EA/TEF Discussion & Technique: Difficult Cases

Microscopic TEF repair. Mhm. Uh, this presentation is next for the thorax repair of, uh, uh, tracheoes fistula. And a We already, uh, presented the, uh, this technique in the, uh, in this journal. 2 year old boy. Tracheusvag fistula, as you can see, and the coil up of the nasal tube. And a For thoracoscopic repair of esophageal reasure, I feel we have to check the length of the gap between proximal and the diesel. distal esophagus and I think this, uh, you know, X-ray is a bit, uh, you know, funny, but, uh, uh, I don't know why. But anyway, the, uh, this is uh nas the gastric tube. This is a bronchoscope done by anesthetist. Anesthetists can find the orifice of the fistula. Then I asked anesthetist to stop. Then take the X-ray. So this gap would be the, this is the tip of the proximal fistula, sorry, this is the tip of the proximal esophagus. This level. Is the. Proximal site of the distal esophagus. So gap is, in this case, gap is around one vertebra. So what I'm doing, uh, for Thoracos to repair in all cases. And when This is a distal esophagus, this is a trachea, this is a clip. To close the tracheoesophageal fistula, majority of the surgeons. You know, divide the distal esophagus completely, but I don't do that. I leave one quarter of the fistula. And I'll show you later in the video, the reason, because if we divide it completely, the distal esophagus can be retracted cranially and also anastomosis would be difficult. So, You know, there's a fixation of the distal esophagus as you see here, because I left one quarter of the fistula uncut, so When we are Doing a fastert. Easy to get the mucosa as you see here. And also, even for proximal esophagus, this is the tip of the partial esophagus. I don't cut. All of the tip of the perm esophagus, I left 125 to 1/5. Of the You know, cap, maybe I, I can say the cap of the proximal esophagus to grab. This part by a pair of forceps because I don't wanna grab the anesthetic site. Also, if there's a, you know, 1 or 2 to 3 gaps, we can assistant can. Pull the proshima esophagus cranially, sorry, caudally, you know, using. The cup of The proximal esophagus, this part is uncut. You know, that in the conclusion, our technique is useful at the time of the anastomosis during a thoracic repair of a trachealis fistula, and also I have a video. Mark, do you have his video? Yeah, we're gonna show the video in a second here. They're loading it up, Yama. Um-hum. Yama, which, um Which stitch do you put in first? Uh, in the middle of posterior patient anterior wall in the middle. I used to be, I used to be putting the first stitch on the, on the edge, but I found that in the middle is much easier, right, especially with this technique, yeah. OK, we're gonna roll the video. I cannot, I cannot see the video. It's coming. It's a little window. I can see the video in a different place. Can you see the video? Yeah, yeah, I, the, the audience is seeing it fine. You're just in the backstage, so you're seeing a small view. We're seeing it perfectly, I can. OK, but small, that is a very small view. I faster trucker is incited by the not open technique, by the uh uh I use the optical truckers. Then this is uh this slide shows the uh. This is a video showing me a dissection of the fistula and Sorry, I cannot see, ah. Yeah, fistula clipped. Could you start the video again? Yeah, we'll show it again. Huh? This is a this. Hello. Oh. Video didn't show the Now video showing you the dissection of the proximal esophagus. Look carefully. Dissect the trachea and the proximal esophagus, and this is a clip for trachea of a fistula. This is the important part. I don't divide. Completely. You sell esophagus. And also this is proximal esophagus. Start cutting. But I don't remove. Entire tip of the proximal esophagus, leaving 1/5 of the tip of the proximma esophagus. Dissection of the proximal esophagus. So now You will see the first stitch. I you see a 6450 PDS. Here I grabbing the, uh, you know, Cup of the Uncut pork smell esophagus. And this is a Dial Esophagus. We have to Take the mucosa, otherwise, the patient will have a post-operative stenosis. Again, Grabbing the cap of the proximal esophagus. And you can see the mucosa. Of the proximal esophagus nicely. Because of the Then I Divide. The turkey fistula completely at this stage after. 1 or 2 stitches. And after 2 to 3 stitches, I divide, uncut cup of. The proximal esophagus. So what? You know, virtually I don't touch the site of the anasmosis. In the proximal and distal esophagus. That is my technique. Great. Uh, so I want to talk about this, uh, in a second, but I wanted to give just one housekeeping thing. I see all the faculty, you're upset because the video is so small. You have to understand no one else sees it small except you guys because we're in the backstage production area. So Yama, they saw a nice large magnified view of your video, and we saw that video a few months ago in September, uh, and I tried it since then, Yama, and I loved it. It, it was, uh, it worked great. I, I, it's. I would say that it, uh, it was plus minus. I, I, I thought it worked great by keeping traction on it, but I wasn't sure how much I needed it. It, it almost felt like it, it, it, it was just as easy in the, in the cases when I, uh, cut it and grab it and stitch it. So, I probably will do it again. I'll probably, uh, cause you don't hurt yourself. You can leave that last little bit. See if the stitch sets up perfectly. If it does, you take it. If not, you cut it and then you do it. So I think there's no reason to cut the entire fistula when you're dividing through it. So I just wanted to open this up to the uh virtual faculty first. Um, David Vanderzee is joining us now. David, can you hear us? Yes, I can hear you very well. Thank you. Thanks for joining us, and Doctor Vanderzee is professor of pediatric surgery and head of the department of pediatric surgery at University Medical Center at Utrecht. So thank you for joining us, David. What are your thoughts on that? Have you ever used that? And, and if not, what are your thoughts on it? I think it, it might be helpful to, to leave the fistula partially connected to the trachea in the beginning. Uh, personally, we do not do it because we think it's, uh, uh, we use a transfixing suture to close the fistula to make sure it doesn't come off. Uh, and we never use clips because they tend to, to, uh, hook behind the, uh, the suture that you are using. Um, so if we, if we have a, a, a, a, a type C anastomosis, which has a considerable length, we usually put in two sutures and, and then make them into a sliding knot and slowly bring them together, uh, dividing the tension between the, the two ends of the esophagus, uh, and then ultimately, uh, finalize the, the posterior anastomosis before, uh, I call it, uh, putting through, uh, a tube and, uh, closing the anterior wall. Um, at some time, if you have time, I, I, I have a, I, I uploaded a video of how we do our type Cs, but this is Yama's first day, so I don't want to interfere too much. Well, uh, yeah, we can, we'll show that later actually. Um, but I, I, I do want to show that uh TEF video, so we'll get that loaded up. Um, I want, does anyone else have any, uh, comments about Yama's technique? Before I make a comment, no one, OK, so, um, Mark, we put a poll up. Uh, it looks like the polls somehow are not really working because I don't think everyone's answering it. Well, we have 50% on all the polls, so there must be something funky, um, so unless we have an exact divide in our audience on, on all opinions, people are only 2 people are voting, so we wanna ask everyone to vote and if you're voting and it's not working, let us know so we know our polling system isn't working, um. What's that? Right, so we have to check in. Please, everyone go ahead and answer and let's see if those numbers change. Um, so I, I would curious who out there does thoracoscopic TEF. So if we can put that, are you using, uh, are you performing thoracoscopy with your TEF repairs? Um, Mark Wolkan presented an interesting technique from Atlanta where they put a a a stitch, but somebody's phones ringing there. Uh, if we put a stitch through the abdominal, through the chest wall, through the proximal end, through the distal end and back out through the chest wall, and they hold it up as they do their anastomosis, just one more way of doing, uh, of setting up the two ends together. Um, you know, and I think in the spirit of a trick, I mean, this is one that you think, jeez, is there any downside? No. So it's just one to put in your armamentarium and say, hey, give it a go. If it can help you, great. If it doesn't, it's one of those that there's no loss and it may be an, maybe an aid. That's a great point. That's a great point. And unless, uh, as David said, you don't clip, uh, you're, that wouldn't be the only situation. But if you do a clip. I, I, I think you're right. I think you could still use this with the transfix stitch. Why not? With your stitch, you wrap it around both of it, yeah, OK, um, I'm Jeff Blair here. Um, this is very interesting. I, I'm just wondering if we're in a limbo stage here, if in the next decade we're going to actually see mechanical devices actually put down through the upper pouch that will mechanically grab and seal the lower pouch. Um, it might be thoracoscopically facilitated, but I think we're, we're actually sort of in that just emerging from the dark ages of repairing oesophageal atresias, and in the not too distant future, they'll be mediated with imaging techniques, perhaps plus or minus thoracoscopic, but just my two cents. Yeah, OK. So, with that, we're, uh, Suet, I see you're here. Can you hear us? Yeah, actually, finally I managed to get in and hear you through the phone, so it's a great discussion actually. Thank you very much regarding the, well, I've just joined the discussion now about this vigil atresia, and what I did actually, I clipped the fistula. And it was very easy for me to find the fistula laparoscopically. Imagin like I find it's much, much easier, and you can appreciate how much you, you have to go without leaving a lot of. A esophagus on the trachea side, so it was much easier laparoscopically. However, dissecting the upper, the upper segments of the esophagus, it was a bit difficult, and I think the difficulty was just, you know, how to handle the esophagus without really making a lot of A damage to the esophageal wall because this is what you need for your anastomosis. So it was a little bit of handling, but it's managed well. So I think it just needs some tricks how to pull the upper, upper esophagus, the segment of this upper esophagus, so that it doesn't get damaged. OK. Uh, can I just make a comment from somebody who started doing these, uh, a year ago and have just done 3, so I'm sure I'm way behind most of the people on the panel. And my experience so far has been the first half of the case when I'm doing the dissection and dividing the fistul. I'm thinking, oh, this is fantastic. I'm so glad I'm doing it this way. And then as soon as I start to put the esophagus together, I'm thinking, why the heck am I doing it this way? So I'm still trying to figure out exactly the best way to go about it, but if people can just comment about this clips issue, because I know Steve Rothenberg uses clips quite routinely and many others, but we've had several instances where clips seem to erode or be implicated in recurrences. Um, so I'm wondering if what the experience of people are, uh, in terms of how they ligate the fistula. Yeah, I can answer. I, I can tell you that, uh, I've had that too, a clip erode into the esophagus, and I don't know if it, if I would love to blame it on the clip, but I don't, I don't know if you really can. When you look at Steve's data, who clearly probably has the largest data, largest experience, he's never, he's never had a clip erode. So I hear what you're saying, Sharif. I've had a problem too, and it must be something in the technique, because when someone is using clips as much as he does, he's never had one erode. You wonder if it's technique or it's actually the clip. Are they metal clips or the locks? Um, so I'm gonna answer that and then we'll go to Yama. So, um, I use the metal clips, uh, that's what he uses as well. I know a lot of people use the Weck Hema lock clips. I've tried that almost 2 or 3 times and every time I put that clip applier in, it's so big, I can't see as well as when I'm using the metal clip applier. So that's why I don't use it. Plus, if you put it on and you don't like its position, it's not really easy to take off, um, Yama. Yeah, I think the key for clipping the esophageal fistula, I think if we clip very tightly, it will erode the muscle of the esophagus. So I think when I clip the fistula, I just try to oppose the clip. I think it doesn't cause the erosion, but if you clip very tightly, it will crush the muscle and erode it, and it causes a recurrence of the fistula. That's what I thought. I don't know. I don't know. I'd have to, I'm not, I'm not convinced, but I hear what you're saying. I, I, I, I squeeze it pretty tight. I don't want it falling off. So, uh, but, uh, uh, a good point. Um, let's, uh, I think unless anyone else has a last-minute comment, we're, we want to take a break. Um, so I want to see if anyone has a comment to make. And then we will revisit this later on when we show David's video. So let's take a