](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=40) Historical context and terminology clarification (Ep 11)
- [1:46](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=106) Rothenberg's initial experience and proposed benefits (Ep 11)
- [4:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=240) Single-center comparative study from Tübingen (Ep 11)
- [5:40](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=340) Multi-center international experience (Holcomb series) (Ep 11)
- [7:10](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=430) Japanese multi-center study and musculoskeletal concerns (Ep 11)
- [8:40](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=520) Long-term musculoskeletal outcomes study (Ep 11)
- [10:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=600) Meta-analyses: 2012 and 2016 studies (Ep 11)
- [10:50](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=650) Pilot randomized controlled trial (Ep 11)
- [11:10](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=670) Conclusions and audience poll results (Ep 11)
- [12:06](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=726) Faculty discussion: Rothenberg's perspective on thoracotomy morbidity (Ep 11)
- [14:57](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=897) Training paradigm challenges in the United States (Ep 11)
- [16:56](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=1016) Debate on patient selection and technical visualization (Ep 11)
- [0:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=0) Introduction and technique overview: partial fistula division (Ep 12)
- [4:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=270) Video demonstration of surgical technique (Ep 12)
- [9:45](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=585) Faculty discussion: alternative techniques and clip use (Ep 12)
- [14:28](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=868) Clip erosion concerns and future directions (Ep 12)
- [0:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=0) Introduction and Initial Workup of Esophageal Atresia (Ep 13)
- [7:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=420) Surgical Approach: Right vs. Left Thoracotomy and Aortic Arch Position (Ep 13)
- [15:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=900) Role of Preoperative Bronchoscopy (Ep 13)
- [22:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1320) Open Repair Technique and Suture Material (Ep 13)
- [28:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1680) Thoracoscopic Repair: Indications, Technique, and Training Challenges (Ep 13)
- [35:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2100) Long-Gap Atresia Management and Esophageal Replacement (Ep 13)
- [0:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=0) Introduction and Aspiration Framework (Ep 1)
- [10:40](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=640) Case 1: Second H-Type TEF After Primary Repair (Ep 1)
- [22:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1320) Dual-Scope Technique and Endoscopic TEF Repair (Ep 1)
- [35:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2100) Positive-Pressure Air Test and Repeat Endoscopic Repair (Ep 1)
- [50:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3000) Complex Case: Type D TEF and Slide Tracheoplasty (Ep 1)
- [60:00](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3600) Button Battery Injuries and Slide Tracheoplasty Failures (Ep 1)

## Statements
Every statement is attributed, typed, and timestamped; the link is the citation.
- The bugbee cautery is useful and underutilized among general surgeons for treating recurrent tracheoesophageal fistulas. — Todd Ponsky (opinion) [Ep 7 · 0:04](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4)
- A 70-degree endoscope is a difficult tool to use but useful for tracking down hard-to-find tracheoesophageal fistulas. (clinical) [Ep 7 · 0:37](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=37)
- Routine bronchoscopy is now standard practice for all type C esophageal atresia cases, though this represents a change from earlier training when it was not necessarily performed. — Dan (clinical) [Ep 7 · 1:13](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=73)
- General surgeons may underappreciate tracheomalacia or laryngomalacia, making collaboration with ENT colleagues valuable for comprehensive airway assessment. — Todd Ponsky (opinion) [Ep 7 · 1:53](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=113)
- Pediatric surgery fellows at this institution complete a one-month attachment with ENT to perform bronchoscopies as part of their training. (clinical) [Ep 7 · 2:22](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=142)
- Dual scoping (simultaneous bronchoscopy and esophagoscopy) is enormously valuable for complicated TEF patients, providing different information and advantages in visualization. — Dan (clinical) [Ep 7 · 6:41](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=401)
- During dual scoping, you can see the light from one scope through the epithelium, inject material that may come through subtle holes, or observe bubbles from air insufflation, making simultaneous visualization quite valuable. — Phil (clinical) [Ep 7 · 7:33](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=453)
- For combined bronchoscopy and esophagoscopy in small children, a 2.8 mm flexible bronchoscope is typically used alongside an infant gastroscope (5.4 or 6 mm outer diameter). — Phil (clinical) [Ep 7 · 8:19](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=499)
- An infant gastroscope will fit retrograde through a 16 French gastrostomy tube. — Phil (clinical) [Ep 7 · 8:36](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=516)
- The concept of endoscopic TEF repair is to demucosalize the tract because mucosa is a non-stick surface; you want raw against raw with a tiny bit of fibrin glue to seal it while it scars off. (clinical) [Ep 7 · 11:01](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=661)
- When using fibrin glue for TEF repair, use a very small amount (about 0.1 ml) via a Duplo double-lumen catheter to avoid forming a foreign body. (clinical) [Ep 7 · 11:36](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=696)
- Trichloroacetic acid (TCA) can be used for TEF demucosalization, but it is difficult to control precisely and leaves white tissue everywhere, whereas the bugbee provides more precise control. — Todd Ponsky (clinical) [Ep 7 · 12:21](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=741)
- When using bugbee cautery for TEF repair, place something in the esophagus (such as an endotracheal tube) as a spacer to avoid burning the back of the esophageal wall. (clinical) [Ep 7 · 13:36](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=816)
- A bugbee catheter will go down an EGD scope, allowing cauterization from the esophageal side if the tract angle is favorable. (clinical) [Ep 7 · 14:29](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=869)
- A 3 French bugbee fits through a 2.8 mm flexible bronchoscope with a 1.2 mm suction channel, providing precise control of the tip. — Bob Wood (clinical) [Ep 7 · 15:10](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=910)
- When passing a bugbee through a rigid scope, bending the end at a slight angle before insertion allows steering by rotation. (clinical) [Ep 7 · 15:32](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=932)
- Endoscopic TEF repair often needs to be performed more than once; the average is approximately 2 procedures, with some requiring 1 and others 3-4 attempts. (clinical) [Ep 7 · 22:37](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1357)
- The success rate for endoscopic TEF closure is running about 80%, not 100%. (clinical) [Ep 7 · 24:18](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1458)
- After 3 or 4 failed endoscopic TEF repair attempts, it is typically time to give up and discuss alternative approaches. (clinical) [Ep 7 · 24:27](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1467)
- When cauterizing a TEF, you should particularly try to get the edges and sides because as they scar in, that will narrow the whole mouth, making re-intervention easier if needed. (clinical) [Ep 7 · 24:59](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1499)
- To reduce airway fire risk during bugbee cautery, insufflated oxygen should be kept at 30% or less. (clinical) [Ep 7 · 25:51](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1551)
- Patients can tolerate a minute or two of lower oxygen saturation during cautery procedures to maintain safe oxygen levels below 30%. — Bob Wood (clinical) [Ep 7 · 26:10](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1570)
- Radiance voice gel (used for vocal cord injection) can be injected into the wall beside a TEF to obliterate the potential space and hold raw surfaces together; it only lasts a few weeks. (clinical) [Ep 7 · 27:05](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1625)
- For TEF repair, all that matters is achieving raw-on-raw tissue contact for healing. — Todd Ponsky (clinical) [Ep 7 · 69:25](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4165)
- Thoracoscopic diaphragmatic hernia repairs may have a higher recurrence rate than open repairs, possibly because they do not cause enough raw-on-raw tissue contact. — Todd Ponsky (opinion) [Ep 7 · 69:33](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4173)
- Slide tracheoplasty is a useful technique for big complex TEF holes, using part of the trachea to repair the esophageal defect. (clinical) [Ep 7 · 30:55](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1855)
- Sternal periosteum is an excellent interposition graft material—it is like Kevlar, bulletproof, abundant, and very strong, though almost impossible to suture. (clinical) [Ep 7 · 34:02](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2042)
- Slide tracheoplasty appears to be a learning-curve, surgeon-dependent operation, unlike many operations where the surgeon does not matter long-term. (opinion) [Ep 7 · 57:09](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3429)
- Button batteries are extremely dangerous and can cause ongoing tissue damage that extends beyond what is visible and beyond the expected time frame. — Dan (clinical) [Ep 7 · 43:17](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2597)
- The institutional protocol for button battery ingestion is to remove them within 2 hours of identification, as it is considered a medical emergency. — Phil (guideline) [Ep 7 · 44:04](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2644)
- The American Society of Pediatric Otolaryngology has a task force working to introduce legislation requiring skull-and-crossbones etching on all button batteries to distinguish them from coins on X-ray. (guideline) [Ep 7 · 44:22](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2662)
- In the series of approximately 12 slide tracheoplasties for TEF, there were two failures, both in button battery cases, and both patients were the only button battery cases in the series. (clinical) [Ep 7 · 41:00](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2460)
- For button battery ingestions, if there was a witnessed ingestion, the patient is asymptomatic, removal occurs within a couple of hours, and the mucosa looks good, the likelihood of doing well is high. — Phil (clinical) [Ep 7 · 46:02](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2762)
- Late deaths from aortoesophageal fistulas have occurred following unwitnessed button battery ingestions that were not terribly prolonged. — Phil (clinical) [Ep 7 · 46:18](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2778)
- For button battery cases, CT angiography to look at the aorta may provide as much information about risk of sudden death as endoscopic evaluation, though sensitivity data is lacking. — Phil (opinion) [Ep 7 · 47:10](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2830)
- The style of button battery matters for risk: large round flat 3-volt batteries are by far the most potentially damaging, while smaller fatter batteries pose less risk. (clinical) [Ep 7 · 48:01](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2881)
- The protocol is to remove button batteries from the stomach because if they do not leave and sit in one spot, they create considerable injury, especially in the distal stomach/antrum where scarring or stenosis can occur. — Phil (clinical) [Ep 7 · 49:22](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2962)
- For transtracheal TEF repair, a three-layer closure is performed: esophageal layer with knots in the esophageal lumen, interposition graft (typically sternal periosteum), and tracheal layer with knots in the tracheal lumen to reduce refistulization risk. (clinical) [Ep 7 · 54:11](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3251)
- Transtracheal repair is a relatively two-dimensional operation where the surgeon matters less than in three-dimensional operations like slide tracheoplasty. (opinion) [Ep 7 · 56:21](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3381)
- The primary complication of transtracheal TEF repair is refistulization, whereas slide tracheoplasty complications include dehiscence, which is a much bigger deal. (clinical) [Ep 7 · 56:03](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3363)
- When repairing high H-type fistulas from a thoracic approach, there is a temptation to ligate the fistula on the esophageal side, which can leave a large tracheal pouch/diverticulum that causes problems if the patient needs a tracheostomy. (clinical) [Ep 7 · 64:18](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3858)
- Endoscopic suturing in the trachea is remarkably humbling and painful, and the hardest part is tying the knot. (opinion) [Ep 7 · 68:11](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4091)
- Nitinol clips could theoretically be used for endoscopic TEF repair, though they are permanent. — Dan (opinion) [Ep 7 · 68:33](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4113)
- Metal clips can be used with endoscopic sutures for laryngeal cleft repairs from the esophageal side to hold sutures; the patient swallows the clip when the PDS dissolves. (clinical) [Ep 7 · 69:01](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4141)
- Anal fistula plugs made of biologic material (surgesis) can be used for TEF repair by wrapping them with barbed VOC suture and inserting them into the fistula tract to promote scarring and collagen matrix formation. — Todd Ponsky (clinical) [Ep 7 · 97:24](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5844)
- Long skinny TEF tracts from proximal to distal are the ideal candidates for endoscopic repair, while short, fat, wide tracts do not tend to do well with endoscopic techniques. (clinical) [Ep 7 · 63:58](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3838)
- H-type fistulas are relatively short tracks straight from trachea to esophagus and do not do nearly as well with endoscopic repair compared to longer tracts. (clinical) [Ep 7 · 63:46](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=3826)
- Positive pressure testing for TEF involves placing an endotracheal tube with cuff in the esophagus and applying 30 cm H2O pressure of air, then observing for air blowing out of the fistula; the stomach must be suctioned afterward. (clinical) [Ep 7 · 21:36](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1296)
- For proximal fistulas, intubation with a cuffed tube past the hole is preferred so the cuff holds the hole occluded during repair; this is not possible for fistulas on the carina. (clinical) [Ep 7 · 23:29](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1409)
- One of the problems with endoscopic TEF cauterization is not being aggressive enough; you need to destroy the mucosa, not just give it a fright. — Bob Wood (clinical) [Ep 7 · 17:42](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1062)
- With a flexible bronchoscope, you can insufflate through the suction channel and distend the lumen to get a better view and sweep the inside of the lumen during cauterization. — Bob Wood (clinical) [Ep 7 · 18:03](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1083)
- Laryngeal clefts are incredibly easy to miss and must be actively looked for and probed, not just visually inspected. (clinical) [Ep 7 · 20:10](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=1210)
- A flexible bronchoscope is not a reliable tool for diagnosing laryngeal clefts; you cannot find them even when you know they are there 95% of the time due to limitations of flexible instrumentation. — Bob Wood (clinical) [Ep 7 · 103:43](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6223)
- For anything suspected in the posterior commissure, subglottic space, or cervical trachea, a rigid scope with probing is mandatory, not just visual inspection. — Bob Wood (clinical) [Ep 7 · 104:02](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6242)
- The retroflexed (upside-down) flexible bronchoscopy technique allows greater angulation at the scope tip in one direction than the opposite, making it useful for examining the posterior tracheal wall. — Bob Wood (clinical) [Ep 7 · 73:30](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4410)
- Insufflating with oxygen through the suction channel at about 2 L/min during bronchoscopy spreads tissue apart, does not hurt respirations, and gives a better view. — Bob Wood (clinical) [Ep 7 · 74:15](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4455)
- When advancing a flexible bronchoscope through the nose and glottis, it is very easy to miss pathology in the cervical trachea and subglottis; it is easier to see these areas while slowly withdrawing the scope than while advancing. — Bob Wood (clinical) [Ep 7 · 74:51](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4491)
- High tracheoesophageal fistulas are very difficult to find from the esophageal side because they are just below the esophageal inlet where a forward-viewing gastroscope does not deflect well enough to get an en face view. — Phil (clinical) [Ep 7 · 4:43](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=283)
- Going retrograde up the esophagus provides easier maneuvering just below the esophageal inlet for finding high fistulas. — Phil (clinical) [Ep 7 · 5:17](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=317)
- Bronchoesophageal fistulas can be very hard to find because there are so many subsegmental bronchi. (clinical) [Ep 7 · 5:36](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=336)
- During dual scoping for bronchoesophageal fistula, you can shake hands across the fistula if you can track it down, and seeing the other operator's scope is usually a giveaway. (clinical) [Ep 7 · 5:50](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=350)
- During dual scoping, you can see the light from the other scope through the epithelium, inject material that may come through a hole, or see bubbles from insufflation, making simultaneous scoping quite valuable. — Phil (clinical) [Ep 7 · 7:33](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=453)
- Operators can turn off their light during dual scoping so the other person can see their light and determine if they are in the right region. (clinical) [Ep 7 · 7:58](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=478)
- A 2.8 mm flexible bronchoscope is typically used for combined procedures, and the GI scope for small children is an infant scope (5.4 or 6 mm outer diameter). — Phil (clinical) [Ep 7 · 8:19](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=499)
- An infant gastroscope will fit retrograde through a 16 French gastrostomy tube, which is why 16 French G-tubes are preferred over 14 French. — Phil (clinical) [Ep 7 · 8:36](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=516)
- A bronchoscope can be used retrograde in the esophagus because it fits through smaller openings. — Bob Wood (clinical) [Ep 7 · 8:57](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=537)
- For patients with Down syndrome, swallow studies are difficult to interpret due to cooperation issues. (clinical) [Ep 7 · 71:25](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4285)
- If a patient is clinically aspirating with a history of TEF repair, maintain a high index of suspicion for recurrent fistula or laryngeal cleft even if initial studies are negative. (clinical) [Ep 7 · 71:44](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4304)
- After TEF repair, patients may have persistent bronchiectasis from years of aspiration, requiring months of care with vibrating vest and chest physiotherapy even after successful fistula closure. (clinical) [Ep 7 · 82:40](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=4960)
- Tracheal pouches/diverticula can cause problems during tracheostomy tube changes because the tube may go into the pouch instead of the trachea, causing the patient to decompensate. (clinical) [Ep 7 · 104:45](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6285)
- Tracheal pouches can be marsupialized using a Storz ClickLine biopsy forceps (pediatric laparoscopic instrument) with suction and cautery at about 40 watts to divide the common party wall. (clinical) [Ep 7 · 105:12](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6312)
- Marsupializing tracheal pouches can make tracheomalacia worse symptomatically, though usually it does not and kids do well. — Bob Wood (clinical) [Ep 7 · 106:00](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6360)
- After marsupialization of tracheal pouches, what remains tends to scar to the sides and becomes almost invisible. (clinical) [Ep 7 · 106:29](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=6389)
- Hearing aid molds are radiolucent and can be missed on chest X-ray. (clinical) [Ep 7 · 84:50](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5090)
- Airway stents can erode and create new fistulas into the esophagus. (clinical) [Ep 7 · 87:49](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5269)
- A Y-shaped stent placed in both bronchi and up the trachea with a trach tube into the stent can successfully bypass a bronchoesophageal fistula, allowing significant clinical improvement. (clinical) [Ep 7 · 88:07](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5287)
- Pectus excavatum can worsen tracheobronchomalacia, and sternotomy for other procedures can make the pectus worse. (clinical) [Ep 7 · 86:40](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5200)
- Placing a pectus bar can improve severe tracheobronchomalacia by pulling the chest wall forward. (clinical) [Ep 7 · 87:33](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=5253)
- Patients with a transanastomotic tube had a 2.72 times higher risk of developing a stricture post-operatively after esophageal atresia with tracheoesophageal fistula repair (clinical) [Ep 4 · 1:10](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=70)
- The Midwest Pediatric Surgery Consortium study examined every patient who had a laparoscopic pyloric myotomy to identify patent processus vaginalis and followed them annually (clinical) [Ep 4 · 1:30](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=90)
- Of 526 patients enrolled in the PPV study, 283 had a patent processus vaginalis (bilateral, right, or left) (epidemiological) [Ep 4 · 2:00](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=120)
- Of 208 patients with at least one year follow-up, only three underwent inguinal hernia repair, all within the first year (clinical) [Ep 4 · 2:13](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=133)
- Most patent processus vaginalis do not turn into inguinal hernias based on four-year interim analysis data (clinical) [Ep 4 · 2:35](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=155)
- Liver transplantation for biliary atresia can be performed as initial treatment (primary) or after failed Kasai hepatoportoenterostomy (salvage) (clinical) [Ep 4 · 2:45](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=165)
- The current standard in the US for biliary atresia is Kasai first and liver transplant only if that fails (guideline) [Ep 4 · 3:05](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=185)
- Children who had an early salvage liver transplant (before age one) and children who had a primary liver transplant had similar outcomes (clinical) [Ep 4 · 3:30](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=210)
- Children who had a late salvage liver transplant had improved graft survival compared to other groups (clinical) [Ep 4 · 3:45](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=225)
- Some children who undergo the Kasai procedure will never end up needing a liver transplant (clinical) [Ep 4 · 4:00](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=240)
- Social risk screening in pediatrics involves screening for risk factors including food and housing insecurity, financial strain, and unsafe environments (clinical) [Ep 4 · 4:30](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=270)
- There is low concordance between screening results showing who might need resources and who is actually asking for more resources (epidemiological) [Ep 4 · 5:00](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=300)
- Families may feel uncomfortable with social risk screening and may think there might be downstream repercussions based on their answers (opinion) [Ep 4 · 5:15](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=315)
- There may be racial biases in screening practices, with non-white patients potentially being asked social risk questions more often (epidemiological) [Ep 4 · 5:28](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=328)
- Current social risk screening protocols may not be effective and may actually lead to more inequities (opinion) [Ep 4 · 4:50](https://library.globalcastmd.com/watch/quick-literature-updates-episode-9-6770?t=290)
- Slide tracheoplasty can be used as a method of repairing challenging tracheoesophageal fistulas — Michael Rutter (clinical) [Ep 5 · 0:49](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=49)
- In a case with complete tracheal rings and TEF, both conditions were repaired simultaneously because there was no other option — Michael Rutter (clinical) [Ep 5 · 1:11](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=71)
- The slide tracheoplasty technique involves transecting the trachea above and below the hole with a bevel to avoid losing too much trachea — Michael Rutter (clinical) [Ep 5 · 1:25](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=85)
- Part of the trachea is used to repair the esophagus, then the trachea is slid over the top of it, often with a periosteal interposition graft — Michael Rutter (clinical) [Ep 5 · 1:35](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=95)
- In the slide tracheoplasty repair, a flap of trachea is sewn onto the esophagus so the front wall of the esophagus becomes a piece of trachea, using a quick running suture technique with 4-0 PDS — Michael Rutter (clinical) [Ep 5 · 2:18](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=138)
- When the distance between trachea and esophagus is large, using nerve hooks and slowly tightening multiple throws brings the structures together — Michael Rutter (clinical) [Ep 5 · 2:47](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=167)
- In the Swedish patient case, esophagoscopy at one month post-op showed the suture line where trachea was sewn to esophagus with the front wall being a piece of trachea — Michael Rutter (clinical) [Ep 5 · 3:08](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=188)
- The Swedish patient returned to eating and drinking everything despite having a very short trachea — Michael Rutter (clinical) [Ep 5 · 3:24](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=204)
- In the 4-year-old case, initial stabilization was achieved by placing an esophageal stent, which did not fix the holes but eliminated the mediastinal communication — Michael Rutter (clinical) [Ep 5 · 4:23](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=263)
- A transsternal, transtracheal approach provides fantastic exposure to the esophagus — Michael Rutter (clinical) [Ep 5 · 4:50](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=290)
- Tibial periosteum serves as a good interposition graft — Michael Rutter (clinical) [Ep 5 · 4:55](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=295)
- Periosteum is effective at protecting one lumen from another — Michael Rutter (clinical) [Ep 5 · 5:05](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=305)
- Slide tracheoplasty is not appropriate for every TEF case, but it is useful to know the option is available — Michael Rutter (opinion) [Ep 5 · 6:26](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=386)
- The vision of the Aerodigestive and Esophageal Center is to improve efficiency and communication between team members and the family. — Claire Miller (clinical) [Ep 6 · 1:28](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=88)
- The clinical assessment is a poor predictor when there are airway protection issues. — Claire Miller (clinical) [Ep 6 · 2:44](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=164)
- High-resolution pharyngeal manometry allows objective assessment of the pressures of the swallow to understand what is underlying a swallowing dysfunction. — Claire Miller (clinical) [Ep 6 · 3:13](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=193)
- Patients with TEF have a lot of other things other than incompetent lower esophageal sphincters, including motility problems, hernias, and delayed emptying. — Scott Pentik (clinical) [Ep 6 · 4:31](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=271)
- Impedance is a tool used to measure reflux and distinguish between a swallow versus actual reflux. — Scott Pentik (clinical) [Ep 6 · 4:48](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=288)
- Patients with eosinophilic esophagitis often have procedures performed on them even before their diagnosis. — Scott Pentik (clinical) [Ep 6 · 5:21](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=321)
- The center now performs endoscopy as part of workup prior to even considering surgery. — Scott Pentik (guideline) [Ep 6 · 5:35](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=335)
- Kids will have Nissans and then have hernias later. — Scott Pentik (clinical) [Ep 6 · 5:49](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=349)
- Motility issues after TEF repairs include narrowing of the esophagus and the esophagus not squeezing, leading to more reflux, more dysphagia, and impactions. — Scott Pentik (clinical) [Ep 6 · 5:58](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=358)
- Patients at risk for pulmonary insufficiency typically present with chronic symptoms including tachypnea, shortness of breath, retractions, non-apneic hypoxemia, and in older patients, exercise intolerance. — Sherry Torres Silva (clinical) [Ep 6 · 7:06](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=426)
- Patients at risk for chronic pulmonary aspiration include preemie babies, those with swallowing dysfunction, GI dysmotility, cardiothoracic esophageal and airway history, and syndromes including CHARGE syndrome, Mobius, Criducha, and trisomy. — Sherry Torres Silva (clinical) [Ep 6 · 7:32](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=452)
- Patients with airway obstruction, especially upper airway, will have symptoms with sleep and significant exertion or agitation, and noisy breathing might be one of the most significant symptoms reported. — Sherry Torres Silva (clinical) [Ep 6 · 8:02](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=482)
- Tracheomalacia is a very common comorbidity in patients with history of esophageal fistula or atresia. — Sherry Torres Silva (clinical) [Ep 6 · 8:22](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=502)
- High-resolution CT is the gold standard for diagnosis because it is highly sensitive and detects early changes of the small airways, and 3D reconstructions can be performed. — Sherry Torres Silva (clinical) [Ep 6 · 8:36](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=516)
- Flexible bronchoscopy is used starting in the nose and ending in the subsegmental bronchi, and bronchoalveolar lavage helps with identification of infections and markers of aspiration. — Sherry Torres Silva (clinical) [Ep 6 · 8:49](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=529)
- Pulmonologists perform medical management of aspiration including control of sialorrhea, optimization of airway clearance, and use of anti-inflammatory medications for chronic aspiration or inflammation. — Sherry Torres Silva (clinical) [Ep 6 · 9:02](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=542)
- Most children who aspirate have a functional or neurological problem (cerebral palsy, CHARGE syndrome); some have anatomical problems (TEF, laryngeal cleft, pharyngeal scar, esophageal stenosis). — Michael Rutter (clinical) [Ep 1 · 4:39](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=279)
- Lipid-laden macrophages are non-specific markers of aspiration; their recovery depends on the lipid content of aspirated material, the amount aspirated, and time since aspiration. — Bob Wood (clinical) [Ep 1 · 8:05](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=485)
- Multi-channel intraluminal impedance testing detects reflux but does not diagnose aspiration; it tells you whether something is delivered from the stomach to the esophagus, not what happens after. — Phil Putnam (clinical) [Ep 1 · 9:38](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=578)
- If a patient is aspirating from above (oropharyngeal or esophageal source), an anti-reflux procedure does not help and may make them worse. — Daniel von Allmen (clinical) [Ep 1 · 9:58](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=598)
- A 3-French bugbee cautery is a smooth, excellent probe for identifying subtle tracheoesophageal fistulas. — Michael Rutter (clinical) [Ep 1 · 12:10](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=730)
- A 70-degree endoscope is a difficult tool to use but can visualize TEFs that are otherwise hard to see with standard forward-viewing scopes. — Michael Rutter (clinical) [Ep 1 · 13:21](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=801)
- Routine bronchoscopy is now standard practice for all type C TEF repairs at Cincinnati Children's, often done in collaboration with ENT colleagues. — Daniel von Allmen (clinical) [Ep 1 · 14:02](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=842)
- Pediatric surgery fellows at Cincinnati Children's complete a one-month attachment with ENT to perform bronchoscopies and gain airway expertise. — Michael Rutter (clinical) [Ep 1 · 14:51](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=891)
- Dual scoping (simultaneous bronchoscopy and esophagoscopy) allows scopes to 'shake hands' across a fistula, light transillumination through tissue, and injection of saline or air to reveal subtle openings. — Daniel von Allmen (clinical) [Ep 1 · 19:37](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1177)
- A 2.8 mm flexible bronchoscope and a 5.4–6 mm infant gastroscope are the typical scopes used for combined airway-esophageal examination in small children. — Phil Putnam (clinical) [Ep 1 · 21:02](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1262)
- Endoscopic TEF closure requires demucosalization of the tract (mucosa is a non-stick surface); the goal is raw-against-raw apposition with minimal fibrin glue (0.1 mL) to seal the tract while scarring occurs. — Michael Rutter (clinical) [Ep 1 · 23:41](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1421)
- Endoscopic TEF repair success rate is approximately 80%, typically requiring 2 attempts; after 3–4 failed attempts, open repair should be considered. — Michael Rutter (clinical) [Ep 1 · 37:01](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2221)
- Positive-pressure air insufflation (30 cm H₂O) via an endotracheal tube in the esophagus can reveal a TEF by causing air to bubble out of the tracheal opening. — Michael Rutter (clinical) [Ep 1 · 34:20](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2060)
- Injection of an inert material (e.g., Radiesse voice gel) into the walls adjacent to a TEF tract can obliterate the potential space and promote raw-on-raw apposition; the material is absorbed over a few weeks. — Michael Rutter (clinical) [Ep 1 · 39:48](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2388)
- Slide tracheoplasty for TEF involves transecting the trachea above and below the fistula, beveling the edges, turning in the tracheal wings to repair the esophagus, interposing sternal periosteum, and reconnecting the trachea; it is a three-layer repair. — Michael Rutter (clinical) [Ep 1 · 45:48](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2748)
- Sternal periosteum is an excellent interposition graft material: it is abundant, in the surgical field, and extremely strong ('like Kevlar'), though difficult to suture. — Michael Rutter (clinical) [Ep 1 · 46:52](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2812)
- Button batteries can cause ongoing tissue injury for weeks after ingestion, even if 'dead' (they retain ~2 volts); institutional protocol mandates removal within 2 hours of identification. — Michael Rutter (guideline) [Ep 1 · 53:37](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3217)
- Button battery injuries in the esophagus can progress to aortoesophageal fistula; CT angiography and close follow-up for 6 weeks post-removal are recommended, especially if the battery was at the aortoesophageal junction. — Phil Putnam (guideline) [Ep 1 · 59:02](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3542)
- Two slide tracheoplasty repairs for button battery TEF both dehisced (one at 10 days, one at 3 months); both were successfully revised. This may be more than coincidence, suggesting button battery injuries pose unique challenges. — Michael Rutter (clinical) [Ep 1 · 54:02](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3242)
- Transtracheal TEF repair is a two-dimensional operation with lower complication risk than slide tracheoplasty; the primary complication is re-fistulization, whereas slide tracheoplasty dehiscence is a more serious event. — Michael Rutter (opinion) [Ep 1 · 69:04](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=4144)
- Transtracheal repair technique: anterior tracheotomy, identify the fistula from within the trachea, separate tracheal and esophageal layers, three-layer closure (esophageal mucosa with knots in lumen, sternal periosteum, tracheal wall with knots in lumen). — Michael Rutter (clinical) [Ep 1 · 64:43](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=3883)
- In patients with retroesophageal subclavian artery, the right recurrent laryngeal nerve is non-recurrent and at higher risk during neck dissection; awareness is critical during transtracheal or slide tracheoplasty approaches. — Michael Rutter (clinical) [Ep 1 · 94:43](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5683)
- Flexible bronchoscopy cannot reliably diagnose laryngeal clefts; rigid microlaryngoscopy with active probing is mandatory when posterior glottic pathology is suspected. — Bob Wood (clinical) [Ep 1 · 116:27](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6987)
- When examining the cervical trachea and subglottis with a flexible bronchoscope, it is easier to see pathology while slowly withdrawing the scope than while advancing it, due to the need to flex and extend the tip to navigate the glottis. — Bob Wood (clinical) [Ep 1 · 87:43](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5263)
- Insufflation with oxygen at 2 L/min through the suction channel of a flexible bronchoscope spreads tissue apart, improves visualization, and does not impair respirations. — Bob Wood (clinical) [Ep 1 · 86:58](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5218)
- The degree of angulation at the tip of a flexible bronchoscope is much greater in one direction (retroflexion) than the other; rotating the scope 180° (Sabode maneuver) can reveal posterior tracheal pathology more easily. — Bob Wood (clinical) [Ep 1 · 86:30](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5190)
- Endoscopic closure of bronchoesophageal fistulas is feasible but challenging; proximity to large vessels (e.g., pulmonary artery branches) may preclude safe cautery and necessitate surgical resection. — Michael Rutter (clinical) [Ep 1 · 107:43](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6463)
- In a patient with multiple bronchoesophageal fistulas and chronic bronchiectasis, lobectomy with resection of the esophageal pseudo-diverticulum can be performed safely; the esophagus can be primarily closed if not strictured. — Daniel von Allmen (clinical) [Ep 1 · 112:36](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6756)
- A Y-shaped airway stent from both bronchi into the trachea, with the tracheostomy tube sitting within the stent, can effectively bypass a bronchoesophageal fistula and allow clinical stability when further repair is not feasible. — Michael Rutter (clinical) [Ep 1 · 100:56](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6056)
- Tracheal pouches (diverticula) can be marsupialized endoscopically using a Storz ClickLine laparoscopic biopsy forceps with cautery at 40 watts; the technique is quick, well-tolerated, and eliminates the risk of tracheostomy tube misplacement. — Michael Rutter (clinical) [Ep 1 · 118:01](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=7081)
- When cauterizing in the airway with a bugbee, oxygen concentration should be kept below 30% to minimize fire risk; brief periods of lower oxygen saturation are tolerable. — Michael Rutter (clinical) [Ep 1 · 38:35](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=2315)
- A 3-French bugbee cautery fits through the 1.2 mm suction channel of a 2.8 mm flexible bronchoscope, allowing precise control and steering of the cautery tip. — Bob Wood (clinical) [Ep 1 · 27:54](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1674)
- Trichloroacetic acid (TCA) can be used to demucosalize TEF tracts, but control is less precise than with bugbee cautery; TCA is applied on a pledget and can cause unintended burns if it contacts tissue during insertion. — Todd Ponsky (clinical) [Ep 1 · 25:08](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=1508)
- Anal fistula plugs (biologic, cone-shaped, made of Surgisis) can theoretically be used to occlude distal airway fistulas; they are wrapped with barbed suture and inserted into the tract to promote collagen matrix formation and scarring. — Todd Ponsky (clinical) [Ep 1 · 110:04](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6604)
- Slide tracheoplasty appears to be a learning-curve, surgeon-dependent operation; revision cases have been necessary as experience was gained. — Michael Rutter (opinion) [Ep 1 · 69:59](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=4199)
- After 7 years of aspiration through a TEF, a child may have significant bronchiectasis; repair of the fistula does not immediately resolve lower airway disease, and ongoing chest physiotherapy and airway clearance are required. — Michael Rutter (clinical) [Ep 1 · 95:23](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5723)
- Hearing aid molds are radiolucent and can be missed on chest X-ray; high clinical suspicion is required when a foreign body ingestion is reported but not visualized. — Michael Rutter (clinical) [Ep 1 · 97:35](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5855)
- Pectus excavatum can worsen tracheobronchomalacia; placement of a pectus bar can improve airway support and reduce the need for stenting or tracheostomy. — Michael Rutter (clinical) [Ep 1 · 99:49](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=5989)
- Airway stents can erode into the esophagus, creating secondary fistulas; long-term stent management requires vigilance and may necessitate alternative strategies (e.g., Y-stent with tracheostomy tube within the stent). — Michael Rutter (clinical) [Ep 1 · 100:32](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=6032)
- When repairing a high TEF from a thoracic approach, ligation of the fistula on the esophageal side can leave a large tracheal pouch; if the patient has tracheomalacia and requires a tracheostomy, the tube may enter the pouch, causing life-threatening obstruction. — Michael Rutter (clinical) [Ep 1 · 77:21](https://library.globalcastmd.com/watch/aerodigestive-esophageal-surgery-difficult-tracheal-esophageal-fistula-739?t=4641)
- At Cincinnati Children's, if a child has no gas in the abdomen, they place a G-tube and may put something up the distal esophagus for a fluoro shot, then wait a couple of weeks for a protocol gap measurement in interventional radiology. — Daniel von Allmen (clinical) [Ep 2 · 0:46](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=46)
- Stretch is a very strong promoter of growth, and if you put things on tension they will actually grow over time, which is how the cardiovascular system develops in utero. — Daniel von Allmen (clinical) [Ep 2 · 2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130)
- The philosophy of traction-based elongation is that with traction, you can get the two ends of the esophagus to grow, and if you can get them to grow far enough, you can put them together. — Daniel von Allmen (clinical) [Ep 2 · 2:10](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=130)
- The colon can be used as an interposition for esophageal replacement. — Daniel von Allmen (clinical) [Ep 2 · 4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276)
- Common problems with colonic interposition are that the colon can dilate and become tortuous, and it's not uncommon to get a sigmoid sink drain deformity just above the diaphragm. — Daniel von Allmen (clinical) [Ep 2 · 8:00](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=480)
- Von Allman was initially taught that sigmoid redundancy in colonic interposition can't be fixed and that it's too dangerous because it will risk the blood supply, but he found that this is not really true. — Daniel von Allmen (opinion) [Ep 2 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497)
- Von Allman passes the colonic interposition posterior to the stomach, which leaves the vascular pedicle along the spine, allowing mobilization of the colon by dividing the gastric duodenotomy and colon attachment to the stomach, then mobilizing the sigmoid redundancy transhiatally and reanastomosing the colon to the stomach. — Daniel von Allmen (clinical) [Ep 2 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497)
- Colonic interpositions sometimes need to be revised, but it is not impossible to revise them and the kids tend to do pretty well. — Daniel von Allmen (opinion) [Ep 2 · 8:17](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=497)
- You can get extraordinary length with colonic interposition, allowing treatment of cases with caustic injuries extending to the pharynx by sewing the colon to the pharynx and down to the stomach, which is tough to do with a gastric pull-up. — Daniel von Allmen (clinical) [Ep 2 · 9:03](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=543)
- Von Allman states we don't know whether esophageal elongation is growth or stretch and should do studies to understand that, but notes that tension is a very good physiologic growth promoter in other organs, making this an area ripe for more basic science. — Daniel von Allmen (opinion) [Ep 2 · 9:56](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=596)
- The endpoint of chest infection in the azygous vein meta-analysis was not clearly defined across studies—some used 'chest infection,' some 'pneumonitis,' some 'pneumonia'—making it a non-homogeneous endpoint — Jose Campos (clinical) [Ep 3 · 4:45](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=285)
- Congenital esophageal stenosis is associated with esophageal atresia in 7% to 10% of cases and most are diagnosed really late, sometimes after the anastomosis fails — Jose Campos (epidemiological) [Ep 3 · 9:44](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=584)
- Passing a tube through the anastomosis to check for resistance can help identify distal esophageal stenosis intraoperatively — Jose Campos (clinical) [Ep 3 · 9:58](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=598)
- If a leak occurs, it doesn't always drain through the chest tube — Todd Ponsky (clinical) [Ep 3 · 11:23](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=683)
- A chest tube may injure, suck on, or increase the chance of disruption of the anastomosis — Todd Ponsky (opinion) [Ep 3 · 11:30](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=690)
- Chest tubes are painful for patients — Todd Ponsky (clinical) [Ep 3 · 11:39](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=699)
- Giving PPIs to neonates can increase pneumonia in different populations, but the risk is very minimal — Jose Campos (clinical) [Ep 3 · 14:24](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=864)
- Not giving antibiotics postoperatively helps detect complications early rather than having antibiotics cover a complication — Jose Campos (clinical) [Ep 3 · 14:10](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=850)
- The green telepresence system from Stanford Research Institute was originally designed as an open surgical platform, not for minimally invasive surgery. — Marc Michalsky (clinical) [Ep 8 · 7:56](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=476)
- Colonel Rick Satava had an 'aha moment' after seeing Jacques Marescaux's laparoscopic cholecystectomy video, leading him to propose marrying robotic and laparoscopic technologies. — Marc Michalsky (clinical) [Ep 8 · 8:34](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=514)
- Computer Motion's 5mm instruments were sunsetted by Intuitive after acquisition, creating a persistent gap for pediatric applications. — Marc Michalsky (clinical) [Ep 8 · 13:09](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=789)
- The transition from da Vinci SI to XI was transformational, creating much more flexible range of motion. — Marc Michalsky (clinical) [Ep 8 · 12:20](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=740)
- One large children's hospital acquired a robot without planning; it sat unused for 18 months costing $25,000/month in maintenance. — Marc Michalsky (clinical) [Ep 8 · 22:12](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=1332)
- Nationwide formed a steering committee with pediatric surgery, urology, anesthesia, nursing, and periop administration to develop integrated multidisciplinary program. — Marc Michalsky (clinical) [Ep 8 · 23:14](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=1394)
- Robotic cases garner a higher facility charge (level 5, ~$4000 per 15 minutes) versus laparoscopic cases (level 3, ~$2200 per 15 minutes). — Marc Michalsky (clinical) [Ep 8 · 60:27](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3627)
- Nationwide has seen no insurance denials for robotic pre-certification and no patient reports of astronomical bills or surcharges attributed to robot use. — Marc Michalsky (clinical) [Ep 8 · 61:21](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3681)
- Maintenance of certification requires at least 10 robotic cases over a 2-year credentialing cycle plus mandatory quarterly digital simulation. — Marc Michalsky (guideline) [Ep 8 · 30:19](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=1819)
- Block time overlay system assigns automated robot availability on top of surgeons' existing block time, with 14-day release mechanism if unused. — Marc Michalsky (clinical) [Ep 8 · 32:20](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=1940)
- Using longer 'bariatric' instruments spreads out the robot above the patient and reduces likelihood of external arm collisions, even in smaller children. — Marc Michalsky (clinical) [Ep 8 · 34:36](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=2076)
- In Nationwide's experience of ~1000 patients, 12% of robotic cases were performed on patients less than 15kg, primarily driven by urology. — Marc Michalsky (epidemiological) [Ep 8 · 35:29](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=2129)
- No difference in operating time, 30-day complications, or readmissions for sleeve gastrectomy above versus below BMI 50. — Marc Michalsky (clinical) [Ep 8 · 36:43](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=2203)
- Learning curve for robotic sleeve gastrectomy decreased from 132 minutes with SI to 36 minutes with XI; speaker has performed cases in 21 minutes. — Marc Michalsky (clinical) [Ep 8 · 41:44](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=2504)
- Robotic sleeve gastrectomy initially took 30 minutes longer than laparoscopic but patients were discharged earlier. — Marc Michalsky (clinical) [Ep 8 · 41:07](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=2467)
- No difference in time or complications for robotic acute cholecystitis versus elective cholecystectomy. — Marc Michalsky (clinical) [Ep 8 · 43:51](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=2631)
- Robotic surgery experience has made the speaker a better laparoscopic surgeon, particularly for intracorporeal knot tying. — Marc Michalsky (opinion) [Ep 8 · 44:29](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=2669)
- Intuitive has 4 pediatric surgeons working for it, including James Wall, all with Stanford/Palo Alto connections. — Marc Michalsky (clinical) [Ep 8 · 58:25](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3505)
- Intuitive is working with FDA to reconfigure clearance from specific case indications to categories, which will include pediatrics. — Marc Michalsky (clinical) [Ep 8 · 58:25](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3505)
- Carl Storz platform has 5mm instrumentation and strong interest in pediatric applications. — Marc Michalsky (clinical) [Ep 8 · 59:07](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3547)
- Intuitive will not build a pediatric-specific robot as it would require ~$1 billion investment without adequate ROI. — Marc Michalsky (opinion) [Ep 8 · 59:17](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3557)
- Fellow credentialing requires 10 bedside assists and 20 console cases as primary surgeon, plus skills/drills and certificate completion. — Marc Michalsky (guideline) [Ep 8 · 62:42](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3762)
- Hopkins performed a robotic cholecystectomy in a pig cadaver model with effectively no human input earlier this summer. — Marc Michalsky (clinical) [Ep 8 · 55:30](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3330)
- J&J has partnership with Google for metadata power to develop digital overlay systems incorporating axial imaging into robotic view. — Marc Michalsky (clinical) [Ep 8 · 64:45](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=3885)
- Cincinnati Children's has a multidisciplinary aerodigestive center including ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians — Daniel von Allmen (clinical) [Ep 10 · 2:01](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=121)
- The aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway arms — Daniel von Allmen (clinical) [Ep 10 · 2:46](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=166)
- Physical examination should assess for scaphoid versus full or distended abdomen and respiratory distress — Daniel von Allmen (clinical) [Ep 10 · 3:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=235)
- The surgeon should personally attempt to pass the NG tube rather than relying on nursing reports, as tubes reported as not passing sometimes pass easily — Daniel von Allmen (clinical) [Ep 10 · 4:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=260)
- Injecting air into the NG tube and obtaining a plain film helps visualize proximal pouch distention and assess distal GI gas pattern — Daniel von Allmen (clinical) [Ep 10 · 4:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=295)
- Lack of visible distended proximal pouch raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression — Daniel von Allmen (clinical) [Ep 10 · 5:01](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=301)
- Contrast studies can be performed if there is high suspicion of unusual anatomy, as long as the radiologist knows the esophagus may be obstructed — Daniel von Allmen (clinical) [Ep 10 · 5:42](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=342)
- Echocardiogram is the most important preoperative study to assess cardiac anatomy and rule out right-sided aortic arch — Daniel von Allmen (clinical) [Ep 10 · 6:25](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=385)
- Renal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia — Daniel von Allmen (clinical) [Ep 10 · 6:54](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=414)
- Conventional wisdom is to perform left thoracotomy for right-sided aortic arch — Daniel von Allmen (guideline) [Ep 10 · 7:27](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=447)
- Left thoracotomy for right-sided arch is somewhat more difficult with the heart more in the way and harder proximal pouch mobilization — Daniel von Allmen (clinical) [Ep 10 · 7:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=471)
- It is possible to complete the repair from the right side if right-sided arch is discovered intraoperatively, though some reports suggest higher incidence of swallowing problems — Daniel von Allmen (clinical) [Ep 10 · 8:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=500)
- In a stable larger baby not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting 1-2 days — Daniel von Allmen (clinical) [Ep 10 · 9:31](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=571)
- Should not wait a long time before repair due to risk of colonizing GI tract and soiling lungs — Daniel von Allmen (clinical) [Ep 10 · 9:56](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=596)
- Oscillator ventilation does not make a significant difference in managing large fistulas with abdominal distention — Daniel von Allmen (opinion) [Ep 10 · 10:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=615)
- Large fistula with distention tends to be a bigger problem in more premature infants with significant lung disease, where poor lung compliance drives air into GI tract — Daniel von Allmen (clinical) [Ep 10 · 10:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=615)
- Treating with surfactant and improving lung compliance helps as much as changing ventilator type — Daniel von Allmen (clinical) [Ep 10 · 10:56](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=656)
- Risk of waiting too long to make a decision in worsening distention can lead to emergency situation where child cannot be ventilated — Daniel von Allmen (clinical) [Ep 10 · 11:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=681)
- For reasonably stable but worsening distention, would take child urgently to OR for right thoracotomy and fistula ligation — Daniel von Allmen (clinical) [Ep 10 · 12:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=720)
- Bronchoscopic Fogarty balloon placement sounds good but is difficult unless expertise and equipment are immediately available — Daniel von Allmen (opinion) [Ep 10 · 12:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=720)
- G-tube decompression may paradoxically worsen ventilation by making stomach lower resistance, allowing more air to go there instead of lungs — Daniel von Allmen (clinical) [Ep 10 · 12:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=720)
- Laparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize severe cases, leaving in place for several days before definitive repair — Daniel von Allmen (clinical) [Ep 10 · 12:50](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=770)
- For associated duodenal atresia in stable child, would potentially fix duodenal atresia first to avoid fixing esophagus upstream from obstruction — Daniel von Allmen (clinical) [Ep 10 · 13:36](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=816)
- Both duodenal and esophageal atresia could potentially be fixed at same time if child is old enough and stable enough — Daniel von Allmen (clinical) [Ep 10 · 14:05](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=845)
- Von Allmen changed practice to always perform intraoperative bronchoscopy after exposure to Cincinnati's complex patient population — Daniel von Allmen (clinical) [Ep 10 · 14:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=875)
- Bronchoscopy documents fistula location, assesses for proximal fistula, and most importantly rules out laryngeal cleft which is easily missed — Daniel von Allmen (clinical) [Ep 10 · 14:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=875)
- Many referred patients with multiple thoracotomies never had bronchoscopy and actually have laryngeal cleft — Daniel von Allmen (clinical) [Ep 10 · 14:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=875)
- Second fistula occurs in approximately 1% of cases and can be very difficult to diagnose — Daniel von Allmen (epidemiological) [Ep 10 · 15:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=935)
- High fistulas can range from trifurcation of carina (suggesting difficulty getting ends together) to very high fistulas potentially approachable through neck — Daniel von Allmen (clinical) [Ep 10 · 15:52](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=952)
- Bronchoscopy allows guidance of ET tube placement by anesthesiologist based on fistula location — Daniel von Allmen (clinical) [Ep 10 · 16:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=995)
- For fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula but not into the fistula itself — Daniel von Allmen (clinical) [Ep 10 · 16:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=995)
- Extrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak — Daniel von Allmen (clinical) [Ep 10 · 17:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1039)
- Dividing azygos has no morbidity, gives better access, and frequently guides to the fistula — Daniel von Allmen (clinical) [Ep 10 · 17:41](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1061)
- Open azygos division is done by ligation and division; thoracoscopically can use energy devices or clips — Daniel von Allmen (clinical) [Ep 10 · 17:59](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1079)
- Hook cautery can safely divide vessels if done slowly going up and down to ensure coagulation, learned from robotic Nissen experience dividing short gastrics — Daniel von Allmen (clinical) [Ep 10 · 18:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1131)
- 3mm surgical sealer is ideal device for this size patient and vessel — Daniel von Allmen (opinion) [Ep 10 · 18:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1131)
- Spreading heel of right angle on ribs nicely shows extrapleural plane when going through intercostal muscles — Daniel von Allmen (clinical) [Ep 10 · 19:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1175)
- Important to mobilize pleura up around apex of lung to have access for proximal pouch mobilization — Daniel von Allmen (clinical) [Ep 10 · 19:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1175)
- After azygos division, identify distal esophagus and control with vessel loop, then dissect proximally to identify fistula site — Daniel von Allmen (clinical) [Ep 10 · 19:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1175)
- Muscle-sparing thoracotomy can make exposure more difficult; has not seen significant morbidity from standard posterolateral thoracotomy — Daniel von Allmen (opinion) [Ep 10 · 20:28](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1228)
- Standard teaching has been not to mobilize distal esophagus, but can actually mobilize it significantly especially laterally all the way to diaphragm — Daniel von Allmen (clinical) [Ep 10 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1270)
- Must be careful with medial mobilization of distal esophagus due to blood supply concerns — Daniel von Allmen (clinical) [Ep 10 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1270)
- Extensive proximal pouch mobilization gives the most length to get ends together — Daniel von Allmen (clinical) [Ep 10 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1270)
- Thoracoscopic approach advantage is clearer visualization for proximal pouch mobilization — Daniel von Allmen (opinion) [Ep 10 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1270)
- Proximal pouch dissection is similar to separating rectum and vagina - making two planes out of one without great natural separation — Todd Ponsky (clinical) [Ep 10 · 22:03](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1323)
- Risk of entering trachea during proximal dissection; must be very careful using blade cautery with light buzz and mostly blunt dissection with flat end of blade — Daniel von Allmen (clinical) [Ep 10 · 22:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1340)
- Better to be in esophagus than trachea during high chest dissection; esophagus is thickened from obstruction — Daniel von Allmen (clinical) [Ep 10 · 22:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1340)
- For significant tracheal defect, could perform sleeve resection as trachea is incredibly mobile, then place pericardium or autologous tissue between trachea and esophageal repair — Daniel von Allmen (clinical) [Ep 10 · 23:01](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1381)
- Personal preference is 5-0 PDS - absorbable monofilament suture; not a fan of silk — Daniel von Allmen (opinion) [Ep 10 · 23:59](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1439)
- Not a fan of myotomies as they potentially create even more dysfunctional esophageal segment; motility is already clearly abnormal in esophageal atresia — Daniel von Allmen (opinion) [Ep 10 · 24:42](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1482)
- For cases too tight for primary repair, would ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for couple weeks, then return to put together — Daniel von Allmen (clinical) [Ep 10 · 24:42](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1482)
- Traction or pressure is very strong stimulus to growth throughout cardiovascular system and lungs — Daniel von Allmen (clinical) [Ep 10 · 25:38](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1538)
- For thoracoscopic approach, can place traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing return within a week for anastomosis — Daniel von Allmen (clinical) [Ep 10 · 26:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1570)
- Would not do classic Foker technique with prolonged paralysis and sequential suture tensioning — Daniel von Allmen (opinion) [Ep 10 · 26:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1570)
- Rusty Jennings and Foker published series in JPS showing 98% success getting ends together in primary atresia versus only 67% in secondary approaches after previous surgeries — Daniel von Allmen (epidemiological) [Ep 10 · 27:38](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1658)
- Foker technique requires patients intubated and paralyzed spending weeks in ICU, which is probably worth it if you get good result — Daniel von Allmen (clinical) [Ep 10 · 27:38](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1658)
- For thoracoscopic procedure, rotate patient past 90 degrees to allow gravity to move lungs out of way — Daniel von Allmen (clinical) [Ep 10 · 29:18](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1758)
- Standard port placement: camera in center, posterior port inferiorly, anterior port superiorly — Daniel von Allmen (clinical) [Ep 10 · 29:18](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1758)
- Uses 3mm instruments for thoracoscopic TEF repair — Daniel von Allmen (clinical) [Ep 10 · 29:52](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1792)
- Important to do same quality operation thoracoscopically as would do open — Daniel von Allmen (opinion) [Ep 10 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810)
- Sewing the anastomosis is one of the challenges with thoracoscopic TEF repair and requires most experience with minimally invasive techniques — Daniel von Allmen (clinical) [Ep 10 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810)
- Would use clips for dividing fistula thoracoscopically, less worried about them falling off esophagus than blood vessel — Daniel von Allmen (opinion) [Ep 10 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810)
- Thoracoscopic visualization is very helpful for mobilizing proximal pouch — Daniel von Allmen (opinion) [Ep 10 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810)
- Simulation courses for TEF repair will be great advantage for trainees as these cases are not done often enough to get practice — Daniel von Allmen (opinion) [Ep 10 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1810)
- Marcelo Martinez Ferro's 'spaghetti trick' - grabbing and twirling tip of proximal pouch shows the dissection plane nicely — Todd Ponsky (clinical) [Ep 10 · 31:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1881)
- Vicryl ties down nice and tight but cannot use knot pusher for first stitch under tension as it will tear through esophagus; need monofilament for extracorporeal knots — Todd Ponsky (clinical) [Ep 10 · 32:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1930)
- Braided suture is safe for all intracorporeal technique — Todd Ponsky (clinical) [Ep 10 · 32:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1930)
- After clipping fistula, do not divide it completely until ready to place first stitch so distal esophagus doesn't drop toward diaphragm — Todd Ponsky (clinical) [Ep 10 · 32:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1965)
- Hanging stitch helps let go of some tension as first couple stitches are placed, providing some degree of approximation before throwing down first stitches — Avi Schlager (clinical) [Ep 10 · 33:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2001)
- Must be able to see and incorporate mucosa on every stitch; hanging stitch helps visualize lumen of both proximal and distal ends — Todd Ponsky (clinical) [Ep 10 · 33:54](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2034)
- Thoracoscopic ventilation management depends more on anesthesiologist than ventilator type; need anesthesiologist comfortable with procedure who pays attention during operation — Daniel von Allmen (clinical) [Ep 10 · 34:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2070)
- Can position ET tube after bronchoscopy to selectively ventilate left lung — Todd Ponsky (clinical) [Ep 10 · 34:48](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2088)
- Little CO2 insufflation with some time will collapse lung as long as anesthesiologist isn't fighting with positive pressure — Daniel von Allmen (clinical) [Ep 10 · 35:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2120)
- Anesthesiologists can get scared seeing initial shunting but things settle down if they wait — Daniel von Allmen (clinical) [Ep 10 · 35:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2120)
- Concern about reintubation exists, but equally concerned that positive pressure puts pressure on tracheal repair — Daniel von Allmen (clinical) [Ep 10 · 36:05](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2165)
- Prefer spontaneous breathing with negative pressure in trachea rather than positive pressure — Daniel von Allmen (opinion) [Ep 10 · 36:05](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2165)
- If patient had good lung function preoperatively and operation went smoothly, advocate extubating as soon as possible, even conceivably in operating room — Daniel von Allmen (clinical) [Ep 10 · 36:05](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2165)
- Gets contrast study at 5-7 days before pulling chest drain, timing depends on avoiding weekends — Daniel von Allmen (clinical) [Ep 10 · 36:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2195)
- Uses small TLS drain rather than formal chest tube, especially for open extrapleural approach — Daniel von Allmen (clinical) [Ep 10 · 36:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2195)
- Does not use transanastomotic tube based on Midwest Pediatric Surgical Consortium study showing much higher stricture and leak rate with transanastomotic tubes — Daniel von Allmen (clinical) [Ep 10 · 37:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2240)
- Midwest consortium study was presented at APSA and should be published in JPS soon — Daniel von Allmen (clinical) [Ep 10 · 37:37](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2257)
- Unless incredibly tight stricture risking complete obstruction, would wait several weeks before first dilation — Daniel von Allmen (clinical) [Ep 10 · 37:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2275)
- Always appears to be narrowing at anastomosis because proximal pouch is dilated; as long as patent with free contrast flow distally, would hold off on dilation — Daniel von Allmen (clinical) [Ep 10 · 37:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2275)
- Fairly aggressive with dilations: dilate, wait 1-2 weeks, restudy, potentially dilate again — Daniel von Allmen (clinical) [Ep 10 · 38:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2303)
- Huge spectrum from very tight strictures requiring many dilations to kids fine after one dilation — Daniel von Allmen (clinical) [Ep 10 · 38:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2303)
- If case goes well and post-op study looks great, does not get routine follow-up esophagrams; studies based on clinical symptoms suggesting stricture — Daniel von Allmen (clinical) [Ep 10 · 38:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2303)
- Balloon or radial dilation is less traumatic for tissue than bougie dilators — Daniel von Allmen (clinical) [Ep 10 · 39:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2359)
- Dilations done with GI colleagues in aerodigestive center for bigger kids or with interventional radiologists — Daniel von Allmen (clinical) [Ep 10 · 39:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2359)
- For small leak with child not sick, would absolutely wait and do nothing, leaving drain in; vast majority close — Daniel von Allmen (clinical) [Ep 10 · 39:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2391)
- Leak increases risk of postoperative stricture — Todd Ponsky (clinical) [Ep 10 · 40:04](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2404)
- Would only go to OR for leak if child getting sicker, wide open leak, or large uncontrollable pneumothorax — Daniel von Allmen (clinical) [Ep 10 · 40:09](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2409)
- Even reasonably significant leaks will heal, then can deal with stricture postoperatively — Daniel von Allmen (clinical) [Ep 10 · 40:09](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2409)
- Usually waits one week between esophagrams for leak; if child continues to do well, restudies — Daniel von Allmen (clinical) [Ep 10 · 40:34](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2434)
- Sometimes little outpouching where leak happened makes it unclear if still leaking; if nothing from tube and nothing goes further, leak probably healed and would remove tube — Daniel von Allmen (clinical) [Ep 10 · 40:34](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2434)
- Pediatric surgeons don't do fantastic job of long-term follow-up with TEF patients — Todd Ponsky (opinion) [Ep 10 · 41:09](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2469)
- International esophageal atresia meeting occurs every 2 years and is multidisciplinary including patients — Daniel von Allmen (clinical) [Ep 10 · 41:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2479)
- Patients in their 20s-40s at international meeting discuss long-term issues; surgeons tend to follow until eating well or age 18 then never see them again — Daniel von Allmen (clinical) [Ep 10 · 41:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2479)
- Have a lot to learn about long-term complications; personally follows patients for at least couple years which is probably not long enough — Daniel von Allmen (opinion) [Ep 10 · 41:19](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2479)
- Biggest challenges in long-term follow-up are reflux and recurrent strictures — Daniel von Allmen (clinical) [Ep 10 · 42:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2535)
- More concerning are patients with ongoing reflux due to unknown long-term impact on Barrett's esophagus and potential malignant change — Daniel von Allmen (clinical) [Ep 10 · 42:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2535)
- If patient has stricture dilated 2-3 times, next move would be to address reflux — Daniel von Allmen (clinical) [Ep 10 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2565)
- Most patients left on anti-reflux medications when discharged from hospital — Daniel von Allmen (clinical) [Ep 10 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2565)
- Virtually all patients have some degree of gastroesophageal reflux — Daniel von Allmen (clinical) [Ep 10 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2565)
- Very aggressive about fundoplication for strictures not responsive to dilations (dilates easily then restrictures) — Daniel von Allmen (clinical) [Ep 10 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2565)
- Does Nissen fundoplication in patients with poor esophageal motility but makes them loose and short, using 2 or at most 3 stitches — Daniel von Allmen (clinical) [Ep 10 · 43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2606)
- For pure esophageal atresia, approach is G-tube placement with calibration of gap length using distal catheter pushed up and NG tube in proximal pouch — Daniel von Allmen (clinical) [Ep 10 · 43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2606)
- Would wait 4-6 weeks to see how close ends come together, then attempt primary repair once within 2 vertebral bodies — Daniel von Allmen (clinical) [Ep 10 · 43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=2606)
- The retrospective data suggest no difference in leak rate or stricture rate between thoracoscopic and open TEF repair. — Alex Gibbons (clinical) [Ep 11 · 12:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=750)
- There is potential benefit with thoracoscopic approach in time to extubation, time to first oral feeding, overall hospital length of stay, and musculoskeletal sequelae. — Alex Gibbons (opinion) [Ep 11 · 12:45](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=765)
- The chief limitation of thoracoscopic TEF repair is the technical demand, specifically the challenge of the anastomosis done in situ. — Alex Gibbons (opinion) [Ep 11 · 13:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=780)
- There remains a need for a powered randomized controlled trial comparing thoracoscopic and open TEF repair. — Alex Gibbons (opinion) [Ep 11 · 13:15](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=795)
- The primary reason for doing thoracoscopic TEF repair is eliminating the thoracotomy and its associated morbidity. — Steven Rothenberg (opinion) [Ep 11 · 12:40](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=760)
- No matter what kind of thoracotomy is performed, there is morbidity associated with having a thoracotomy as an infant. — Steven Rothenberg (opinion) [Ep 11 · 12:55](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=775)
- In US training programs, fellows who are not as experienced as staff are being trained to do the TEF operation, making them perhaps the least experienced person in the operating room. (opinion) [Ep 11 · 15:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=930)
- In the multi-center report from 13-14 years ago, the surgeons were very experienced in MIS, which contributed to the good results (3 recurrences in 104 patients). (opinion) [Ep 11 · 16:10](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=970)
- Thoracoscopic TEF repair requires surgeons who are skilled in MIS to perform it and pass that skill on to trainees. — Steven Rothenberg (opinion) [Ep 11 · 16:33](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=993)
- Rothenberg reports he has never had to resect a diverticulum after thoracoscopic TEF repair, whereas he has had to resect a number of diverticulums that were all done open. — Steven Rothenberg (clinical) [Ep 11 · 17:50](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=1070)
- Thoracoscopically, the fistula is seen coming in directly at 90 degrees perpendicular, which is not seen when the operation is done open. — Steven Rothenberg (clinical) [Ep 11 · 18:10](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=1090)
- Less than half of esophageal atresia cases are detected antenatally, typically by small stomach and polyhydramnios. (epidemiological) [Ep 13 · 1:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=60)
- Echocardiography is performed preoperatively to rule out congenital heart defects and determine aortic arch sidedness (right vs. left). (clinical) [Ep 13 · 2:12](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=132)
- VACTERL workup (renal ultrasound, vertebral X-rays, anorectal exam) can be completed electively after initial repair. (clinical) [Ep 13 · 2:31](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=151)
- Right-sided aortic arch does not necessarily require left thoracotomy; multiple surgeons report successful repairs from the right side despite right arch. (clinical) [Ep 13 · 9:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=540)
- Echocardiography may misidentify aortic arch sidedness; one surgeon encountered a double arch after echo reported right arch. (clinical) [Ep 13 · 10:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=600)
- Preoperative bronchoscopy can identify double fistulas and predict gap length: fistula at mid-trachea suggests shorter gap, fistula at carina suggests longer gap. (clinical) [Ep 13 · 13:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=780)
- For thoracoscopic repair, bronchoscopy helps the surgeon understand fistula location and anticipate gap distance. (clinical) [Ep 13 · 14:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=840)
- Standard open approach uses right posterolateral thoracotomy, extrapleural dissection to vertebral bodies, with azygos vein as landmark for fistula location. (clinical) [Ep 13 · 17:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1020)
- For uncomplicated EA, tissue interposition between trachea and esophagus is not routinely used because adequate tissue is difficult to find. (clinical) [Ep 13 · 17:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1050)
- Chest tube is placed in extrapleural space on water seal (not suction) and removed after postoperative contrast study confirms no leak. (clinical) [Ep 13 · 18:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1080)
- Retrospective study of ~100 patients found no difference in complications between Vicryl and silk suture for EA repair. (clinical) [Ep 13 · 21:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1260)
- For thoracoscopic repair using knot-pusher technique, PDS must be used for the first stitch to avoid sawing through tissue; Vicryl can be used for intracorporeal ties. (clinical) [Ep 13 · 21:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1290)
- Approximately 75% of EA/TEF patients are candidates for thoracoscopic repair; complicated congenital heart disease may preclude thoracoscopic approach due to longer operative time. (clinical) [Ep 13 · 23:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1380)
- If the two esophageal ends cannot be approximated thoracoscopically, conversion to open is appropriate—surgeons get one good chance at primary repair. (opinion) [Ep 13 · 23:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1410)
- Babies under 2 kg are more difficult for thoracoscopic repair due to limited space for lung retraction and intracorporeal suturing. (clinical) [Ep 13 · 26:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1560)
- In US training programs, fellows typically perform 4-8 EA repairs during fellowship, raising questions about adequate thoracoscopic training volume. (epidemiological) [Ep 13 · 27:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1620)
- For thoracoscopic repair, ports should be spaced widely and staggered, with patient positioned more prone than lateral since esophagus is posterior mediastinal. (clinical) [Ep 13 · 29:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1740)
- High-frequency oscillatory ventilation in the OR keeps the lung collapsed during thoracoscopic repair; disadvantage is the baby shaking, but hypercarbia is avoided. (clinical) [Ep 13 · 30:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1800)
- C1 or TF needles (5-0 PDS) are preferred for thoracoscopic EA repair due to appropriate curve and ability to pass through 5-6mm trocars without tip damage. (clinical) [Ep 13 · 34:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2040)
- Starting the anastomosis at the lateral (far) corner is most common; some start with a middle back-row stitch tied intracorporeally. (clinical) [Ep 13 · 34:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2070)
- The first anastomotic stitch does not need to be tied tight; subsequent stitches are tightened once approximation is confirmed. (clinical) [Ep 13 · 35:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2130)
- Exteriorizing the first stitch through the chest wall with a hemostat can help bring the gap closer before placing subsequent sutures. (clinical) [Ep 13 · 36:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2160)
- For long-gap atresia (pure EA with gasless abdomen), G-tube placement allows gap assessment; if gap is ≤2 vertebral bodies, primary repair is attempted. (clinical) [Ep 13 · 37:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2250)
- Interventional radiology can pass a wire and catheter up the distal esophagus via G-tube to define the gastroesophageal junction and measure gap accurately. (clinical) [Ep 13 · 38:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2280)
- Cervical esophagostomy commits the patient to esophageal replacement; most surgeons avoid it and attempt delayed primary anastomosis. (opinion) [Ep 13 · 38:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2310)
- For long-gap EA, waiting up to 3 months with G-tube feeds (advancing to bolus feeds to encourage distal esophageal growth) is reasonable before declaring the gap irreparable. (clinical) [Ep 13 · 39:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2340)
- Routine bougienage of the proximal pouch does not reliably promote esophageal growth; growth occurs spontaneously over time. (opinion) [Ep 13 · 39:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2340)
- For thoracoscopic TEF repair, spk_0 assesses the gap between proximal and distal esophagus preoperatively using bronchoscopy (to identify the fistula orifice) followed by X-ray with the bronchoscope in place and a gastric tube, measuring the gap in vertebral body units. — Yama (clinical) [Ep 12 · 0:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=0)
- In the presented case, the gap between proximal and distal esophagus was approximately one vertebral body. — Yama (clinical) [Ep 12 · 2:12](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=132)
- The majority of surgeons divide the distal esophagus completely during TEF repair, but spk_0 leaves one quarter of the fistula uncut. — Yama (clinical) [Ep 12 · 2:31](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=151)
- If the distal esophagus is divided completely, it can retract cranially and anastomosis becomes more difficult. — Yama (clinical) [Ep 12 · 3:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=180)
- Leaving one quarter of the fistula uncut provides fixation of the distal esophagus and makes it easier to grasp the mucosa during anastomosis. — Yama (clinical) [Ep 12 · 3:20](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=200)
- spk_0 does not cut all of the tip of the proximal esophagus; he leaves one-quarter to one-fifth of the cap of the proximal esophagus to grab with forceps, avoiding grasping the anastomotic site. — Yama (clinical) [Ep 12 · 3:50](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=230)
- If there is a 1-3 vertebral body gap, the assistant can pull the proximal esophagus caudally using the uncut cap. — Yama (clinical) [Ep 12 · 4:20](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=260)
- spk_0 places the first anastomotic stitch in the middle of the posterior wall, not at the edge, finding this easier especially with his technique. — Yama (clinical) [Ep 12 · 4:47](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=287)
- spk_0 uses 6-0 or 5-0 PDS suture for the anastomosis. — Yama (clinical) [Ep 12 · 7:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=450)
- The mucosa of both proximal and distal esophagus must be included in the anastomotic stitches; otherwise the patient will have postoperative stenosis. — Yama (clinical) [Ep 12 · 7:40](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=460)
- spk_0 divides the tracheoesophageal fistula completely after placing one or two anastomotic stitches. — Yama (clinical) [Ep 12 · 8:40](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=520)
- spk_0 divides the uncut cap of the proximal esophagus after placing 2-3 anastomotic stitches. — Yama (clinical) [Ep 12 · 9:00](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=540)
- spk_0 does not touch the site of the anastomosis in the proximal and distal esophagus during his technique. — Yama (clinical) [Ep 12 · 9:20](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=560)
- spk_1 tried spk_0's technique after seeing the video in September and found it worked well, though he was uncertain how much he needed the traction provided by the uncut tissue. (opinion) [Ep 12 · 9:45](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=585)
- spk_1 suggests there is no downside to leaving the last bit of fistula uncut initially; if the stitch sets up perfectly, it can be taken, and if not, it can be cut and the anastomosis completed. (opinion) [Ep 12 · 10:40](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=640)
- David Vanderzee (spk_2) thinks leaving the fistula partially connected to the trachea initially might be helpful, but his group does not do it. — David Vanderzee (opinion) [Ep 12 · 11:13](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=673)
- David Vanderzee's group uses a transfixing suture to close the fistula to ensure it does not come off, and never uses clips because they tend to hook behind the anastomotic suture. — David Vanderzee (clinical) [Ep 12 · 11:30](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=690)
- For type C esophageal atresia with considerable length, David Vanderzee's group puts in two sutures, makes them into sliding knots, and slowly brings the esophageal ends together, dividing tension between the two ends. — David Vanderzee (clinical) [Ep 12 · 11:55](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=715)
- David Vanderzee's group finalizes the posterior anastomosis before putting through a tube and closing the anterior wall. — David Vanderzee (clinical) [Ep 12 · 12:25](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=745)
- Jeff Blair (spk_3) speculates that in the next decade, mechanical devices may be used to grab and seal the lower esophageal pouch via the upper pouch, possibly with thoracoscopic or imaging facilitation. — Jeff Blair (opinion) [Ep 12 · 15:06](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=906)
- Suet (spk_4) found it much easier to identify the fistula laparoscopically (likely meant thoracoscopically) and to appreciate how much esophagus to leave on the tracheal side. — Suet (opinion) [Ep 12 · 15:40](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=940)
- Suet found dissecting the upper segment of the esophagus difficult, particularly in handling the esophagus without damaging the wall needed for anastomosis. — Suet (opinion) [Ep 12 · 16:10](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=970)
- Sharif (spk_5), who started doing thoracoscopic TEF a year ago and has done three cases, finds the dissection and fistula division phase easy but the anastomotic phase difficult. — Sharif (opinion) [Ep 12 · 16:34](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=994)
- spk_1 has had a clip erode into the esophagus in his experience. (clinical) [Ep 12 · 17:40](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1060)
- spk_1 uses metal clips for fistula closure. (clinical) [Ep 12 · 18:10](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1090)
- spk_1 has tried Weck Hema-lock clips 2-3 times but finds the clip applier too large, reducing visualization compared to the metal clip applier. (opinion) [Ep 12 · 18:20](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1100)
- Weck Hema-lock clips are not easy to remove if their position is unsatisfactory. (clinical) [Ep 12 · 18:40](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1120)
- spk_0 believes that if the fistula is clipped very tightly, it will erode the muscle of the esophagus, but if the clip is applied just to oppose (not crush), it does not cause erosion. — Yama (opinion) [Ep 12 · 18:50](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1130)
- Tight clipping may crush the esophageal muscle, erode it, and cause recurrence of the fistula. — Yama (opinion) [Ep 12 · 18:50](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1130)
- Cincinnati Children's has a multidisciplinary aerodigestive center that includes ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians — Daniel von Allmen (clinical) [Ep 14 · 2:01](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=121)
- The aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway pathways — Daniel von Allmen (clinical) [Ep 14 · 2:46](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=166)
- Physical examination findings in suspected esophageal atresia include assessment for scaphoid versus distended abdomen and respiratory distress — Daniel von Allmen (clinical) [Ep 14 · 3:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=235)
- Personal confirmation of NG tube passage is important as some patients started on treatment for esophageal atresia are later found to have tubes that pass normally — Daniel von Allmen (clinical) [Ep 14 · 4:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=260)
- Injecting air into the NG tube and obtaining a plain film helps visualize the proximal pouch and assess GI tract gas pattern — Daniel von Allmen (clinical) [Ep 14 · 4:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=295)
- Lack of visible distended proximal pouch on plain film raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression — Daniel von Allmen (clinical) [Ep 14 · 5:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=310)
- Contrast studies can be performed when there is high suspicion of anatomic variants, with no contraindication as long as radiologist is aware of potential obstruction — Daniel von Allmen (clinical) [Ep 14 · 5:42](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=342)
- Preoperative echocardiogram is essential to assess cardiac anatomy and rule out right-sided aortic arch — Daniel von Allmen (clinical) [Ep 14 · 6:25](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=385)
- Renal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia — Daniel von Allmen (clinical) [Ep 14 · 6:54](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=414)
- Conventional wisdom for right-sided aortic arch is to perform left thoracotomy rather than right thoracotomy — Daniel von Allmen (guideline) [Ep 14 · 7:27](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=447)
- Left thoracotomy for right-sided arch is somewhat more difficult with heart more in the way and harder proximal pouch mobilization — Daniel von Allmen (clinical) [Ep 14 · 7:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=471)
- It is possible to complete the repair from right thoracotomy even with right-sided arch, though some reports suggest higher incidence of swallowing problems — Daniel von Allmen (clinical) [Ep 14 · 8:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=500)
- In stable larger babies not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting until the next day — Daniel von Allmen (clinical) [Ep 14 · 9:31](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=571)
- Prolonged delay should be avoided due to concern for colonizing GI tract and soiling lungs — Daniel von Allmen (clinical) [Ep 14 · 9:56](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=596)
- Oscillator ventilation has not been found to make significant difference in managing unstable TEF patients — Daniel von Allmen (clinical) [Ep 14 · 10:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=615)
- Air preferentially entering GI tract versus lungs tends to be a bigger problem in more premature infants with significant lung disease and poor lung compliance — Daniel von Allmen (clinical) [Ep 14 · 10:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=635)
- Treating with surfactant and improving lung compliance helps as much as changing ventilator type in managing air leak through fistula — Daniel von Allmen (clinical) [Ep 14 · 10:56](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=656)
- Risk of waiting too long to make a decision in deteriorating patient can lead to emergency situation where ventilation becomes impossible — Daniel von Allmen (clinical) [Ep 14 · 11:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=681)
- For reasonably stable but worsening patient, approach is urgent right thoracotomy with fistula ligation — Daniel von Allmen (clinical) [Ep 14 · 11:40](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=700)
- Bronchoscopic placement of Fogarty balloon in fistula is difficult unless expertise and equipment are immediately available — Daniel von Allmen (clinical) [Ep 14 · 12:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=720)
- G-tube decompression may paradoxically worsen ventilation by making stomach lower resistance path, allowing more air to go there rather than to lungs — Daniel von Allmen (clinical) [Ep 14 · 12:25](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=745)
- Laparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize unstable patient for several days — Daniel von Allmen (clinical) [Ep 14 · 12:50](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=770)
- In stable child with associated duodenal atresia, consider fixing duodenal atresia first to avoid repairing esophagus upstream from obstruction — Daniel von Allmen (clinical) [Ep 14 · 13:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=831)
- Both esophageal and duodenal atresia can potentially be repaired in same operative setting if child is stable enough — Daniel von Allmen (clinical) [Ep 14 · 14:13](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=853)
- Routine intraoperative bronchoscopy is important to document fistula location, assess for proximal fistula, and rule out laryngeal cleft — Daniel von Allmen (clinical) [Ep 14 · 14:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=875)
- Laryngeal clefts are easily missed and have been seen many times in referred patients who had multiple thoracotomies without anyone doing bronchoscopy — Daniel von Allmen (clinical) [Ep 14 · 15:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=910)
- Second fistulas are very uncommon, occurring in perhaps 1% of cases, and can be difficult to diagnose — Daniel von Allmen (epidemiological) [Ep 14 · 15:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=930)
- High fistulas can be seen bronchoscopically ahead of time and range from trifurcation of carina to fistulas potentially approachable through the neck — Daniel von Allmen (clinical) [Ep 14 · 15:52](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=952)
- Bronchoscopy allows guidance of anesthesiologist for ET tube placement relative to fistula location — Daniel von Allmen (clinical) [Ep 14 · 16:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=995)
- For fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula — Daniel von Allmen (clinical) [Ep 14 · 17:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1020)
- Extrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak — Daniel von Allmen (clinical) [Ep 14 · 17:16](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1036)
- Dividing azygos vein has no morbidity and gives better access, frequently guiding to the fistula — Daniel von Allmen (clinical) [Ep 14 · 17:41](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1061)
- For open repair, azygos is typically ligated and divided with suture — Daniel von Allmen (clinical) [Ep 14 · 17:59](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1079)
- Spreading intercostal muscles with heel of right angle on ribs nicely shows extrapleural plane — Daniel von Allmen (clinical) [Ep 14 · 19:35](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1175)
- Mobilizing pleura up around apex of lung is important to have access for proximal pouch mobilization — Daniel von Allmen (clinical) [Ep 14 · 20:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1200)
- Distal esophageal segment is controlled with vessel loop to allow proximal dissection to identify fistula — Daniel von Allmen (clinical) [Ep 14 · 20:24](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1224)
- Standard teaching has been not to mobilize distal esophagus, but it can be mobilized extensively laterally and to some degree medially with care for blood supply — Daniel von Allmen (clinical) [Ep 14 · 21:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1270)
- Extensive proximal pouch mobilization is most important for gaining length to approximate the ends — Daniel von Allmen (clinical) [Ep 14 · 21:40](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1300)
- Proximal pouch dissection is similar to separating rectum and vagina, making two planes out of one with risk of entering trachea if not careful — Todd Ponsky (clinical) [Ep 14 · 22:03](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1323)
- Blade electrocautery with light buzz and mostly blunt dissection with flat end of blade, staying right on thickened obstructed esophagus, is preferred technique for proximal dissection — Daniel von Allmen (clinical) [Ep 14 · 22:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1340)
- Better to be in esophagus than in trachea high in chest during proximal dissection — Daniel von Allmen (clinical) [Ep 14 · 22:44](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1364)
- Large tracheal defect would require sleeve resection, with trachea being incredibly mobile, and placement of pericardium or autologous tissue between trachea and esophageal repair — Daniel von Allmen (clinical) [Ep 14 · 22:51](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1371)
- Personal preference is 5-0 PDS for anastomosis, favoring absorbable monofilament over silk or other sutures — Daniel von Allmen (opinion) [Ep 14 · 23:59](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1439)
- Circular myotomies are not favored as they potentially create even more dysfunctional esophageal segment in patients who already have abnormal motility — Daniel von Allmen (opinion) [Ep 14 · 24:42](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1482)
- For long-gap cases, approach is to ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for several weeks, then return for anastomosis — Daniel von Allmen (clinical) [Ep 14 · 25:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1510)
- Traction or pressure is a strong stimulus to growth throughout the body including cardiovascular system and lungs — Daniel von Allmen (clinical) [Ep 14 · 25:38](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1538)
- Internal Foker technique uses traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing rapid lengthening within about a week — Daniel von Allmen (clinical) [Ep 14 · 26:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1560)
- Boston series by Jennings and Foker showed 98% success getting ends together in primary atresia versus only 67% in secondary cases after previous surgeries — Daniel von Allmen (epidemiological) [Ep 14 · 27:38](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1658)
- Foker technique requires patients to be intubated and paralyzed, spending weeks in ICU, which is significant cost but may be worth it for good result — Daniel von Allmen (clinical) [Ep 14 · 28:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1690)
- For thoracoscopic approach, patient is rotated past 90 degrees to allow gravity to move lungs out of the way — Daniel von Allmen (clinical) [Ep 14 · 29:18](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1758)
- Standard thoracoscopic port placement uses camera in center with posterior port inferiorly and anterior port superiorly — Daniel von Allmen (clinical) [Ep 14 · 29:40](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1780)
- 3mm instruments are used for thoracoscopic TEF repair — Daniel von Allmen (clinical) [Ep 14 · 29:52](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1792)
- Thoracoscopic visualization is very helpful for mobilizing proximal pouch — Daniel von Allmen (clinical) [Ep 14 · 30:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1810)
- Anastomosis is the most difficult part of thoracoscopic repair, requiring significant experience with minimally invasive suturing techniques — Daniel von Allmen (clinical) [Ep 14 · 30:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1830)
- Clips are preferred for dividing fistula thoracoscopically, with less concern about them falling off esophagus than blood vessels — Daniel von Allmen (opinion) [Ep 14 · 31:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1860)
- Hook electrocautery can safely divide vessels if used carefully with up-and-down motion ensuring coagulation — Daniel von Allmen (clinical) [Ep 14 · 31:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1881)
- 3mm surgical sealer is ideal device for this size patient and vessel size — Daniel von Allmen (opinion) [Ep 14 · 31:50](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1910)
- Spaghetti trick described by Martinez Ferro involves grabbing tip of proximal pouch and twirling it to show dissection plane — Todd Ponsky (clinical) [Ep 14 · 31:37](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1897)
- Hanging stitch technique (first stitch brought out of chest) helps line up anastomosis similar to duodenal atresia repair — Daniel von Allmen (clinical) [Ep 14 · 32:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1920)
- Vicryl ties down nicely but cannot use knot pusher for first stitch under tension as it will tear through esophagus; monofilament needed for knot pusher technique — Todd Ponsky (clinical) [Ep 14 · 32:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1950)
- Fistula should not be completely divided distally after clipping until ready to place first stitch, preventing it from dropping toward diaphragm — Todd Ponsky (clinical) [Ep 14 · 33:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=1980)
- Hanging stitch helps release tension as first stitches are placed and allows visualization of mucosa in both proximal and distal lumens — Daniel von Allmen (clinical) [Ep 14 · 33:54](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2034)
- Incorporating mucosa on every stitch is critical and easier to verify with thoracoscopic visualization — Daniel von Allmen (clinical) [Ep 14 · 34:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2055)
- Ventilator management is more dependent on anesthesiologist comfort and attention than ventilator type — Daniel von Allmen (clinical) [Ep 14 · 34:23](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2063)
- Anesthesiologist must understand goals and pay attention during operation, as they can significantly help or hurt with ventilation approach — Daniel von Allmen (clinical) [Ep 14 · 34:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2085)
- Little CO2 insufflation with time will collapse lung as long as anesthesiologist is not fighting with positive pressure — Daniel von Allmen (clinical) [Ep 14 · 35:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2120)
- Concern about reintubation is balanced by greater concern that positive pressure puts pressure on tracheal repair — Daniel von Allmen (clinical) [Ep 14 · 35:58](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2158)
- Spontaneous breathing creates negative pressure in trachea, which is preferable to positive pressure on repair — Daniel von Allmen (clinical) [Ep 14 · 36:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2175)
- For patients with good preoperative lung function and smooth operation, advocate extubating as soon as possible, even in operating room — Daniel von Allmen (clinical) [Ep 14 · 36:34](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2194)
- Contrast esophagram is obtained at 5-7 days postoperatively before pulling chest drain — Daniel von Allmen (clinical) [Ep 14 · 36:43](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2203)
- Small TLS drains are used rather than formal chest tube, especially for open extrapleural approach — Daniel von Allmen (clinical) [Ep 14 · 37:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2235)
- Trans-anastomotic tubes are not used based on Midwest Pediatric Surgical Consortium study showing much higher stricture and leak rates with their use — Daniel von Allmen (clinical) [Ep 14 · 37:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2240)
- Unless stricture is incredibly tight, would wait several weeks before first dilation to avoid complete obstruction — Daniel von Allmen (clinical) [Ep 14 · 37:53](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2273)
- Proximal pouch is always dilated so there is always reported narrowing at anastomosis; as long as contrast flows freely distally, can wait on dilation — Daniel von Allmen (clinical) [Ep 14 · 38:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2295)
- Fairly aggressive dilation approach: dilate, wait 1-2 weeks, restudy, potentially dilate again — Daniel von Allmen (clinical) [Ep 14 · 38:40](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2320)
- If case goes well and post-op study looks great, do not get routine follow-up esophagrams; study only based on clinical symptoms suggesting stricture — Daniel von Allmen (clinical) [Ep 14 · 39:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2340)
- Balloon or radial dilation is less traumatic to tissue than bougie dilators — Daniel von Allmen (clinical) [Ep 14 · 39:21](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2361)
- For small leak in non-sick child, absolutely wait and do nothing, leaving drain in place; vast majority close spontaneously — Daniel von Allmen (clinical) [Ep 14 · 39:44](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2384)
- Small leaks increase risk of postoperative stricture — Todd Ponsky (clinical) [Ep 14 · 40:04](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2404)
- Indications for operative intervention for leak are child getting sicker, wide open leak, or large uncontrollable pneumothorax — Daniel von Allmen (clinical) [Ep 14 · 40:09](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2409)
- Even reasonably significant leaks will heal, then stricture can be dealt with postoperatively — Daniel von Allmen (clinical) [Ep 14 · 40:34](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2434)
- Typically wait one week between esophagrams for leak, though timing is somewhat arbitrary — Daniel von Allmen (clinical) [Ep 14 · 40:40](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2440)
- Pediatric surgeons do not do a fantastic job of long-term follow-up with TEF patients — Daniel von Allmen (opinion) [Ep 14 · 41:11](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2471)
- International esophageal atresia meetings show patients in their 20s-40s with long-term issues that surgeons are unaware of because patients are lost after age 18 — Daniel von Allmen (clinical) [Ep 14 · 41:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2490)
- Personal practice is to follow patients for at least a couple years, which is probably not long enough — Daniel von Allmen (opinion) [Ep 14 · 42:15](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2535)
- Patients with ongoing reflux are more concerning than those with recurrent strictures due to unknown long-term impact on Barrett's esophagus and malignant change risk — Daniel von Allmen (opinion) [Ep 14 · 42:30](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2550)
- Most patients are discharged on anti-reflux medications — Daniel von Allmen (clinical) [Ep 14 · 42:45](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2565)
- Virtually all TEF patients have some degree of gastroesophageal reflux — Daniel von Allmen (clinical) [Ep 14 · 42:55](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2575)
- After 2-3 dilations for recurrent stricture, next move is to address reflux with fundoplication — Daniel von Allmen (clinical) [Ep 14 · 43:10](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2590)
- For patients with poor esophageal motility, still perform Nissen but make it loose and short using 2 or at most 3 stitches — Daniel von Allmen (clinical) [Ep 14 · 43:26](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2606)
- For pure esophageal atresia, approach is G-tube placement with gap calibration using distal catheter and proximal NG tube — Daniel von Allmen (clinical) [Ep 14 · 43:56](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2636)
- Wait 4-6 weeks to see how close ends come together, then attempt primary repair once within 2 vertebral bodies — Daniel von Allmen (clinical) [Ep 14 · 44:20](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=2660)
- For thoracoscopic EA/TEF repair, the gap between proximal and distal esophagus should be assessed preoperatively using X-ray with nasogastric tube and bronchoscope positioning to identify the fistula orifice. — Yama (clinical) [Ep 15 · 0:00](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=0)
- Leaving one-quarter of the fistula uncut prevents cranial retraction of the distal esophagus and makes anastomosis easier. — Yama (clinical) [Ep 15 · 2:00](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=120)
- Preserving one-fifth to one-quarter of the proximal esophageal tip provides a 'cap' for grasping without touching the anastomotic site. — Yama (clinical) [Ep 15 · 3:00](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=180)
- If there is a 1-2 to 3 vertebral body gap, the assistant can pull the proximal esophagus caudally using the uncut cap. — Yama (clinical) [Ep 15 · 3:20](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=200)
- The first stitch should be placed in the middle of the posterior wall rather than at the edge. — Todd Ponsky (clinical) [Ep 15 · 4:48](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=288)
- Optical trocars are used for initial port insertion in this technique. — Yama (clinical) [Ep 15 · 5:38](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=338)
- The mucosa of the distal esophagus must be included in sutures to prevent postoperative stenosis. — Yama (clinical) [Ep 15 · 7:30](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=450)
- The tracheoesophageal fistula is divided completely after 1-2 stitches are placed. — Yama (clinical) [Ep 15 · 8:40](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=520)
- The uncut cap of the proximal esophagus is divided after 2-3 stitches are placed. — Yama (clinical) [Ep 15 · 9:10](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=550)
- 6-0 PDS suture is used for the anastomosis. — Yama (clinical) [Ep 15 · 7:30](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=450)
- Todd Ponsky tried Yama's technique after seeing the video in September and found it worked well, though he was uncertain how much the traction contributed versus standard technique. — Todd Ponsky (opinion) [Ep 15 · 9:49](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=589)
- There is no downside to leaving the last bit of fistula attached—if the stitch sets up perfectly, it can be taken; if not, it can be cut. — Todd Ponsky (opinion) [Ep 15 · 10:30](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=630)
- David Vanderzee uses a transfixing suture to close the fistula rather than clips to ensure it doesn't come off. — David Vanderzee (clinical) [Ep 15 · 11:17](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=677)
- David Vanderzee avoids clips because they tend to hook behind the suture being used for anastomosis. — David Vanderzee (clinical) [Ep 15 · 11:50](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=710)
- For type C anastomosis with considerable length, David Vanderzee places two sutures and makes them into sliding knots to slowly bring the ends together, dividing tension between the two ends. — David Vanderzee (clinical) [Ep 15 · 12:10](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=730)
- David Vanderzee finalizes the posterior anastomosis before placing a tube and closing the anterior wall. — David Vanderzee (clinical) [Ep 15 · 12:20](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=740)
- Jeff Blair predicts that in the next decade, mechanical devices will be developed that can be passed through the upper pouch to mechanically grab and seal the lower pouch, possibly with thoracoscopic or imaging guidance. — Jeff Blair (opinion) [Ep 15 · 14:32](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=872)
- Suet found the fistula much easier to identify and appreciate laparoscopically, allowing better assessment of how much esophagus to leave on the tracheal side. — Suet (clinical) [Ep 15 · 15:18](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=918)
- Suet found dissecting the upper esophageal segment difficult, particularly in handling the esophagus without damaging the wall needed for anastomosis. — Suet (clinical) [Ep 15 · 16:10](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=970)
- Todd Ponsky's experience with thoracoscopic TEF repair (3 cases over one year) has been that the first half during dissection and fistula division feels advantageous, but the anastomosis phase makes him question the approach. — Todd Ponsky (opinion) [Ep 15 · 16:37](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=997)
- Todd Ponsky has experienced a clip eroding into the esophagus. — Todd Ponsky (clinical) [Ep 15 · 17:29](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=1049)
- Todd Ponsky uses metal clips, the same type Steve Rothenberg uses. — Todd Ponsky (clinical) [Ep 15 · 18:02](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=1082)
- Weck Hema lock clips are used by many surgeons, but the applier is large and impairs visualization compared to metal clip appliers. — Todd Ponsky (clinical) [Ep 15 · 18:05](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=1085)
- Weck Hema lock clips are difficult to remove if their position is unsatisfactory. — Todd Ponsky (clinical) [Ep 15 · 18:15](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=1095)
- If the fistula clip is applied very tightly, it will crush the esophageal muscle and cause erosion, leading to recurrent fistula; the clip should just oppose the tissue rather than crush it. — Yama (clinical) [Ep 15 · 18:28](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=1108)
- 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 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 17 · 8:57](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=537)
- Blind probing of the distal esophagus in long-gap EA can inadvertently push the diaphragm of an infant all the way up to the upper chest cavity without causing perforation, leading to overestimation of the gap. (clinical) [Ep 19 · 0:04](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=4)
- The gastroesophageal junction in pure long-gap esophageal atresia is very tiny and requires manipulation of the scope to enter, as it tends to flip out. (clinical) [Ep 19 · 0:04](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=4)
- Using an endoscope to measure the gap does not allow objective measurement of the boost force applied, unlike using a Hegar dilator with force measurement. — Bagalo (clinical) [Ep 19 · 1:20](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=80)
- Gap measurement should wait at least 15 days after gastrostomy placement before the first measurement, using a Hegar number 4 dilator after endoscopic confirmation of the cardia location. — Bagalo (clinical) [Ep 19 · 1:20](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=80)
- Some babies with long-gap EA have no cardia at all. — Bagalo (clinical) [Ep 19 · 1:20](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=80)
- A contrast study performed at 3 weeks after gastrostomy placement, even in Trendelenburg position, may not fill the distal esophageal segment completely, giving a false sense of the real gap. (clinical) [Ep 19 · 2:51](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=171)
- Professor Spitz would not perform a cervical esophagostomy immediately in a gasless abdomen case, but would wait a couple of weeks to assess the gap using a Hagar or urethral dilator under fluoroscopic control. — Spitz (clinical) [Ep 19 · 4:00](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=240)
- Professor Spitz would opt for esophageal replacement if the gap is more than 5 or 6 vertebrae at 4 to 6 weeks. — Spitz (clinical) [Ep 19 · 4:00](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=240)
- Miguel's approach is to place a laparoscopic gastrostomy, measure the gap every 2 weeks until it is less than 2 vertebral bodies, and start thinking about replacement if this is not achieved by 8 weeks. — Miguel (clinical) [Ep 19 · 4:48](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=288)
- Professor Bagalo performs gastrostomy at birth and gap measurement every 15 days until 6 weeks, at which point delayed anastomosis is generally possible for inborn babies. — Bagalo (clinical) [Ep 19 · 5:10](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=310)
- Holger endoscopes all long-gap patients to intubate the lower esophageal sphincter and assess both the length and quality of the lumen. — Holger (clinical) [Ep 19 · 5:41](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=341)
- Holger clips the fistula and leaves it attached, waiting to observe for spontaneous growth, then assesses with endoscope in both upper and lower pouches; if the gap is less than 3 vertebral bodies or centimeters, he proceeds with primary repair. — Holger (clinical) [Ep 19 · 5:41](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=341)
- Jack's institution has interventional radiology place the G-tube and check the gap using a wire threaded through the G-tube into the esophagus, checking every month and allowing up to 3 months for the ends to grow close enough together. — Jack (clinical) [Ep 19 · 6:44](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=404)
- Dr. Folker's institution performs an unstressed gappogram with contrast above and into the lower esophagus to assess the gap, and proceeds with operation once the child is 3 to 3.5 kg and sturdy if the lower esophageal segment is fairly good size. — Holger (clinical) [Ep 19 · 7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462)
- If after mobilization the tension is judged to be more than desired, Dr. Folker places the esophageal ends on internal traction and waits one week, during which significant growth is achieved and the ends can then be anastomosed. — Holger (clinical) [Ep 19 · 7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462)
- Even esophageal ends that are 2 to 4 millimeters in size, when placed on traction, will grow into a serviceable esophagus. — Holger (clinical) [Ep 19 · 7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462)
- Dr. Folker's first patient from Boston was reported to have a gap of 2 centimeters, but this was due to pushing the diaphragm up into the chest; the actual distal esophagus was only a 5 to 6 millimeter nubbin. — Holger (clinical) [Ep 19 · 7:42](https://library.globalcastmd.com/watch/long-gap-discussion-ea-tef-1077?t=462)
- Transpleural vs. retropleural approach makes no difference in modern era with antibiotics; historical preference for retropleural was to reduce mediastinitis risk if leak occurred — Corn (clinical) [Ep 18 · 1:41](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=101)
- Cameron Haight's first successful EA repair in 1941 used left thoracotomy with rib resection and extrapleural approach due to absence of antibiotics — Corn (clinical) [Ep 18 · 1:41](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=101)
- Technique for proximal pouch dissection: place Replogle tube in upper pouch, have anesthesiologist push down to visualize tip, place traction stitch through pouch tip and tube (not esophagus itself) to enable lateral traction and visualization of plane between membranous trachea and medial esophageal wall — Corn (clinical) [Ep 18 · 3:15](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=195)
- When uncertain of plane during proximal dissection, err on side of cutting esophageal muscle rather than risking membranous trachea injury — Corn (clinical) [Ep 18 · 4:20](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=260)
- Water-soluble contrast study of upper pouch can detect proximal fistula: narrower-than-expected upper pouch suggests proximal fistula (pouch doesn't enlarge in utero when fistula present) — Corn (clinical) [Ep 18 · 6:16](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=376)
- Proximal fistulas are far more common than realized; many cases called 'pure long-gap EA' are actually cases with missed upper pouch fistula — Corn (clinical) [Ep 18 · 7:22](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=442)
- Does not routinely perform bronchoscopy unless suspicious; has seen one proximal fistula in 20 years; priority is rapid control of distal fistula before baby decompensates — Steve (opinion) [Ep 18 · 7:24](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=444)
- Has seen babies decompensate during bronchoscopy, making urgent fistula control more difficult — Steve (clinical) [Ep 18 · 8:00](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=480)
- During proximal dissection, can inadvertently push upper pouch fistula out of the way with blunt dissection (Q-tip), missing it entirely; fistulas typically sit at cervicothoracic junction — Miguel (clinical) [Ep 18 · 8:22](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=502)
- Has seen at least three patients referred for 'recurrent TEF' where fistula was actually a missed upper pouch fistula from initial repair by experienced surgeons — Todd Ponsky (clinical) [Ep 18 · 9:06](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=546)
- Bronchoscopy assesses vocal cord motility preoperatively (some patients have congenital vocal cord paresis/paralysis) and measures gap even in type C EA; meta-analysis shows >50% of long gaps occur in type C — Bagulo (clinical) [Ep 18 · 12:45](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=765)
- Incidence of upper pouch fistula in standard type C EA is 1-2%, vs. 13-15% in EA without distal fistula (no gas in stomach); bronchoscopy mandatory in latter group, selective in former — Louis Spitz (epidemiological) [Ep 18 · 14:16](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=856)
- In type C EA, must ligate distal fistula regardless, so can evaluate upper pouch directly at surgery; preoperative bronchoscopy does not change management — Steve (opinion) [Ep 18 · 16:14](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=974)
- Meta-analyses on long-gap EA are problematic because studies use inconsistent definitions; some papers call 2.5cm gaps 'long gap' when most surgeons would not — Todd Ponsky (opinion) [Ep 18 · 16:59](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1019)
- Preoperative objective gap measurement would allow standardized assessment and comparison of outcomes across centers — Bagulo (opinion) [Ep 18 · 18:25](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1105)
- Case example: thoracoscopic repair where fistula inserted very high into trachea (3-4cm above carina), causing intraoperative confusion about leaving diverticulum vs. entering membranous trachea; preoperative bronchoscopy would have helped — Todd Ponsky (clinical) [Ep 18 · 19:38](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1178)
- Myth that distal pouch should not be extensively dissected is false; primary goal is minimizing anastomotic tension to prevent leaks — Corn (opinion) [Ep 18 · 22:06](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1326)
- 70% of recurrent TEF cases had previous anastomotic leak after initial repair — Corn (epidemiological) [Ep 18 · 22:40](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1360)
- Distal pouch should be dissected as far as necessary, even to diaphragmatic hiatus, to achieve tension-free anastomosis — Corn (clinical) [Ep 18 · 22:55](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1375)
- Robert Gross's 1953 textbook states: 'don't hesitate to dissect as far down on lower segment as needed to get two ends together' — Corn (guideline) [Ep 18 · 22:55](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1375)
- Historical belief that distal pouch blood supply comes from direct aortic branches is false; extensive dissection causes no significant bleeding — Louis Spitz (clinical) [Ep 18 · 23:34](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1414)
- During distal pouch dissection, no significant bleeding is seen from bluntly dissected vessels — Corn (clinical) [Ep 18 · 24:05](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1445)
- Vagus nerve and main branches can be preserved during distal dissection; easier to visualize thoracoscopically due to magnification — Steve (clinical) [Ep 18 · 25:13](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1513)
- Concept that EA esophagus was normal, divided, and reconnected to work normally is false; inherent dysmotility exists regardless of surgical technique — Steve (opinion) [Ep 18 · 26:00](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1560)
- Patients with standard type C EA and minimal dissection still have dysmotility; kids with perfect repairs and no stricture can present with food impaction due to abnormal peristaltic waves — Steve (clinical) [Ep 18 · 26:30](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1590)
- Surgical outcomes vary widely even with identical technique (complete distal dissection, tension-free anastomosis); esophageal function depends on pre-existing anatomy, not surgical dissection extent — Miguel (opinion) [Ep 18 · 28:43](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1723)
- Thoracoscopic magnified view shows no vessels entering distal pouch during extensive dissection — Steve (clinical) [Ep 18 · 29:58](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1798)
- Has never seen distal pouch necrosis from extensive dissection — Steve (clinical) [Ep 18 · 30:30](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1830)
- Primary long-term problems in EA are short esophagus with reflux and stricture formation, not inability to eat (assuming those issues are managed) — Steve (clinical) [Ep 18 · 30:45](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1845)
- Knowledge about esophageal innervation in EA babies is insufficient to categorically mandate nerve preservation — Corn (opinion) [Ep 18 · 31:36](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1896)
- Cannot recall any patient who had esophageal surgery for non-EA reasons showing postoperative dysmotility from dissection — Corn (clinical) [Ep 18 · 32:00](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1920)
- For past 20 years, performs anastomoses under extreme tension but electively paralyzes and ventilates patients for 5 days; has had no leaks in this group — Louis Spitz (clinical) [Ep 18 · 32:53](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1973)
- Historical technique: stitch between chin and chest to maintain neck flexion and reduce anastomotic tension (no longer used due to appearance) — Corn (clinical) [Ep 18 · 34:10](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=2050)
- During 5-7 day paralysis period, esophagus under tension grows substantially and tension resolves; this is mechanism of benefit, not just protecting static anastomosis — Jack (clinical) [Ep 18 · 34:53](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=2093)
- Two-thirds of esophageal peristaltic function travels through muscle layer syncytium; fibrous healing at anastomosis interrupts this wave, leaving sporadic contractions that are usually sufficient for esophageal emptying — Jack (clinical) [Ep 18 · 35:30](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=2130)
- At Great Ormond Street, patients are fed by day 3-4 after TEF repair without routine contrast studies or chest tubes — Spitz (clinical) [Ep 20 · 0:00](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=0)
- Minor leaks after TEF repair are of no consequence and will heal without intervention — Spitz (clinical) [Ep 20 · 0:00](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=0)
- At Minnesota, routine contrast studies are not obtained for easy type C cases, but difficult cases get day 14 contrast to check for reflux — John Fokker (clinical) [Ep 20 · 0:52](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=52)
- Type C TEF patients almost always have reflux — John Fokker (clinical) [Ep 20 · 0:52](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=52)
- The decision to obtain contrast study with large or tension pneumothorax depends on distinguishing complete dehiscence from manageable leak — Jack (clinical) [Ep 20 · 2:30](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=150)
- With large or tension pneumothorax, exploration may reveal a single loose stitch that can be repaired with one additional suture — Louis (clinical) [Ep 20 · 2:52](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=172)
- Early re-exploration (days 3-6) for leak can result in esophageal loss because the esophagus is edematous and inflamed, appearing like 'Hamburg' — Arnie (clinical) [Ep 20 · 3:14](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=194)
- Dehiscence usually occurs in the first 48 hours — Arnie (clinical) [Ep 20 · 3:14](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=194)
- Indications for operative exploration are a very sick baby or contrast showing complete disruption — Arnie (clinical) [Ep 20 · 5:03](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=303)
- With complete disruption, the main priority is to save the patient's life by abandoning the esophagus — Holger (clinical) [Ep 20 · 6:04](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=364)
- Major reasons for anastomotic disruption are tension or poor vascularization — Holger (clinical) [Ep 20 · 6:17](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=377)
- Re-doing the anastomosis after disruption faces the same problems of tension and poor vascularization as the initial repair — Holger (clinical) [Ep 20 · 6:31](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=391)
- Once an esophagostomy is performed, the esophagus is lost in most cases — Louis (clinical) [Ep 20 · 5:23](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=323)
- For a sick baby with complete disruption, esophagostomy should be placed on the right side where the surgeon is already operating — Arnie (clinical) [Ep 20 · 7:41](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=461)
- For a more stable baby, left-sided esophagostomy is preferred because replacement operation into the left neck is easier — Arnie (clinical) [Ep 20 · 7:41](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=461)
- The distal esophagus should be taken down low and closed in 2-3 layers, not merely tied off, to prevent recurrent fistula formation — Spitz (clinical) [Ep 20 · 8:33](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=513)
- If a leak cannot be detected on esophagram but the patient is managed conservatively, the inability to detect it does not matter because management would not change — Arnie (clinical) [Ep 20 · 9:30](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=570)
- For a medium leak with evidence of infection but cardiovascular stability, placing a chest tube and administering antibiotics while observing is appropriate management — Arnie (clinical) [Ep 20 · 10:17](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=617)
- The concern with leaks is hemodynamic instability and sepsis, not the leak itself — Arnie (clinical) [Ep 20 · 11:04](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=664)
- One case required thoracoscopic repair of persistent leak at two weeks with pleural flap coverage — Steve (clinical) [Ep 20 · 11:57](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=717)
- Leaving a drain at the time of initial operation provides insurance against leaks and avoids later manipulation to place one — Steve (opinion) [Ep 20 · 12:40](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=760)
- If leak rate is less than 10%, routine drainage means draining 90% of patients unnecessarily — Steve (clinical) [Ep 20 · 14:04](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=844)
- Drains sitting against the anastomosis may cause leaks, so they must be anchored 1-2 cm away — Jack (clinical) [Ep 20 · 14:19](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=859)
- Chest drains often fail to drain contained leaks even when leaks are present on contrast studies (clinical) [Ep 20 · 14:41](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=881)
- When a drain fails to drain a leak, interventional radiology can place a drain into the leaking area — Spitz (clinical) [Ep 20 · 15:08](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=908)
- Echocardiogram is obtained preoperatively to rule out congenital heart defects and determine aortic arch sidedness (right vs. left) (clinical) [Ep 16 · 1:37](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=97)
- VACTERL workup includes renal ultrasound, vertebral X-rays, evaluation for imperforate anus, and sometimes assessment for VACTERL association (clinical) [Ep 16 · 1:37](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=97)
- Preoperative bronchoscopy helps identify fistula location: mid-tracheal fistula predicts shorter gap, while fistula at carina predicts longer gap (clinical) [Ep 16 · 7:02](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=422)
- Bronchoscopy can detect double fistula, though this is rare (clinical) [Ep 16 · 7:02](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=422)
- Standard open approach uses muscle-sparing right posterolateral thoracotomy with extrapleural dissection to vertebral bodies (clinical) [Ep 16 · 8:44](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=524)
- Azygos vein serves as anatomic landmark for fistula location during open repair (clinical) [Ep 16 · 8:44](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=524)
- Small chest tube is placed in extrapleural space on water seal (not suction) and removed after postoperative contrast study (clinical) [Ep 16 · 8:44](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=524)
- Retrospective study of approximately 100 patients showed no difference in complications between Vicryl and silk suture material (epidemiological) [Ep 16 · 10:59](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=659)
- For thoracoscopic repair with knot pusher technique, PDS must be used rather than Vicryl to avoid sawing through tissue (clinical) [Ep 16 · 10:59](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=659)
- Approximately 75% of EA/TEF patients are candidates for thoracoscopic repair (epidemiological) [Ep 16 · 13:54](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=834)
- Complicated congenital heart disease is a relative contraindication to thoracoscopic repair due to longer operative time and cardiovascular stability requirements (clinical) [Ep 16 · 13:54](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=834)
- EA/TEF repair is a 'one shot operation' where initial repair quality is critical due to significant complications from revision (opinion) [Ep 16 · 13:54](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=834)
- Gap distance is the primary determinant of whether thoracoscopic repair can be completed; conversion to open is appropriate if ends cannot be approximated (clinical) [Ep 16 · 16:04](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=964)
- Baby size under 2 kg makes thoracoscopic repair more difficult due to limited space and difficulty retracting lung (clinical) [Ep 16 · 17:17](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1037)
- Proximal pouch mobilization is the most difficult aspect of thoracoscopic repair (clinical) [Ep 16 · 17:17](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1037)
- Training fellows in thoracoscopic TEF repair is challenging with typical fellow exposure of 4-8 cases over training period (epidemiological) [Ep 16 · 17:17](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1037)
- Thoracoscopic ports should be spaced widely and staggered (not in same line) for optimal ergonomics (clinical) [Ep 16 · 19:24](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1164)
- Patient positioning should be more prone than lateral because esophagus is posterior mediastinal structure (clinical) [Ep 16 · 19:24](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1164)
- High-frequency oscillating ventilator in operating room keeps lung collapsed during thoracoscopic repair, though baby shaking is a disadvantage (clinical) [Ep 16 · 19:59](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1199)
- First stitch does not need to be tied tight; subsequent stitches are tied down tight once approximation is confirmed (clinical) [Ep 16 · 28:35](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1715)
- Delayed primary anastomosis approach involves waiting months (up to 3 months) for esophageal growth before attempting repair (clinical) [Ep 16 · 34:39](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=2079)
- Esophageal growth occurs spontaneously over time; weekly bougienage does not necessarily promote growth (opinion) [Ep 16 · 34:39](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=2079)
- Bolus gastrostomy tube feeds may promote distal esophageal growth in long-gap cases (clinical) [Ep 16 · 36:00](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=2160)
- Given lack of good esophageal replacement options, surgeons should try everything possible (including long waiting periods) before proceeding to replacement (opinion) [Ep 16 · 36:00](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=2160)
- Even very small distal esophagus may eventually come together with delayed approach, though some cases ultimately require replacement (clinical) [Ep 16 · 36:00](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=2160)
- Foker procedure can achieve primary anastomosis but may require fundoplication and strictureplasty, resulting in 'long ride' for patient (clinical) [Ep 16 · 36:00](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=2160)
- Distal esophageal cartilaginous rings should be resected rather than dilated, as dilation is ineffective — Wolfgang (clinical) [Ep 21 · 5:19](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=319)
- Hybrid thoracoscopic-endoscopic approach with transillumination is essential for localizing distal esophageal strictures that are not visible thoracoscopically — Wolfgang (clinical) [Ep 21 · 2:30](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=150)
- Upper pouch fistulas or H-type fistulas are very difficult to see and can be missed even by experienced endoscopists, requiring repeated investigations — Todd Ponsky (clinical) [Ep 21 · 6:22](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=382)
- Contrast studies should be used in addition to bronchoscopy when evaluating for fistulas, as what may be missed with bronchoscope could be picked up with contrast (clinical) [Ep 21 · 8:05](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=485)
- Thoracoscopic approach is feasible even after previous open thoracotomy on the same side, with adhesions being manageable (clinical) [Ep 21 · 9:21](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=561)
- Rapid spillover of contrast into the trachea with less than 1 millimeter of contrast should raise suspicion for laryngotracheoesophageal cleft — Cynthia (clinical) [Ep 21 · 24:43](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=1483)
- During bronchoscopy, one should attempt to separate the posterior commissure of the vocal cords to identify a laryngotracheoesophageal cleft — Cynthia (clinical) [Ep 21 · 25:10](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=1510)
- Esophageal flap repair can convert a grade 3 laryngotracheoesophageal cleft to a grade 2 cleft, allowing for safer subsequent endoscopic repair — Cynthia (clinical) [Ep 21 · 22:30](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=1350)
- For right-sided aortic arch with EA/TEF, left chest approach is easier because the aorta is out of the way — Todd Ponsky (clinical) [Ep 21 · 32:11](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=1931)
- Rigid bronchoscopy provides better examination than flexible bronchoscopy for identifying fistulas — Todd Ponsky (clinical) [Ep 21 · 52:21](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=3141)
- Flexible bronchoscopy through an endotracheal tube will miss proximal fistulas because the tube is positioned too far distally — Wolfgang (clinical) [Ep 21 · 51:32](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=3092)
- For patients with CHARGE syndrome and swallowing problems, if esophageal replacement is required, colon interposition is preferable to gastric transposition because the stomach can remain in the abdomen for gastrostomy feeding — Todd Ponsky (opinion) [Ep 21 · 39:20](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=2360)
- Post-pneumonectomy syndrome is a risk in young patients with esophageal lung, potentially requiring placement of tissue expander to stabilize the mediastinum — Todd Ponsky (clinical) [Ep 21 · 64:18](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=3858)
- The younger the patient undergoing pneumonectomy, the greater the risk of post-pneumonectomy syndrome — Todd Ponsky (clinical) [Ep 21 · 65:20](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=3920)

## Host summaries
Recaps by a host of what the experts said — not the host's own clinical position.
- Dead button batteries still have about 2 volts and continue to cause damage. — Todd Ponsky summarizing the discussion [Ep 7 · 45:31](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2731)
- Button batteries can be distinguished from coins on AP X-ray by a visible rim, eliminating the need for a lateral view. — Todd Ponsky summarizing the discussion [Ep 7 · 45:37](https://library.globalcastmd.com/watch/tef-presentations-aerodigestive-esophageal-surgery-1037?t=2737)
- Finding an H-type TEF can be quite difficult and is done via tracheoscopy or esophagoscopy — Kim Priban summarizes what Dr. Michael Rutter said [Ep 5 · 2:06](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=126)
- Serial esophagoscopies provide a good picture of outcomes in challenging TEF repair cases — Kim Priban summarizes what Dr. Michael Rutter said [Ep 5 · 2:59](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=179)
- A slide tracheoplasty open approach provides much better visualization in the operating field for complex cases — Kim Priban summarizes what Dr. Michael Rutter said [Ep 5 · 4:42](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=282)
- A pulmonologist aids the surgeon by looking down the ET tube, which allows for additional visualization and identification of the fistula — Kim Priban summarizes what Dr. Michael Rutter said [Ep 5 · 5:34](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=334)
- The repair includes transection of the trachea and esophagus, performing a slide esophagoplasty, placing the interposition graft, and closing the trachea — Kim Priban summarizes what Dr. Michael Rutter said [Ep 5 · 5:42](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=342)
- In the 4-year-old case, the patient was extubated the next day with esophagram and bronchoscopy performed at one week — Kim Priban summarizes what Dr. Michael Rutter said [Ep 5 · 6:03](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=363)
- The 4-year-old patient was back to eating ice cream at 10 days post-op — Kim Priban summarizes what Dr. Michael Rutter said [Ep 5 · 6:09](https://library.globalcastmd.com/watch/quad-6-slide-tracheoplasty-for-tef-otolaryngology-approach-with-dr-mike-rutter-8114?t=369)
- Cincinnati Children's Hospital hosted the Quad Conference in October 2022, combining four conferences: International Organization for Esophageal Atresia, Aerodigestive Society Conference, Cincinnati Children's Airway Course, and Cincinnati Children's Pediatric Dysphagia Series. — Lizzie Lee summarizing the discussion [Ep 6 · 0:15](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=15)
- Cincinnati Children's has one of the largest aerodigestive centers in the world. — Lizzie Lee summarizing the discussion [Ep 6 · 0:47](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=47)
- The expert multidisciplinary team includes speech pathology, otolaryngology, gastroenterology, pulmonology, and pediatric general surgery. — Lizzie Lee summarizing the discussion [Ep 6 · 0:55](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=55)
- The center provides coordinated multidisciplinary care to children with congenital or acquired complex digestive and airway disorders. — Lizzie Lee summarizing the discussion [Ep 6 · 1:37](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=97)
- Video fluoroscopic swallowing study analyzes different phases of swallowing. — Lizzie Lee summarizing the discussion [Ep 6 · 2:52](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=172)
- FEES (fiber optic endoscopic evaluation of swallowing study) allows visualization of pharyngeal and laryngeal structures and assessment of function, aspiration, and residual after each swallow. — Lizzie Lee summarizing the discussion [Ep 6 · 2:59](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=179)
- ENT looks at swallowing study results and helps stratify the risk of proceeding with airway reconstruction and decannulation. — Lizzie Lee summarizing the discussion [Ep 6 · 3:48](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=228)
- In aerodigestive patients, ENT performs esophageal and airway reconstruction, cleft repair, drool procedures, and manages vocal folds and mobility. — Lizzie Lee summarizing the discussion [Ep 6 · 3:54](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=234)
- GERD pathophysiology includes an incompetent lower esophageal sphincter. — Lizzie Lee summarizing the discussion [Ep 6 · 4:19](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=259)
- General signs and symptoms of GERD include regurgitation, vomiting, and heartburn. — Lizzie Lee summarizing the discussion [Ep 6 · 4:42](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=282)
- Data shows an increase in airway surgery complications in patients who were later found to have eosinophilic esophagitis. — Lizzie Lee summarizing the discussion [Ep 6 · 5:28](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=328)
- Anatomic issues in aerodigestive patients include strictures that need balloon dilations or stenting. — Lizzie Lee summarizing the discussion [Ep 6 · 5:40](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=340)
- When 25 patients in the aerodigestive program were assessed, 76% of them had a feeding disorder. — Lizzie Lee summarizing the discussion [Ep 6 · 6:13](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=373)
- Patients at risk for pulmonary insufficiency include preemies with chronic lung disease, patients with restrictive lung disease, congenital or acquired abnormalities, and heart disease like pulmonary hypertension. — Lizzie Lee summarizing the discussion [Ep 6 · 6:54](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=414)
- Underlying pulmonary insufficiency should be suspected if patients have had complicated respiratory infections requiring positive pressure ventilation. — Lizzie Lee summarizing the discussion [Ep 6 · 7:20](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=440)
- Risk factors for upper airway obstruction include airway abnormalities like mid-face hypoplasia, skeletal dysplasia, decreased muscle tone, and syndromes associated with airway obstruction. — Lizzie Lee summarizing the discussion [Ep 6 · 7:48](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=468)
- Risk factors for lower airway obstruction include acquired or congenital thoracic deformities and those who had thoracotomies done in the past. — Lizzie Lee summarizing the discussion [Ep 6 · 8:13](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=493)
- For patients with ventilatory insufficiency, the pulmonologist determines if the child still needs ventilatory support and whether they are ready for decannulation. — Lizzie Lee summarizing the discussion [Ep 6 · 9:15](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=555)
- The pulmonologist assesses how ready the patient is for weaning from the vent and whether they can start or advance feeding. — Lizzie Lee summarizing the discussion [Ep 6 · 9:26](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=566)
- In the NICU, general surgeons obtain feeding access, manage anorectal malformations, and perform surgical procedures such as tracheopexies and lung resections. — Lizzie Lee summarizing the discussion [Ep 6 · 9:41](https://library.globalcastmd.com/watch/quad-27-multidisciplinary-how-do-teams-enhance-outcomes-by-the-cchmc-adec-team-10201?t=581)
- In the Foker technique, the surgeon ties sutures to either end of the esophagus through an open incision, brings them out through the chest wall, ties them together in a knot, and places spacers underneath periodically (about every day) until the ends come together for primary anastomosis. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 1:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=68)
- The van der Zee technique uses the same concept as Foker but is done thoracoscopically with no external sutures, so all tension is inside the thorax. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 2:39](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=159)
- The Kimura technique involves creating a spit fistula and periodically moving it down the chest wall over time to stretch the proximal pouch closer to the distal pouch, but is not used all that often anymore. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 2:39](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=159)
- In the Boston Group 2015 study, the primary group (de novo cases) achieved an intact esophagus in 96% of patients, while the secondary group (patients with previous operations) achieved this in about two thirds of patients. — Daniel von Allmen summarizing a resource [Ep 2 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195)
- In the Boston Group 2015 study, the primary group had a median ICU stay of 70 days with a couple of weeks being paralyzed, and the secondary group had a median ICU stay of 110 days with a month of being paralyzed. — Daniel von Allmen summarizing a resource [Ep 2 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195)
- In the Boston Group 2015 study, about two thirds of patients with primary repair were able to get full oral nutrition and about 10% of patients who had secondary repair achieved full oral nutrition. — Daniel von Allmen summarizing a resource [Ep 2 · 3:15](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=195)
- The surgical group from INOEA recommends gastric pull up as the first option for esophageal replacement, dividing the esophageal stump at the esophageal hiatus and mobilizing the fundus to pull it up in either the anterior or posterior mediastinum. — Daniel von Allmen summarizing a resource [Ep 2 · 4:36](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=276)
- In colonic interposition, the piece of colon chosen is based on the blood supply and the diameter needed. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308)
- In colonic interposition, a pyloroplasty is performed to help with gastric emptying. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 5:08](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=308)
- The short interval between time of traction and anastomosis (less than five days) raises the question of whether the mechanism is stretching or growth, which will impact results and likely reflects on complications. — Rod Gerardo summarizes what Dr. Daniel von Allmen said [Ep 2 · 9:27](https://library.globalcastmd.com/watch/treatment-for-long-gap-esophageal-atresia-esophageal-elongation-and-replacement-4791?t=567)
- The azygous vein drains the bronchi, trachea, and esophagus, and its division may lead to impaired function postoperatively and impaired clearance of mucus and debris from the tracheobronchial tree — Jose Campos summarizing a resource [Ep 3 · 3:25](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=205)
- In a meta-analysis of almost 700 neonates, preserving the azygous vein resulted in significantly lower postoperative pneumonitis compared to division — Ellen Encisco summarizes what Dr. Jose Campos said [Ep 3 · 3:02](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=182)
- There was no significant difference in anastomotic leak rate or stricture rate between azygous vein preservation and division — Ellen Encisco summarizes what Dr. Jose Campos said [Ep 3 · 3:11](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=191)
- In the Quebec study of 244 patients, the overall anastomotic stricture rate at one year was 30% — Ellen Encisco summarizes what Dr. Jose Campos said [Ep 3 · 6:43](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=403)
- 36% of patients with transanastomotic tubes developed strictures compared to 19% without tubes, a difference that remained significant after multivariable analysis — Ellen Encisco summarizes what Dr. Jose Campos said [Ep 3 · 6:50](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=410)
- Patients with transanastomotic tubes had 2.72 times higher odds of developing a stricture compared to those without — Ellen Encisco summarizes what Dr. Jose Campos said [Ep 3 · 7:06](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=426)
- The Quebec study adjusted for gestational age, leak, length of gap, and tension, and still found almost 3 times higher stricture rates with transanastomotic tubes — Jose Campos summarizing a resource [Ep 3 · 7:32](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=452)
- Patients with transanastomotic tubes started feeding on day 2 versus day 10 for those without tubes, but early feeding did not lead to less TPN—duration was 9 days in both groups — Em Gootee summarizes what Dr. Jose Campos said [Ep 3 · 7:54](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=474)
- In a meta-analysis of about 500 newborns, there was no significant difference in leak occurrence, pneumothorax, or mortality based on whether a chest drain was placed — Em Gootee summarizes what Dr. Jose Campos said [Ep 3 · 12:20](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=740)
- The group that received a chest drain had a significantly higher chance of returning to the operating room — Em Gootee summarizes what Dr. Jose Campos said [Ep 3 · 12:31](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=751)
- Giving acid suppression to neonates increases the risk of necrotizing enterocolitis according to neonatologists' concerns — Todd Ponsky summarizes what Dr. Jose Campos said [Ep 3 · 13:41](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=821)
- In the Midwest Pediatric Surgery Consortium study, antibiotics for more than 24 hours and acid suppression showed no difference in strictures or leaks — Ellen Encisco summarizes what Dr. Jose Campos said [Ep 3 · 14:54](https://library.globalcastmd.com/watch/case-based-journal-review-esophageal-atresia-in-2022-5631?t=894)
- Dr. Clatworthy was the first pediatric surgeon in Ohio, trained by Dr. Gross at Boston Children's, and became first surgeon-in-chief at Columbus Children's Hospital. — Marc Michalsky summarizing the discussion [Ep 8 · 4:32](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=272)
- Teen-LABS data at 10 years shows effectively no difference in outcomes between Roux-en-Y gastric bypass and sleeve gastrectomy. — Marc Michalsky summarizing the discussion [Ep 8 · 39:10](https://library.globalcastmd.com/watch/dr-marc-michalsky-pediatric-robotic-assisted-surgery-developing-a-programmatic-paradigm-11169?t=2350)
- EA/TEF is a basic concept in pediatric surgery. — Jill Knepprath summarizing a resource [Ep 9 · 0:05](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=5)
- In normal anatomy, the esophagus goes straight down to the stomach with no atresia or interruptions, and the trachea goes straight down to the lungs with no connections between the two. — Jill Knepprath summarizing a resource [Ep 9 · 0:10](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=10)
- Type A EA/TEF consists of esophageal atresia proximally and distally in the esophagus, preventing solids and liquids from reaching the stomach, with no connection between esophagus and trachea. — Jill Knepprath summarizing a resource [Ep 9 · 0:29](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=29)
- Type B EA/TEF has distal esophageal atresia and a proximal fistula, allowing solids and liquids to enter the trachea while the stomach remains empty. — Jill Knepprath summarizing a resource [Ep 9 · 0:45](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=45)
- Type C EA/TEF is the most common type. — Jill Knepprath summarizing a resource [Ep 9 · 1:08](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=68)
- Type C EA/TEF has proximal esophageal atresia and a distal fistula, allowing air to reach both lungs and stomach while solids and liquids cannot reach the stomach. — Jill Knepprath summarizing a resource [Ep 9 · 1:13](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=73)
- Type D EA/TEF has both a distal fistula and a proximal fistula, allowing solids and liquids into the trachea and air into both lungs and stomach. — Jill Knepprath summarizing a resource [Ep 9 · 1:28](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=88)
- Type E EA/TEF has no atresia but does have a tracheoesophageal fistula, which is often pretty high. — Jill Knepprath summarizing a resource [Ep 9 · 1:43](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=103)
- Type E EA/TEF is also known as H-type because of its anatomical appearance. — Jill Knepprath summarizing a resource [Ep 9 · 1:52](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=112)
- Type E (H-type) EA/TEF has the best results and is usually the easiest to fix. — Jill Knepprath summarizing a resource [Ep 9 · 1:56](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=116)
- Children with Type E (H-type) EA/TEF may present with symptoms later because they are still able to get solids and liquids down to the stomach and air to the lungs. — Jill Knepprath summarizing a resource [Ep 9 · 2:01](https://library.globalcastmd.com/watch/esophageal-atresia-tracheoesophageal-fistula-types-explained-for-pediatric-surgery-14001?t=121)
- TEF is a defining procedure of pediatric surgery with challenges including long gap atresia, recurrent fistulas, and strictures — The host summarizes what Dr. Daniel von Allmen said [Ep 10 · 0:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=0)
- Atlanta group uses stay stitch between two ends brought out of chest to hold anastomosis up for subsequent stitches, similar to duodenal atresia technique — Daniel von Allmen summarizing a resource [Ep 10 · 31:37](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-300?t=1897)
- The first successful open repair of tracheoesophageal fistula was performed in 1941 by Dr. Cameron Haight. — Alex Gibbons summarizing the discussion [Ep 11 · 1:24](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=84)
- In the year 2000, Dr. Steven Rothenberg performed the first successful repair of a tracheoesophageal fistula with a minimally invasive approach (esophageal atresia had been the year before). — Alex Gibbons summarizes what Dr. Steven Rothenberg said [Ep 11 · 1:46](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=106)
- In Rothenberg's first decade of experience with 62 patients, he reported that thoracoscopic approach offered better visualization of the anatomy. — Alex Gibbons summarizes what Dr. Steven Rothenberg said [Ep 11 · 2:10](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=130)
- Rothenberg reported that performing the operation entirely in situ reduced manipulation of the trachea and therefore potentially reduced risk for tracheomalacia. — Alex Gibbons summarizes what Dr. Steven Rothenberg said [Ep 11 · 2:40](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=160)
- Rothenberg reported decreased tension on the esophageal anastomosis with thoracoscopic approach. — Alex Gibbons summarizes what Dr. Steven Rothenberg said [Ep 11 · 3:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=180)
- Rothenberg reported that smaller incisions would result in fewer musculoskeletal deformities such as scapular winging, chest wall asymmetry, and scoliosis. — Alex Gibbons summarizes what Dr. Steven Rothenberg said [Ep 11 · 3:10](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=190)
- The Tübingen Germany single-center study found the minimally invasive group was slightly larger at about 2,700g compared to 2,100g in the open group. — Alex Gibbons summarizing the discussion [Ep 11 · 4:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=240)
- The Tübingen study found slightly more associated anomalies in the minimally invasive group at about 40% compared to 31% in the open group. — Alex Gibbons summarizing the discussion [Ep 11 · 4:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=270)
- The Tübingen study found no statistically significant difference between groups in complication rate or time to postoperative extubation. — Alex Gibbons summarizing the discussion [Ep 11 · 5:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=300)
- The Tübingen study found operative time was slightly longer at about half an hour longer in the minimally invasive group than in the open group. — Alex Gibbons summarizing the discussion [Ep 11 · 5:15](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=315)
- The Tübingen study found higher intraoperative PaCO2 in the MIS group, but postoperatively there was no statistically significant difference. — Alex Gibbons summarizing the discussion [Ep 11 · 5:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=330)
- The Holcomb multi-center study included 6 hospitals (Stanford California, Kansas City Missouri, Denver Colorado, Buenos Aires Argentina, Utrecht Netherlands, and Hong Kong China) with 104 total patients. — Alex Gibbons summarizing the discussion [Ep 11 · 5:50](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=350)
- The Holcomb study found results equivalent to historical open controls in mortality rate and need for postoperative fundoplication. — Alex Gibbons summarizing the discussion [Ep 11 · 6:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=390)
- The Holcomb study found results compared favorably to historical controls in terms of leak and recurrence. — Alex Gibbons summarizing the discussion [Ep 11 · 6:45](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=405)
- The Japanese multi-center study of 7 hospitals with 58 patients found equivalence in mortality, leak rate, and recurrence between MIS and open approaches. — Alex Gibbons summarizing the discussion [Ep 11 · 7:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=450)
- The Japanese study found a higher stricture rate in the minimally invasive group at about 48% compared to 17% in the open group. — Alex Gibbons summarizing the discussion [Ep 11 · 7:50](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=470)
- The Hanover Germany study of patients who had minimally invasive or open thoracic procedures for benign conditions found improved rate of mild scoliosis in MIS group: over 50% in thoracotomy group compared to less than 10% in minimally invasive group. — Alex Gibbons summarizing the discussion [Ep 11 · 9:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=540)
- The Hanover study found patients were more satisfied with scarring in the MIS group based on Manchester scarring criteria. — Alex Gibbons summarizing the discussion [Ep 11 · 9:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=570)
- The Hanover study found chest wall asymmetry was improved in the minimally invasive group, specifically in chest wall diameter and distance of nipple to xiphoid. — Alex Gibbons summarizing the discussion [Ep 11 · 9:40](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=580)
- The Hanover study found no difference in shoulder range of motion between MIS and open groups. — Alex Gibbons summarizing the discussion [Ep 11 · 9:55](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=595)
- A 2012 meta-analysis of 4 articles representing 166 patients (69 MIS, 97 open) found no statistically significant difference in stricture rate, leak rate, operative time, or time to postoperative extubation. — Alex Gibbons summarizing the discussion [Ep 11 · 10:10](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=610)
- A 2016 meta-analysis of 8 articles with 452 patients (221 MIS, 231 open) found no difference in stricture rate or leak rate. — Alex Gibbons summarizing the discussion [Ep 11 · 10:35](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=635)
- The 2016 meta-analysis found operative time was about 20 minutes longer in the minimally invasive group. — Alex Gibbons summarizing the discussion [Ep 11 · 10:50](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=650)
- The 2016 meta-analysis found time to postoperative extubation and first postoperative feeding were about 2.5 days sooner in the MIS group. — Alex Gibbons summarizing the discussion [Ep 11 · 11:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=660)
- The 2016 meta-analysis found hospital length of stay was almost 11 days shorter in the MIS group. — Alex Gibbons summarizing the discussion [Ep 11 · 11:15](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=675)
- A pilot randomized controlled trial at Children's Hospital London with 10 patients (randomized to MIS or open) found no difference in intraoperative PaCO2, pH, time in OR, peak inspiratory pressure, or length of ICU stay. — Alex Gibbons summarizing the discussion [Ep 11 · 11:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=690)
- The London pilot RCT found 1 stricture in the open group compared to 3 strictures in the thoracoscopic group, and 1 leak in the thoracoscopic group compared to none in the open group. — Alex Gibbons summarizing the discussion [Ep 11 · 12:00](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=720)
- A recent study from the Midwest Consortium of approximately 10 hospitals showed less than 15% of TEF cases were done thoracoscopically in major US training centers. — Steven Rothenberg summarizing the discussion [Ep 11 · 14:30](https://library.globalcastmd.com/watch/thoracoscopic-tef-repair-is-it-really-better-than-open-update-course-2018-356?t=870)
- Early thoracoscopic series (2008-2010) showed lower stricture rates with thoracoscopic vs. open repair, but more recent data show equivalent stricture rates. — The host summarizing the discussion [Ep 13 · 25:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1500)
- Average US attending surgeon performs 1-2 TEF repairs per year, making advanced thoracoscopic technique acquisition challenging. — The host summarizing the discussion [Ep 13 · 27:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1650)
- Low-cost training models for EA repair are available and should be used at society meetings (IPEG, APSA) to address low case volume. — The host summarizing the discussion [Ep 13 · 31:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1860)
- Marcello reports doing all EA repairs thoracoscopically for over 10 years after performing ~150 open repairs, finding the approach natural and comfortable. — The host summarizing the discussion [Ep 13 · 31:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1890)
- Wet clips are a fast and reliable method for dividing the TEF during thoracoscopic repair. — The host summarizing the discussion [Ep 13 · 32:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1920)
- Yama's technique: divide only 3/4 of the fistula initially, leaving partial attachment as traction to facilitate anastomosis, then complete division. — The host summarizing the discussion [Ep 13 · 33:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=1980)
- Passing a transanastomotic feeding tube after back-row sutures provides volume to help guide the needle through the anterior wall. — The host summarizing the discussion [Ep 13 · 35:00](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2100)
- Minimal dissection of the distal esophagus preserves blood supply and reduces trauma, even in long-gap cases. — The host summarizing the discussion [Ep 13 · 36:30](https://library.globalcastmd.com/watch/esophageal-atresia-627?t=2190)
- Mark Wolkan presented a technique from Atlanta in which a stitch is placed through the chest wall, through the proximal esophageal end, through the distal end, and back out through the chest wall, and held up during anastomosis. — The host summarizing the discussion [Ep 12 · 13:50](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=830)
- Steve Rothenberg uses clips routinely for TEF repair. — Sharif summarizing the discussion [Ep 12 · 17:10](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1030)
- There have been several instances where clips seem to erode or be implicated in TEF recurrences. — Sharif summarizing the discussion [Ep 12 · 17:25](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1045)
- Steve Rothenberg, who has the largest experience with thoracoscopic TEF, has never had a clip erode. — The host summarizing the discussion [Ep 12 · 17:55](https://library.globalcastmd.com/watch/thoracoscopic-repair-of-tracheo-esophageal-fistula-tricks-pediatric-surgery-424?t=1075)
- Tracheoesophageal fistula is a defining procedure of pediatric surgery with challenges including long gap atresia, recurrent fistulas, and strictures — Em Gootee summarizing the discussion [Ep 14 · 0:00](https://library.globalcastmd.com/watch/tracheoesophageal-fistula-with-dr-daniel-von-allmen-956?t=0)
- Mark Woflan from Atlanta uses a technique where a stitch is placed through the chest wall, through the proximal end, through the distal end, and back out through the chest wall, holding the ends together during anastomosis. — Todd Ponsky summarizing the discussion [Ep 15 · 13:40](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=820)
- Steve Rothenberg uses clips routinely and has the largest experience, but has never had a clip erode. — Todd Ponsky summarizing the discussion [Ep 15 · 17:29](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=1049)
- Several instances have occurred where clips seem to erode or be implicated in recurrent fistula. — Todd Ponsky summarizing the discussion [Ep 15 · 17:10](https://library.globalcastmd.com/watch/ea-tef-discussion-technique-difficult-cases-1053?t=1030)
- More than 50% of long-gap EA cases are type C. — The host summarizing the discussion [Ep 17 · 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 17 · 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 17 · 7:09](https://library.globalcastmd.com/watch/tips-and-tricks-ea-tef-1075?t=429)
- Most surgeons use a muscle-sparing incision for open TEF repair — The host summarizing the discussion [Ep 18 · 0:44](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=44)
- Extrapleural approach provides easier exposure in open repair because single retractor can hold all three lung lobes; transpleural requires separate lobe retraction — Todd Ponsky summarizing the discussion [Ep 18 · 2:25](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=145)
- Thoracoscopic approach eliminates pleural approach debate because lung collapse provides exposure without retraction — Todd Ponsky summarizing the discussion [Ep 18 · 3:00](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=180)
- Complete proximal pouch dissection all the way to neck is necessary to discover proximal fistula if present (teaching from Siggy Ein) — Jack summarizing the discussion [Ep 18 · 5:27](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=327)
- Bronchoscopy before every EA repair is important to determine presence of proximal fistula — Todd Ponsky summarizing the discussion [Ep 18 · 5:46](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=346)
- Incidence of additional upper fistula is 5-8%, meaning 95% of bronchoscopies provide no benefit — Steve summarizing the discussion [Ep 18 · 9:51](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=591)
- Bach showed that shorter upper pouch length correlates with higher likelihood of proximal fistula — Steve summarizing the discussion [Ep 18 · 10:10](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=610)
- Contrast study technique: maximum 1.5cc water-soluble dye, surgeon must be present and perform study under fluoroscopy, immediately suction out dye to prevent aspiration — Holger summarizing the discussion [Ep 18 · 12:04](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=724)
- Bronchoscopy helpful to know where fistula inserts into trachea (especially high insertions) and for fellow training — Holger summarizing the discussion [Ep 18 · 19:21](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1161)
- Japanese study performed manometry on proximal and distal pouches pre-repair (via gastrostomy access) in pure EA patients; found normal coordinated peristalsis between pouches that was completely disrupted post-repair — Jack summarizing the discussion [Ep 18 · 27:57](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=1677)
- Anastomosis is weakest at 5-7 days post-repair, which is when patients are routinely extubated — Todd Ponsky summarizing the discussion [Ep 18 · 33:23](https://library.globalcastmd.com/watch/introduction-and-panel-discussion-ea-tef-1076?t=2003)
- If contrast study shows half going down and half into chest in a stable baby, the consensus is to do nothing — The host summarizing the discussion [Ep 20 · 4:39](https://library.globalcastmd.com/watch/leak-after-esophageal-atresia-repair-tef-repair-discussion-of-world-experts-1082?t=279)
- Antenatal detection of esophageal atresia occurs in less than half of cases, identified by small stomach and polyhydramnios — Bob Gootee summarizing the discussion [Ep 16 · 1:37](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=97)
- Right-sided aortic arch can be successfully repaired through right thoracotomy without switching to left side, though technically more challenging — Bob Gootee summarizing the discussion [Ep 16 · 4:10](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=250)
- Recent literature (European Journal of Pediatric Surgery Volume 23) shows little difference in outcomes between open and thoracoscopic repair — Bob Gootee summarizing the discussion [Ep 16 · 15:04](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=904)
- Some recent studies (2008-2010) showed better stricture rates with thoracoscopic approach, though more recent data shows equivalent rates — Bob Gootee summarizing the discussion [Ep 16 · 16:04](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=964)
- Average attending pediatric surgeon performs 1-2 TEF repairs per year according to Maury Ziegler's data — The host summarizing the discussion [Ep 16 · 17:17](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1037)
- Low-cost training models for thoracoscopic TEF repair have been developed, including one from Argentina presented at IPEG Beijing meeting — Bob Gootee summarizing the discussion [Ep 16 · 21:17](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1277)
- Wet clips are fast and reliable method for fistula division during thoracoscopic repair — Bob Gootee summarizing the discussion [Ep 16 · 21:17](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1277)
- Poll results show 35% of participants perform thoracoscopic repair while 60% perform open repair — Bob Gootee summarizing the discussion [Ep 16 · 23:58](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1438)
- Cathy Barsson at Northwestern developed bovine fetal tissue model for TEF repair training that does not require living tissue — Bob Gootee summarizing the discussion [Ep 16 · 24:35](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1475)
- This training model was used to teach 30 senior fellows from US and Canada and will be deployed at APSA and IPEG meetings — Bob Gootee summarizing the discussion [Ep 16 · 24:35](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1475)
- Thoracoscopic approach is very gentle for lungs, resulting in easier postoperative management, less pain, and smoother extubation — Bob Gootee summarizing the discussion [Ep 16 · 25:45](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1545)
- For thoracoscopic anastomosis, back row stitches are tied intracorporeally while front row knots are tied outside the lumen — Bob Gootee summarizing the discussion [Ep 16 · 26:49](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1609)
- Transanastomotic feeding tube passed after back row helps provide volume and guides needle passage for front row sutures — Bob Gootee summarizing the discussion [Ep 16 · 26:49](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1609)
- 5-0 PDS with C1 needle is preferred suture for thoracoscopic repair; C1 needle has good curve and passes through 5mm trocar without damage — Bob Gootee summarizing the discussion [Ep 16 · 27:53](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1673)
- TF needle is also suitable alternative to C1 needle for thoracoscopic anastomosis — Bob Gootee summarizing the discussion [Ep 16 · 28:24](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1704)
- Stay sutures can be exteriorized through chest wall with hemostat to help bring gap closer before tying subsequent stitches — Bob Gootee summarizing the discussion [Ep 16 · 28:55](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1735)
- Dividing only 3/4 of fistula (rather than complete division) before anastomosis makes repair easier by maintaining traction — Bob Gootee summarizing the discussion [Ep 16 · 29:39](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1779)
- Minimal dissection of distal esophagus preserves blood supply and reduces trauma, even in long-gap cases — Bob Gootee summarizing the discussion [Ep 16 · 29:56](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1796)
- Long gap is defined as greater than two vertebral bodies distance on contrast study through gastrostomy — Bob Gootee summarizing the discussion [Ep 16 · 31:29](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1889)
- Gastrostomy tube placement is first step in long-gap management, allowing gap assessment via contrast injection and wire passage — Bob Gootee summarizing the discussion [Ep 16 · 31:29](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1889)
- Interventional radiology can pass wire up distal esophagus and inject contrast to identify GE junction location for gap measurement — Bob Gootee summarizing the discussion [Ep 16 · 31:29](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1889)
- 160 endoscope can pass through slightly dilated 12 French gastrostomy tube to visualize and push lower esophagus — Bob Gootee summarizing the discussion [Ep 16 · 33:14](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=1994)
- Cervical esophagostomy commits patient to esophageal replacement or substitution procedure — Bob Gootee summarizing the discussion [Ep 16 · 33:40](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=2020)
- Modern approach to long-gap atresia favors multiple attempts at primary anastomosis before proceeding to cervical esophagostomy — Bob Gootee summarizing the discussion [Ep 16 · 33:40](https://library.globalcastmd.com/watch/update-course-2013-ea-tef-1057?t=2020)
- Right chest approach with right-sided arch is feasible but can cause bradycardia when retracting the lung — Em Gootee summarizing the discussion [Ep 21 · 33:04](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=1984)
- The incidence of proximal fistula in patients with pure esophageal atresia is extremely high, much higher than previously thought, according to Klaus Bach's group at Utrecht — Em Gootee summarizing the discussion [Ep 21 · 49:20](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=2960)
- Thoracoscopic approach allows better protection of the recurrent laryngeal nerve during H-type fistula repair because all manipulation is under direct vision — Em Gootee summarizing the discussion [Ep 21 · 51:03](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=3063)
- Esophageal lung is an extremely rare clinical entity where the main stem bronchus connects directly to the lower esophagus, with only 20 cases reported in world literature — Em Gootee summarizing the discussion [Ep 21 · 57:52](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=3472)
- Management of esophageal lung involves pneumonectomy — Em Gootee summarizing the discussion [Ep 21 · 58:40](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=3520)
- Paralytics and sedation may be beneficial postoperatively for long-gap EA repairs with significant tension — Em Gootee summarizing the discussion [Ep 21 · 55:55](https://library.globalcastmd.com/watch/interesting-case-presentations-part-ii-ea-tef-1084?t=3355)
- Proximal fistulas in esophageal atresia can be missed even when rigid bronchoscopy is performed routinely prior to repair of presumed type C esophageal atresia with distal tracheoesophageal fistula. — The host summarizing a resource [Ep 22 · 0:02](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=2)
- Proximal tracheoesophageal fistulas are often subtle and look quite different from distal fistulas. — The host summarizing a resource [Ep 22 · 0:30](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=30)
- The distal fistula in this case was located 1.5 to 2 centimeters proximal to the carina on initial rigid bronchoscopy. — The host summarizing a resource [Ep 22 · 1:30](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=90)
- A routine esophagogram performed 6 days after repair showed a tracheoesophageal fistula despite the absence of a leak or significant stenosis. — The host summarizing a resource [Ep 22 · 2:10](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=130)
- Rigid bronchoscopy to evaluate for missed proximal fistula was performed a week after initial repair to minimize the chances of traumatizing the recently ligated fistula. — The host summarizing a resource [Ep 22 · 2:40](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=160)
- The proximal fistula appeared as a subtle fold approximately 1 centimeter proximal to the distal fistula site on bronchoscopy. — The host summarizing a resource [Ep 22 · 3:10](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=190)
- A thin suction catheter could not be passed through the proximal fistula fold, but a glide wire was easily passed, confirming the presence of a proximal fistula. — The host summarizing a resource [Ep 22 · 3:25](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=205)
- Endoscopic treatment involved using a glide wire to stent the fistula open while cauterizing the tract with bugby cautery until the tract and fistula wall were fully cauterized. — The host summarizing a resource [Ep 22 · 3:40](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=220)
- Following cauterization, Deflux (dextranomer hyaluronic acid copolymer) was injected into the fistula tract. — The host summarizing a resource [Ep 22 · 4:05](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=245)
- The endoscopic procedure was unsuccessful, and the proximal fistula remained patent on esophagogram two weeks later. — The host summarizing a resource [Ep 22 · 4:15](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=255)
- The patient subsequently underwent successful repair of the proximal fistula through a right neck incision. — The host summarizing a resource [Ep 22 · 4:25](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=265)
- If any suspicion of proximal fistula is seen on rigid bronchoscopy, insufflation of air through the esophageal pouch or installation of methylene blue may help confirm a proximal fistula. — The host summarizing a resource [Ep 22 · 4:40](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2230?t=280)
- Proximal fistulas in esophageal atresia can be missed even when rigid bronchoscopy is performed routinely prior to repair of presumed type C esophageal atresia with distal tracheoesophageal fistula. — The host summarizing a resource [Ep 23 · 0:02](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=2)
- Proximal tracheoesophageal fistulas are often subtle and look quite different from distal fistulas. — The host summarizing a resource [Ep 23 · 0:20](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=20)
- The patient was a term male with presumptive esophageal atresia and distal tracheoesophageal fistula who underwent repair through a right thoracotomy on the second day of life. — The host summarizing a resource [Ep 23 · 0:35](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=35)
- Preoperative rigid bronchoscopy was interpreted as showing a distal fistula 1.5 to 2 centimeters proximal to the carina with no other anomalies. — The host summarizing a resource [Ep 23 · 0:50](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=50)
- A routine esophagogram performed 6 days after repair showed a tracheoesophageal fistula, despite the absence of a leak or significant stenosis. — The host summarizing a resource [Ep 23 · 1:18](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=78)
- Repeat rigid bronchoscopy was performed a week after initial repair to minimize the chances of traumatizing the recently ligated fistula. — The host summarizing a resource [Ep 23 · 1:38](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=98)
- A subtle fold was seen approximately 1 centimeter proximal to the distal fistula site on repeat bronchoscopy. — The host summarizing a resource [Ep 23 · 1:58](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=118)
- A glide wire was easily passed through the subtle fold, confirming the presence of a proximal fistula. — The host summarizing a resource [Ep 23 · 2:12](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=132)
- Endoscopic treatment involved using the glide wire to stent the fistula open while cauterizing the tract with bugby cautery until the tract and fistula wall were fully cauterized. — The host summarizing a resource [Ep 23 · 2:22](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=142)
- Following cauterization, Deflux (dextranomer hyaluronic acid copolymer) was injected into the tract. — The host summarizing a resource [Ep 23 · 2:52](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=172)
- The endoscopic procedure was unsuccessful, and the proximal fistula was still patent on esophagogram two weeks later. — The host summarizing a resource [Ep 23 · 3:08](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=188)
- The patient subsequently underwent successful repair through a right neck incision. — The host summarizing a resource [Ep 23 · 3:18](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=198)
- If any suspicion of proximal tracheoesophageal fistula is seen on rigid bronchoscopy, insufflation of air through the esophageal pouch or installation of methylene blue may help confirm a proximal fistula. — The host summarizing a resource [Ep 23 · 3:38](https://library.globalcastmd.com/watch/rigid-bronchoscopy-for-diagnosis-and-treatment-of-proximal-pouch-fistula-in-2246?t=218)

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