Tips and Tricks: EA & TEF

Spitz, when you do your, uh, esophageal resia repairs, do you leave a repole? Uh, I usually left a very fine tube, not a replogo, but a 6 feeding tube just to feed the baby for the first few days after the operation, OK. Uh, Jack, Yeah, do you leave a tube? I leave a tube. I usually leave a 5 French feeding tube, the same as Professor Spitz, mostly for feeding and also to protect the back wall during the anastomosis. All right, Steve, did, before we bring up everyone's webcams, were there any other videos that you want to show, or was that, is that pretty much it for, I think that's, I think that's it for this, yeah. OK, so can everyone go ahead and turn your cameras back on again? Uh, we're gonna have you doing this when, when we show videos. Sorry about that, but go ahead and turn it on. We want to see your pretty faces. Um, so yeah, go ahead. Steve, I do the anastomosis exactly like you. I use a 10 rep logo delete uh uh across the anastomosis, but the one thing I noticed is you were using, uh, cautery to dissect the upper pouch. When you get to the point where you're separating the upper pouch from the membranous trachea, do you use cautery there or you do mainly blunt dissection? Uh, usually blunt and sharp. Unless, if I, if I'm able to dissect it away enough that I can clearly see the tissues so that I'm not, I know I'm not injuring the membranous trachea, then, I'll use cautery just to get rid of any annoying bleeding cause it, the one disadvantage of this is it doesn't take very much bleeding to obscure your view. So, but if it's, if I'm, a lot of times if they're fused, then I do that sharply and I just use scissors in there. I, the reason I asked the question, and I, I, I knew the answer I was going to get, is that, uh, I've seen cases where the surgeon, Has dissected both on an open operation and a thoracoscopic, has dissected the plane between the membranous trachea and the medial wall of the upper pouch of the esophagus and gotten holes into the membranous trachea, and that has resulted in an acquired, uh, tracheoesophageal fistula, a very difficult one to fix. I think you should never use cautery. To dissect that upper pouch off the membranous trachea. You can use it anyplace else you want, whether you're doing it open or closed, but not in that particular plane, and sharp dissection essentially is the only safe way to do it. OK, um. Is Steve, I have learned the hard way from, you know, originally you, you would say that the first stitch in the beginning you like to do an extra corporeal knot, push it down because you wanna watch the tension and not worry about you're not. I don't know, I think you don't do it necessarily that way anymore, but the thing I learned was if you're gonna do an extra corporeal knot on the first couple of stitches, don't use a vicro. Yeah, yeah, you can't. So if you're tying it extra cororally, and I think that's OK, and if, if there's a lot of tension, I'll often tie it extra corporally because I do pay more attention to see if that, I can really focus on whether that stitch is perhaps tearing her out under the, the tension. But vicro, you at least you, it's very hard to tie an extra corporeal knot. So if you, if you're doing it extra corporeally, then you ought to use PDS because it, it, um, slides. It's better. So we have about 1 minute left. Any last minute comments on the standard repair, either open or thoracoscopic? Someone wants to, to impart on the on the audience or any questions before we move on to the second session. Can I make one point? the first part, um, when you have, uh, anastomosis under tension and therefore you're worried about a leak. It's, it's a good idea to think about, and I don't always do it, to think about in those circumstances, getting some tissue between the two suture lines, so you can present, prevent the development of a, uh, uh, of a recurrent fistula. And we're going to get into recurrent fistulas later on in the morning. Uh, but I think sometimes it's good to think ahead. It's not hard to do with a little pleural flap. And we'll talk about the technique of that. In the next session. But I think when you're left with an anastomosis that you look at and you're not super happy with it, it's not inappropriate to spend another 10 or 15 minutes getting some vascularized tissue between the two suture lines. You can use a pericardial flap. That. Or you can use a little pleural flap. And in a baby, the pleura itself is very thin, but you can use a thick pleural flap, which incorporates some of the muscle of the intercostal spaces and some fat. We'll talk about that later, but, I think, I think the, uh, the thing that causes most recurrent fistulas is a leak. The thing that causes most leaks is too much tension on the anastomosis. Uh, I just wonder, do, does anybody routinely put, uh, fiber and glue or any of the tissue seals around it? I don't. Anybody? No. Yeah, I know there's other people that want to make, well, everyone's raising their hand. I don't know if you have a question or you're saying yes. Jack, do you put the glue in? I have a question. I don't use glue, but I just wanted to address the issue of chest tubes because I don't use them unless I'm worried about the anastomosis, but I think most people do. I thought maybe you could do a little poll. I'll a poll. Yep, Holger, you had a question. May I ask a question to the expert, and I'll come back to the, so my question is, um, being all expert and knowing that, um, as we told before that more than 50% of lung gap are type C, uh, how can we. A conclude that this baby is a type C long gap, and if we can conclude that, what do we do? I mean, we, because sometimes we try anyway to do the anastomosis and we conclude that it's a long gap after. Having tried anasnostomosis, so what can we do and what have we to do if we realize that that's a type C not so easy. Well, I'll, I mean, we've, we, for instance, if we have a premature, we've had a few prematures that, uh, had a very small upper pouch, had a fistula. We've gone in and ligated the fistula thoracoscopically, um, and we may, if the baby's doing well, we'll initially see if we can mobilize the upper pouch. If we don't think we can get it together, then we'll, um, put an internal stitch with the upper pouch, put it under a little tension. And then we come back in 4 to 6 weeks and do the anastomosis. So I think the advantage of doing it thoracoscopically is you don't have a big thoracotomy incision. You can go in, you can evaluate it, and you can decide whether or not you can do it. Um, and it's rare that we're not able to get it together at the primary operation, but if with a type C, we have done a couple of cases where we've done that, and then we've come back and we've actually been able to get it, get it together without problem. Holger, you had a comment. No, no, I can share that experience. If it's a premature and you only ligate the fistula maybe even without dissecting so it doesn't slip back and you wait for 4 to 6 to 8 weeks, um, we wait for spontaneous growth. If it happens, uh, you do fine and then you just do the osmosis later. OK, but I wanted to come back to the zygo vein, uh, just to be complete. And I read a paper by Upa Daya in the European Journal of Pediatric Surgery saying that if you like it, the azo vein, there's an increased rate of pneumonia. Now what do we think about that? It happens in Austria, which means we have to just, the point I'm trying to make is, do we have to dissect it? David Vander, for example, says he, he never does it and uh it's superior, it decreases the rate of etc. Maybe that's the tough soft tissue you want in between, Annie. Uh, yeah, I mean, you can actually use, uh, I, I don't, I don't agree with that. I have no data to say it's true or not true, but, uh. I don't think ligating the vasygous vein does anything, but one thing you can do if you ligate it is you can take, uh, the distal end of the vazygous vein if you want to put something over the tracheal suture line, open it, and, uh, and put it, plaster it right onto the, uh, tracheal suture line or the esophageal suture line, either one. and Jack Linger's point about not just using a clip just to ligate. I know Keith Jorgeson says the same thing. Um, Jack, last comment on that, and then we're going to move on to the next session. Well, it's just, uh, you know, bitter experience, uh, having taken a preemie and just put a clip because it was the easiest, quickest thing. Uh, put a clip on the fistula, didn't divide it, and, uh, 3 weeks later, the fistula was back. So what do you do? What did I do? Yeah, what can you do? What, what other way do you, can you ligate it? Well, I think you can, if you want to clip it, it's fine, but I think you have to divide it. I think just putting a clip on, uh, you can recantalize, and that's what happened in our case. I had to go back in and, uh, and divide the fistula. I think the key thing when, when you're doing just a fistula division or ligation is, uh, and you, you, it's pretty clear in the, in the case that you can't put the two ends together. Is to be sure if you divided the distal, uh, segment is to tack it up to the vertebral body. Nobody's mentioned that yet. That's a technique that's been around forever. And, you know, just put a, a good stitch, uh, in the end of the divided, uh, distal fistula and tack it to the prevertebral fascia there, and that'll keep it from shrinking down. All right, let's, let's stop here.