Esophageal Atresia/Tracheoesophageal Fistula Bronchoscopy and Surgical Technique

Hey there, listeners. This is Rob Gerardo, research resident at Cincinnati Children's Hospital Medical Center. Whether you're watching us on YouTube, listening to us on Apple Podcasts, Stitcher, Spotify, SoundCloud, the best way to listen is on the Stay Current Pediatric Surgery app. It's brought to you by Cincinnati Children's Hospital Medical Center, Children's Mercy at Kansas City, and the Journal of Pediatric Surgery. It's in the Apple App Store, it's in the Google Play Store. Download it today, but until then, Enjoy the episode. Is there anything that will make a pediatric surgery fellow more excited than the opportunity to do a tracheoesophageal fistula repair? OK, well, maybe like free pizza in the surgeon's lounge or something like that. But otherwise, this is one of the bread and butter pediatric surgery thoracic cases. So we're gonna talk about it today with some experts from the Aerodigestive Center at Cincinnati Children's Hospital Medical Center. This is from a webinar this past year with Doctor Mike Rutter, Doctor Aaron Garrison, Doctor Dan von Almen, and of course, Doctor Todd Ponsky. So, without further ado, here's Doctor Garrison with a case. So our first case is a term baby who weighs 3.5 kg who Nurses notice starts spitting up with feeds, and as you can see from the X-ray there, the repogal coils in the esophagus. Um, the other important thing is that there is distal bowel gas. OK, OK, hold on, let's get this straight. So you have a newborn who is spitting up feeds, nurse can't pass a repogal, and now you get this X-ray that shows distal bowel gas. This is, say it with me, esophageal tresia with a tracheoesophageal fistula. What do we do next? So, uh, our protocol here and maybe Doctor Rutter wants to go through the BronC cause we, we have our ENT colleagues do, uh, rigid bronc for every, uh, TEF. Here is a sample video of a rigid bronchoscopy on a patient with a TEF. While you're watching it, think to yourself, what is the information we're trying to get from this pre-op bronc? Then they can give us information about the degree of compression of the airway, how much malaysia can we expect. Uh, we'll get into whether that's something we should address at the time of surgery. Um, and also, where's the fistula that really can, um, help you figure out how much tension is gonna be on your anastomosis. And the ENT on this webinar was Doctor Mike Rudder. Here he is. And so what we try to do is firstly, find the fistula if we can, and we usually can cannulate it just um, and this is using a bugby cautery as a probe. So, Three French, it's skinny, it's blunt-ended, and you can bend the tip of it if you need to. And like Doctor Garrison said, they're looking for malaysia, compression, where the fistula is, and one more thing. And usually probing for a laryngeal cleft up front. Keep in mind, this was a live online webinar. So questions were coming in hot. So here's Todd trying to manage the chat box. Somebody who, who, uh, you know, just doesn't know anything about oesophageal atresia, I'm so sorry, Doctor David Vanderzee, uh, has a question. Uh, David wants to know, do you do rigid or flexible bronchoscopy? For these kids, we tend to go rigid. And so this is usually an ENT rigid bronchoscopy. Um, the reason is that while pulmonary is very good at looking and appreciating malaysia, they are not good at looking at the posterior glottis, and so laryngeal clefts are not reliably diagnosable with a flexible bronchoscopy. And if you use The rigid bronc, then you have more tools if you have to pass a catheter or something like that. So the pre-op bronc is gonna be rigid with ENT, but that doesn't mean pulmonary and their really fancy flexible broncs are like totally gone by the wayside. Subsequent follow-up scopes, we usually do it as a combination with both ENT and pulmonology. Ben has another question. He says, do you use a rigid bronc with a ventilating bronchoscope or not? We typically use a Hopkins rod endoscope, and so this video is with the Hopkins rod endoscope. In other words, it's the telescope that is inside the ventilating bronchoscope. We often will have an endotracheal tube loaded on it, so we can place the tip of the endotracheal tube. Proximal or distal to the tracheoesophageal fistula. That way you know exactly where the tip of the tube is. That's helpful for anesthesia. If we do use a ventilating bronchoscope for a proximal fistula, we'll actually sometimes use a ventilating tracheoscope. That's like a bronchoscope, but it doesn't have the side ports, so you can actually ventilate the child, even though the upper ports are above the larynx. Now they make these. Or, or you can make one yourself by taking a bronchoscope and a bit of tape and taping up the sideboards, so you can make a homemade one quite easily. All right, so we have a patient who presented with a really textbook story for tracheoesophageal fistula. Then we did our pre-op rigid bronchoscopy with ENT so we figured out where this fistula is. Now we're gonna start thinking about the surgical approach. So here's Doctor Garrison. Doctor Rothenberg has really kind of refined this, and I think those who are just starting to do it, probably the biggest thing I see is that they're, they aren't prone enough. So, as he has shown in this picture, really having the baby semi-prone is It is crucial to be able to get exposure. All right, let's talk about some anatomy. Just remembering that the esophagus is in the posterior mediastinum followed by the vagus nerve, and that azagous vein really is your, your target for um where the distal fistula is in a type C. Um, following that racing strike, um, of the vagus nerve can, can help quite a bit. All right, next, we're gonna watch this video of a thoracoscopic approach to a TEF repair. Here's the first part, you can see that they are dissecting out the azygous vein. I was not, uh, initially a fan of the scope, honestly, because this was a more comfortable operation, um, open and doing it, uh, with the thoracotomy, I felt more in control. And, uh, as, as much as I hate to admit it, Todd is the one who kind of got me, uh, more comfortable doing this and really getting the benefit of the exposure. Um, you really feel like it's, I really feel now like it's a less traumatic, um, Dissection, just being able to mobilize the proximal pouch, I think is a little bit easier when, um, when you're doing this with the scope. Um, so this is us just taking the distal fistula with a couple of clips. I know some people don't, don't like clips. Um, yeah, so, so just a couple of things real quickly while you're showing. So, yeah, clips can be knocked off. You can use hook pottery, you can use energy. Curious and this is when, uh, you know, we have the anesthetist, um, pushing on the repogo just to kind of try to find where that proximal pouch is. And then Scott uses something cool. What is it? What does he use again? Bakes, the bakes dilators to, to be able to in the proximal pouch, yeah, proximal pouch, yeah. For those of you who are just listening on audio, this part of the video, they're actually dissecting out the proximal portion of the pouch. This, this is something that we always focus with the fellows on is staying on the esophagus on this common wall. You can see it almost, uh, it's like one of the anorectal malformations. When you're doing those, there's a one wall that you have to kind of make two, and it's easy to get too close to the trachea and get in the trachea. So, we really focus on staying right on that proximal pouch and dissecting up into the neck. I just add the comment. First of all, I love that there are all these experts on, so this will be a great session to get input from all these people who are so good at doing this. But, um, just in terms of the other concern I have when we dissect out that proximal pouch is the recurrent laryngeal nerves. And I think either with traction or, or uh cautery injury or whatever, um, you can, we've become more aware of, of that potential for damage. OK, so stop right there. I don't do this. All right, by this, Todd means that he doesn't completely dissect that fistula that you saw them cut through with scissor. Um, I will leave a little bit of The fistula is still stuck until I'm ready to do my first stitch. And then I put my stitch, and then I cut it. And I'm not smart enough for that. Someone on this, on this session here probably taught me that, but that's a little, I think in this one, we did a suspensory stitch, which I, uh, honestly, I'm not sure whether I like it or not. It did work well in this case. And now this part is the esophageal anastomosis. By the way, Faried Al-Alahi says, do you really have to cut the azagous vein? Um, I, I guess it depends. Sometimes, no, but I think most of the time it does give you a little more exposure to the, um, distal pouch or the distal fistula. Now here you can see the repogo getting pushed down through the anastomosis and they're kind of using what they can to guide it through there, and you can see the suspensary stitch there as well. Now, in this video, they use clips to ligate the fistula, but keep in mind that some people suture, so not everyone really likes clips. You know, when you place the clip, Erin, um, do you leave a stump on the other side of the clip or not? Uh, and if you do, are you afraid that it would, it would create like a recantalization? I try very hard not to leave a stump. You really wanna try to be flush with the trachea, um, and not leave a, not leave a stump at all. I think it's part of the, the advantage of the thoracoscopic approach because you can see that really clearly and make sure that you're flush against the trachea when you take it. If you do accidentally leave a long stump, this is what it could look like on the CT. Um, this is what, um, just a couple examples of the long fistula that were left behind. If you look at the top CT, you can see that, um, you know, third trifurcation remnant that was left behind and can soil the lungs, cause pneumonia. Um, or like the, in the bottom picture with that, uh, air fluid level and abscess cavity. As, uh, others have pointed out, really just staying on that esophagus, staying away from the trachea cause this is, uh, a dangerous, um, part of the dissection. Remember when Doctor Garrison said it's kind of like one wall that you're trying to make two? This is what he's talking about. Um, just a few live shots of that, uh, with the common wall, with the, um, fistula with the yellow, yellow, uh, vessel loop. Um, and the repoggo putting tension on the proximal pouch. And then just to, uh, mention that, uh, if we can, we try to put a piece of tissue of some kind between the suture lines, um, uh, either a pleura or even an azygous flap, um, or a little piece of fat if it's around, but just to try to minimize the risk of, uh, Recurrence. One of the great advantages of the posterior tracheopexy is that you can, if you do that, you can isolate the, um, or you can protect the tracheal closure from the esophageal anastomosis by pexing it posteriorly. Uh, and again, a lot of this from Doctor Vanderzee's paper, um, careful traction, beware of the common wall. Um, and then if, if you're doing it open or if not, you can, or if you're doing it with the scope, you can put in sutures just to kinda cross and bring down the tension. Now, there are a lot of ways that people bring the anastomosis together. A lot of it, like they were talking about, depends on the tension that you're working with. So here is Dr. von Almen talking about a different approach. It's too bad Dr. Vanderzee can't, can't give this one because I think this video came from his group of putting sutures in and sliding the ends together, and this is a technique that I I have adopted from them. I love this of just uh putting gentle traction on and keep pulling on the ends until you get them as close together as you can. Uh, once you get them on as much tension as you think they will tolerate, uh, you can wait and then subsequently come back when there's less tension and do your anastomosis, which is what's shown in the, uh, the video that's playing now. Well, uh, Miguel wants to know when do you go back? Um, what about magnets? Um, bring them together with a couple of prolene sutures and go back a few days later. Um, so that's our, my approach. Uh, in fact, I'm doing this tomorrow is going back after 3 days, um, after leaving the end zone traction, go back after 3 days. Wait, stop, back it up. Did you say magnets? How do they work? I'm gonna put in a brief plug as well for just having a team because a lot of the magnet work is actually done by our GI colleagues here and Phil Putnam's just, uh, you know, Extremely good with a flexible esophagoscope, and I know that in many places, this is also something done by the pediatric surgeons, but again, Whoever does it best should be the person involved. Wise words from Doctor Rutter. So in summary, you had a newborn who presented with spitting up feeds. The nurse couldn't pass a repogol, and then we got an X-ray and it showed some distal bowel gas. So we're pretty set on the diagnosis of oesophageal resia with tracheoesophageal fistula. The ENT colleagues came in, did their rigid bronc. They were looking for compression and where the fistula was. They're checking for their own stuff like if there's a larynx. Pal cleft on the posterior wall, and then we went ahead with our thoracoscopic approach. Making sure that the patient is a little bit more prone than you think. First, you're gonna dissect out the azygous vein. Some people ligate it, some people don't. Then you want to take the actual fistula, and again, you have options. Some people clip it, some people suture it. Some people leave a suspensory stitch or Todd just doesn't cut it all the way until he's totally ready. Next, Next, you dissect out the proximal pouch, making sure to stay on that wall of the esophagus and knowing that that common wall can get really hairy. The last part is the esophageal anastomosis. Depending on the tension that's involved, you may need to go grab a cup of coffee and wait for the tension to relieve itself, or a few cups. Like Doctor von Almen says, come back in a few days. But either way, once you bring it together, then your follow-up is gonna involve flexible bronchoscopy, probably with the whole team, including pulmonology because I mean, let's face it, they use those flexible broncs all the time. All right, that's the end of the episode. What did you guys think? Did you hate it? Did you love it? Do you wanna see the rest of it? Because you can on theta Current pediatric surgery app or on our website, Globalcast MD. We have the whole webinar on there if you wanna sit down and Grab a cup of coffee and watch it. And know that we have more content cooking for you, whether it's these videos, podcasts, guidelines, technique videos. All of it can be found on the Stay Current Pediatric Surgery app. It's in the Apple App Store, it's in the Google Play Store. I'm Rod from Cincinnati Children's, and remember, knowledge should be free.