Complications and Beyond
With Dr. Mark Wulkan & Dr. Jason Fraser & Dr. Dan von Allmen & Dr. Sean Barnhart · hosted by Dr. Todd Ponsky · Live Event Content
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Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
CT angiography for congenital lung lesions is typically performed at 3-6 months in clinic rather than in NICU for asymptomatic patients
Neonatologists routinely obtain chest X-rays on newborns with prenatal diagnoses before surgical consultation
Baseline chest X-ray may be useful if patient later presents with respiratory symptoms and consolidation, providing comparison
If chest X-ray is negative for prenatally diagnosed lung lesion, some practitioners still obtain CT scan at 3 months while others follow with serial chest X-rays
Three months is considered the optimal timing for congenital lung lesion resection; operating later results in more inflammation and increased difficulty
For thoracoscopic lobectomy, surgeons should be proficient with all vessel control methods: clips, ties, energy devices, and staplers
Energy devices work well for vessel control in small babies and can be used in bigger children with larger energy devices
Staplers can fail during lobectomy and are not perfect; surgeons must be prepared for this complication
When using energy devices for vessel control, leave enough remnant tissue so the vessel doesn't retract if seal fails, allowing purchase for clip or suture
Obtain proximal control or partially cut across vessel with energy device to detect failure before complete division
When using staplers, visualize the stapler end, use appropriate staple size for tissue, and leave extra tissue around stapler edge for adequate coaptation
Before firing any vessel control device, think through the next two steps if the device fails
Placing a silk suture on the pulmonary vein before using energy device or stapler provides backup control if primary method fails, preventing patient death from loss of visibility during hemorrhage
When vessel is dissected too cleanly with all adventitia removed, it may no longer be suitable for stapling
For flat-surface bleeding from vessel stump, suture is most reliable control method; clips and staplers can worsen bleeding
Surgeons performing thoracoscopic lobectomy must be proficient in intracorporeal suturing and tying before attempting the procedure
Medical acid suppression therapy will not provide lifelong solution for symptomatic paraesophageal hernia; repair is eventually necessary
Paraesophageal hernias after fundoplication will inevitably progress and create larger defects even if initially small
Paraesophageal hernia repair after prior fundoplication requires maximal esophageal mobilization
If crura come together easily during paraesophageal hernia repair, primary closure without mesh is preferred
Biologic mesh is preferred over non-absorbable mesh in pediatric hiatal hernia repair because non-absorbable mesh erodes into esophageal lumen
Overlay mesh technique with SIS reduced redo-redo hernia rate in one center's experience
Since abandoning phrenoesophageal membrane dissection during fundoplication, herniation is less frequent; fundoplication failure is now more common and easier to repair
Mesh is placed with midline cut and central circle, brought down to sit naturally without crossing anteriorly; posterior crossing depends on posterior crural appearance
Posterior defect is the usual problem site in paraesophageal hernia; mesh should cover the posterior repair
Horseshoe mesh configuration from underneath, wide on good tissue on either side below, addresses the posterior recurrence site
Severe dysphagia two weeks after paraesophageal hernia repair warrants contrast study as first step
If temporizing with feeding tube for post-fundoplication dysphagia, wait 4-6 weeks for swelling to resolve, as this is when inflammation truly decreases
Dilation within two weeks of fundoplication risks disrupting the wrap and causing recurrent reflux
Waiting only 3-4 weeks for revision risks operating during maximal inflammation period
After Nissen fundoplication, swelling typically resolves and swallowing normalizes around day 18 based on personal experience
Single posterior crural suture can cause mechanical esophageal obstruction if placed too anteriorly, as esophagus courses anterior-to-posterior crossing diaphragm
Intraoperative contrast injection after removing suspected obstructing stitch can confirm resolution before replacing fundoplication sutures
After completing fundoplication and crural repair, pass bougie into thorax then back to stomach to verify no step-off at crural repair
Post-fundoplication obstruction can result from four sites: mesh, top stitch, bottom stitch, or fundus itself
EGD can be used throughout revision case to assess each intervention's effect on obstruction
If operating soon after initial fundoplication, may be able to release obstructing structure without taking down entire wrap; if a year or more out, likely scarred and requires complete redo
Bougie size for fundoplication should be based on patient age and weight using published charts; anesthesiologist must pass bougie carefully watching for hang-up at GE junction
Kansas City group has eliminated posterior crural sutures in fundoplication using minimal dissection technique, creating retroesophageal window but leaving posterior crura alone
Kansas City group has eliminated collar stitches in fundoplication, now using only 3 stitches all on the fundus
Patients who cycle between reflux and obstruction after multiple fundoplication revisions may never achieve perfect outcome
Fundoplication attempts mechanical fix for physiologic problem, making it inherently difficult operation
Gastric disconnect is excellent operation in cognitively impaired patients who don't eat much and have refractory reflux or multiple failed fundoplications
Gastric disconnect performed as initial operation or after one failed fundo results in smooth recovery; after multiple fundos, recovery is prolonged
Gastric disconnect can be performed thoracoscopically
Newborn with esophageal atresia, dextrocardia, and respiratory instability at birth suggests complex anatomy beyond typical EA/TEF
Echo findings of mesocardia, hypoplastic pulmonary arteries, persistent left SVC, and dilated right ventricle indicate significant cardiac anomalies
Dextrocardia makes thoracoscopic visualization challenging for EA/TEF repair
For unstable EA/TEF patient, laparotomy with G-tube and vessel loop around GE junction allows fistula control and ventilation, deferring thoracic repair until patient stabilizes
Gastric distention from large TEF causing respiratory compromise requires emergent decompression, but decompression itself can cause hemodynamic collapse
For EA/TEF patient decompensating from gastric distention, fastest control is open gastrostomy with immediate esophageal control rather than laparoscopic approach
Vessel loop can be placed around esophagus from abdomen as high as possible, brought out through skin, then removed during subsequent thoracoscopic surgery
Bronchoscopy should be performed in all EA/TEF cases to identify additional fistulas
In esophageal lung, right lung is aerated through esophageal fistula rather than tracheal connection
Tracheal reconstruction for esophageal lung can be performed via median sternotomy: divide trachea, repair esophagus posteriorly, reconstruct trachea and fish-mouth abnormal bronchus to create lung connection
If initial TEF ligation is performed too far from trachea (2cm), significant esophageal length is lost, potentially preventing primary anastomosis
Magnet anastomosis can be attempted when esophageal ends are tacked together but gap prevents primary anastomosis
Tracheal reconstruction for esophageal lung is performed on cardiopulmonary bypass
Esophageal lung is rare congenital anomaly with approximately 30 reported cases where bronchus arises directly from esophagus rather than trachea
Nottingham UK group is collecting series of esophageal lung cases and seeking collaboration with other institutions