2025 Pediatric Surgery Update Course - Updates in Esophageal Atresia Management

All right, we're going to move on to the next session. What's your... Yeah. Who do I call? I'll call you if things go wrong. All right. Simon, thank you. All right, we're going to move on to the next session. Come here. All right. All right. So we're going to talk about updates in the Sofagilatrizia management. We got Dr. Matt Dellinger from Seattle Childrens and Dan and Steve are you both moderating? Yes. Okay. Perfect. All right. Go for it. Supervision. So we're going to talk about updates in the Sofagilatrizia. Three topics I wanted to touch on was the utility of preoperative bronchoscopy when you're in the operating room right before you do the Sofagilatrizia repair. How people think about and manage trachea malacia, intraporidly, and also the role of recurrent laryngeal nerve monitoring during E.A. repair. So we'll jump right into the first scenario. So you have a three kilo baby transferred to your hospital just for no prenatal diagnosis of the Sofagilatrizia. You presume they have a tight C.E.A. they have a replogal coiled in the proximal Sofagilatrizia looks like our arrow got moved down. They also have distal gas. That's not where we just land bunk operation with that. I might be where the fish is. Normal worker breathing on root mayor. The baby's not in any distress. You have an echo cardiogram that's unremarkable with a left aortic arch. So the first question is, should you or would you perform a routine preoperative bronchoscopy? Does the poll auto populate? Does anyone in the audience hear or not perform bronchoscopy? And then at your institutions who performs the bronchoscopy? Show of hands for surgeons. Show of hands for if ENT does it. So it's fit for those in the audience, virtual audience 5050 here. So it looks like what? What? Why are you doing it in my custody? Are you doing it in a secret location? Is the official it is? Or are you looking for some other problem? A global court move there? Or something like that? Yeah. So the question is why do the bronchoscopy is it's a look for the position of the fish shellah or other associated abnormalities? Which we'll touch on there. Well, I think that's an important question because that's the only reason ENT to me would be doing the bronchoscopy would be to look at the vocal court movement. Because they're not going to, it doesn't make much sense to me to be the surgeon sitting in the lounge or even in the room and having ENT doct tell you where the bronchoscopy is. I wish to be where the fish shell is. So anyway, to me, whoever's doing the bronchoscopy, it's relevant on what they're looking for. So this is basically some old data. This is a survey of IPEG surgeons Dr. St. Peter, you did this study survey in 2012 and 60% of IPEG surgeons, about 170 surgeons over 30 countries responded that they would routinely do preoperative bronchoscopy. And our institution as soon as recent five years ago, we were not doing preoperative bronchoscopy. One of the arguments was safety and I think safety, it could be done very safely without major complications. One of the other considerations is the likelihood that you're going to find a proximal fish shellah. So a type C is going to actually be a type D is so low while I do it. But I think there's a lot of utility in doing it. This is an Italian group that looked at bronchoscopy in patients and found that it was useful. You can define useful in various ways in 45% of patients. Approximal fish shell and type A or even type C. But I think fish shellah occlusion, if you're worried about abdominal competition and distending the GI tract with gas when you're intubated in alteration, the operative approach. If you did find a proximal fish shell and you think you need to do a cervical approach, I think there's utility in it. Are ENT surgeons do our bronchoscopies and they actually look at laryngeoclefs as well. So if the baby's stable, they'll put them in suspension and look for laryngeoclefs, which I think is really important just because these children have a lot of respiratory issues, a lot of feeding issues. And there's utility in knowing whether or not they have a laryngeoclefs and developing a safe feeding plan for them. Of those in the room, if you did your own bronchoscopy, how many would consider having ENT bronch that patient before they go home to see if there's a cleft? So for those online, nobody raised their hand. But it's a real diagnosis occurs all the time and we may be ignoring that. So it's all something you should consider. We do the bronchoscopy. We don't look for clefts, right? We don't suspend the patient. We can't see it. So it's something you should consider before they leave is to have the ENT guys just scope them to make sure there's no cleft because they can miss the respiratory issues to go on with it. I think that's why Dr. Holkham's question is so relevant. On the depends on what you're looking at. At least in our center, we try to do it together or at least one doing it, the other one watching. And we get the video and we kind of analyze it together. If you think there's an argument for efficiency in talking to your teammates, I mean, a full ENT ball can take a while and you have a kid who's sort of basking between great and not so great. So it's important to be in the room with them, talking about what your goals are and getting through it in an efficient manner. I just wanted to add, over in Mexico, is the pediatric neurologist with us and we're every one in the room when it's done. Okay. That's it. Yeah, keep going. One last comment about the clefts. Like they come in different forms. So we've had like two major clefts in the last year where you probably shouldn't proceed with general anesthesia without really thinking about that because the kids can decompensate if you try to integrate them. So I think that's another reason that sometimes we don't talk about that it's important to do this bronchoscopy. The other thing I like doing after you've done it with the ventilating bronchoscope, you can take the ventilating part off, put the ET tube over the scope itself and then position the tube tip exactly where you want it. I wanted to just do that beyond the first of the cleft and the proximal fistula. I've had at least three babies with a peak bronchus, an additional bronchus. It's nice to know about it before you do your surgery because that anatomy can actually be a little confusing. Just a couple additional points. I think these are all brought up in the discussion. You can have an unusual fistula location whether that's a peak bronchus or a main stem bronchus fistula. Up to 20% of patients with EA will have a laryngeal cleft and I think it's important to know about that. And then you get more rare things like a subglotic or a molecular cyst that may have implications for respiratory support and how the baby does post-operably. We're going to jump to the next scenario. So you say you're doing a preoperative bronchoscopy, the baby's under anesthesia but they're ventilating spontaneously and you see that the distal trachea collapses during spontaneous ventilation. So this baby has tracheumal acere, you can see that the anterior cartilage is more deshaped and they have a wide trachealis muscle. So what is your intraportive approach to tracheumalacia at the time of the index EA repair? Do you do no intervention? Do you plan a second bronchoscopy before discharged to see how the malacia may have changed with repair? Do you do a selective trachea pexy or do you do a trachea pexy in any child you see that has tracheumal acere on a preoperative bronchoscopy? Who does trachea pexies in the room? So for the virtual audience I think it's two. And so of those that don't do it, who does it in your institution? We thought that time was a good one. Oh you're talking at the time of the index dot-row. We're just gateway trachea pexies to somebody like the cardiac surgeon's person. Can you toggle between the choices just to see the percentages? So it looks about half of people don't intervene. Maybe a quarter to a plan, second bronchoscopy, up to 20% to a selective trachea pexy, and then 7% to a trachea pexy. Does anybody in the room do a trachea pexy selectively or at the original operation? Thanks for asking. I think what is like the hardest thing to decide right now whether to do that or not? I think in Cincinnati we tend to do them selectively. I wish I had a better answer about which kids get it and which don't. If you have a stable patient who had a pretty impressive bronchoscopy before surgery, then I think that's taking 15 to 20 minutes to do a couple extra sutures make sense at that time. I think that's because we don't frequently get asked to go back and do a trachea pexy after which is a lot harder if needed. So hopefully someone can answer this question for us though. I know they all look like that. No, I can't sign that for you. Right. Wait, Rick, you can't talk without a mic. So Aaron, if you're doing a throrchoscopy, TF only takes you 15 minutes to do the trachea pexy. I think that's pretty 45. Fellows are doing of course, right? And then as far as doing the scopes, I do wish that our fellows were able to do them. It's nice to have ENT in the room. No, not infrequently those patients get sick. There's a plug in the bronch and the ET tube and have an ENT around to come in and help or change it to that. We have found helpful in our institution. Yeah, I think we're really bad at predicting what a preoperative bronchoscopy will mean for clinical evidence of tracheumalacia. We're just not very good. The sensitivity is probably only 50%. So this has been studied retrospectively and in patients that did not have evidence of tracheumalacia that about half of them would go on to develop tracheumalacia. It was clinically significant. So I don't think there's a great way even with the shape of the cartilage or the amount of posterior intrusion that you can really predict in a given child what their clinical course will be. We will selectively perform tracheophexy. Usually, it's at the location where you've divided the fish. Usually, we don't do a more robust tracheophexy because that seems to be the area where it's the most prominent collapse. And I agree doing it at the time of the index operation and a baby that's stable as far easier than going back and digging through scar tissue to get to that anatomy. This has been looked at by groups in Boston and Johns Hopkins, all childrens as well as a group in Norway, or excuse me, in the Netherlands. And primary tracheophexy at the time of the A-repair and children that have moderate to severe tracheumalacias or 75% or greater collapse seem to have fewer life threatening events, fewer hospitalizations for respiratory illnesses and actually improve weight for these fours at 12 months of age. And so I do think there's merit in doing a primary tracheophexy at the time of a soft agelatresia. Obviously, there's a learning curve to it and so this may be more generalizable at one point. These are just some brief pictures about posterior tracheophexy for people that may not be as familiar with it. It was originally described in the cases of recurrent tracheosophageal fissula and the question is how do you separate these suture lines to prevent yet a second recurrence. After the fistula is divided, you can see the esophagus and figure Bs move to the right and you put stitches in a horizontal mattress fashion under flexible bronchoscopic guidance. In the posterior remembrance portion of the tracheum, then you suture them to the anterior longitudinal ligament of the spine. And so picture D to picture D nicely where before you have a trachea anteriorly, a recurrent T E F and the esophagus posteriorly. And then once you've divided the fistula and done your tracheophexy, the esophagus is moved into the right chest and the trachea is their pexy to the spine. Anybody do an anterior tracheophexy at this point? Think of a past. No, at all. If you needed to have a tracheophexy, you're three months off from your repair, let's say you're a year out, would anybody do an anterior tracheophexy versus a posterior tracheophexy? Preferentially? I don't know if there's data that's allowed. My whole Lurie children in Chicago, I'm not sure that there's data that say that one is superior to the other. An anterior brosis post-serior tracheophexy. And in fact, maybe thoracoscopically, if you went in through the opposite chest of your repair, it's actually a version territory to do an anterior tracheophexy quite easily. Yeah, we'll keep moving forward in the interest of time. These are just some quick pictures in regards to tracheophexy. You can see the esophagus here that's being tinted anteriorly. You can see the pexy sutures, the trachea is pexy back to the spine and the esophagus falls back into the right chest. Very quickly, three kilo baby undergoing esophageal atreasure repair. Would anybody do recurrent lurinjial nerve monitoring at the time of the index operation? Or would you only do this in a reoperative setting or would you do it if you're going to the next? So the audience poll is no, depends on the sub-tight, only with a cervical dissection or routinely. I would love to do it, but we don't have that size available in Chile. I think that's one of the big challenges in doing this. We've seen the videos of how to adapt one of the big laryngeal nerve monitor electrodes to a tiny tube, but we have not been able to make it, I'm sorry, I have not been able to make it work. I just want to have a couple of minutes. Yeah, it's really challenging to do. And I think to your point, it's hard to modify this for small endotracheotubes and children. I think we injure recurrent lurinjial nerves maybe more than we appreciate. And 11% of patients in this may be an underestimation. H type injuries, which are often addressed through a surgical approach, is up to 50% of patients. Injury rates may be higher during a thoracoscopic repair when you're mobilizing the proximal pouch. There is some data out of Austin that shows that intraoperative recurrent lurinjial nerve monitoring appears to decrease nerve injury rates in high-risk cases, which they define as a soft agiotracheal, cardiac or a combination thereof. So I think there's merit in it, but this is probably something that's going to take a while to get widely adopted in the sense that modifying the electrodes to small endotracheotubes and troubleshooting that is challenging. And there's definitely a learning curve to it. Any other comments or questions? Great, thank you. Thank you. That was perfectly on time. Thank you, Manch. That was awesome. Thanks, Matt. Thank you. All right. Yeah.