Esophageal Atresia/Tracheoesophageal Fistula Bronchoscopy and Surgical Technique

The protocol at Cincinnati Children's includes rigid bronchoscopy performed by ENT colleagues for every TEF case.

Pre-operative bronchoscopy provides information about the degree of airway compression, expected tracheomalacia, and fistula location, which helps determine tension on the anastomosis.

During rigid bronchoscopy, the team attempts to find and cannulate the fistula using a 3 French bugby cautery as a probe, which is skinny, blunt-ended, and can have its tip bent if needed.

Rigid bronchoscopy is used to probe for laryngeal clefts, which are not reliably diagnosable with flexible bronchoscopy because pulmonary specialists are not good at looking at the posterior glottis.

Subsequent follow-up bronchoscopies are usually performed as a combination procedure with both ENT and pulmonology.

A Hopkins rod endoscope is typically used for the rigid bronchoscopy, often with an endotracheal tube loaded on it to place the tip proximal or distal to the TEF, which helps anesthesia know exactly where the tube tip is.

For proximal fistulas, a ventilating tracheoscope (which lacks side ports) can be used to ventilate the child even when upper ports are above the larynx; this can be purchased or made by taping up the side ports of a standard bronchoscope.

Doctor Rothenberg has refined the thoracoscopic approach, with the most important technical point being that the baby must be positioned semi-prone, more prone than surgeons initially think.

The esophagus is in the posterior mediastinum followed by the vagus nerve, and the azygous vein is the target landmark for locating the distal fistula in a type C TEF.

Thoracoscopic dissection feels less traumatic than open thoracotomy, and mobilizing the proximal pouch is easier with the scope.

The distal fistula can be taken with clips, though some surgeons prefer hook cautery or other energy devices because clips can be knocked off.

Bakes dilators are used to identify and manipulate the proximal pouch during dissection.

During proximal pouch dissection, surgeons must stay on the esophagus on the common wall (similar to anorectal malformations where one wall must be made into two), as it is easy to get too close to the trachea and enter it inadvertently.

The recurrent laryngeal nerves are at risk during proximal pouch dissection from traction, cautery injury, or other mechanisms.

One surgical approach is to leave a small portion of the fistula attached until ready to place the first stitch, then place the stitch and cut the fistula, rather than completely dissecting it early.

A suspensory stitch can be used during the repair, though the speaker is uncertain whether they prefer this technique.

When placing clips to ligate the fistula, surgeons should avoid leaving a stump and should be flush with the trachea to prevent recanalization.

The thoracoscopic approach provides clear visualization to ensure the fistula ligation is flush against the trachea.

During dissection of the common wall between esophagus and trachea, surgeons must stay on the esophagus and away from the trachea because this is a dangerous part of the dissection.

If possible, surgeons should place tissue (pleura, azygous flap, or fat) between the suture lines to minimize the risk of recurrence.

Posterior tracheopexy can isolate and protect the tracheal closure from the esophageal anastomosis by pexing the trachea posteriorly.

For the anastomosis, sutures can be placed to cross and bring down tension on the repair.

An alternative technique from Doctor Vanderzee's group involves putting sutures in and sliding the ends together with gentle traction, pulling until they are as close as possible.

After placing the ends on as much tension as they will tolerate, surgeons can wait and come back when there is less tension to perform the anastomosis.

The delayed anastomosis approach involves bringing the ends together with prolene sutures and returning after 3 days to complete the repair.

Magnets can be used to approximate the esophageal ends in long-gap cases, with much of this work performed by GI colleagues using flexible esophagoscopy.