Tracheoesophageal Fistula with Dr. Daniel von Allmen

Tracheoesophageal fistula, really a defining procedure of pediatric surgery. While this operation is very rewarding, it has a lot of challenges with it as well. Long gap atresia, recurrent fistulas, strictures. These are all very challenging things to deal with. And so today we're going to talk to Dr. Dan von Almen from Cincinnati Children's Hospital about how we deal with these complicated situations. Stay Current is a multimedia publication designed to keep healthcare professionals up to date with standards of care and new emerging ideas. Stay Current is created and edited by Todd Ponsky, Ian Glenn, and Sophia Abdulhai and is recorded and produced at Akron Children's Hospital in Akron, Ohio. Welcome to State Current and Pediatric Surgery. This is Todd Ponsky from Akron Children's Hospital joined by Dr. Avi Schlager, uh, who's one of our new partners. And today we're going to be talking about tracheoesophageal fistula and esophageal resia. And with us we have again Dr. Dan von Almen, who is surgeon in Chief of the Lester Martin Chair of Pediatric Surgery, Senior Vice President of Surgical Services, and professor of University of Cincinnati Department of Surgery. Dan, thanks for joining us yet again. My pleasure. Thanks for asking me. I know that this is something that is a particular interest of yours. It certainly is an interest that we have here with a whole group here in Cincinnati, but it can be an incredibly difficult, challenging problem. It's one of the great cases in pediatric surgery and one of the most difficult cases, so it really runs the whole spectrum for sure. Actually, Dan, can you go into a little more detail because I was very impressed when I visited down there. Your multidisciplinary center, can you explain who's in that center and how it works? Sure, I'm very fortunate to have come here and as many people know, there is a pre-existing world class aerodigestive center led by our ENT group, but they have structured a multidisciplinary group to which they invited the esophageal. Center to join that group includes our ENT airway surgeons, our GI docs, our pulmonary docs, our general surgeons such as myself, as well as a lot of support services, nurse practitioners, geneticists, dietitians, and all the various support groups that can help with this difficult patient population. And which patients are seen by this group? Is it only the complicated ones? Typically we do receive the more complicated patients who are referred from outside, and they come either through the esophageal arm of the group or through the airway, frequently through the airway group because they may have had multiple previous operations with vocal cord damage, etc. that brings them in through that that avenue, but it's the advantage of having this multiple disciplinary approach because everybody contributes and these kids usually have way more than one system involved in their complications. Yeah, all right, Dan, let's get started going from discussing complicated patients. Let's talk about the most straightforward. So fun ones, the fun ones exactly. So you get called then for a baby that was born in the nursery. They say that they have had some respiratory spells and they tried to pass an OG tube and and couldn't, and they call you. So on your way there you're sort of wondering, OK, this baby sounds like may have an esophageal atresia but may have other issues as well. How do you start off with your approach to these patients when you first see them in the nursery? So you know this is kind of basic stuff, but I think the first thing to do is go and examine the child, and you can learn a lot from looking at them, examining the abdomen. Do they have a scaphoid abdomen? Is the abdomen full? Is the abdomen distended? Is the child in respiratory distress, all those sorts of assessments that you can get just from a simple exam. The other thing I do is that, as you mentioned, frequently the history is we can't pass the NG tube. Sometimes they've even already obtained a plain film. But I personally like to try to pass the NG tube myself, having been burned with NG tubes that wouldn't go down, and the patient was started on treatment as an oesophageal atresia and subsequently found that the NG tube passes just fine. So I think it is important to Do that yourself. I like to actually inject some air. If it doesn't pass, I inject some air into the tube and obtain a plain film just of the chest and abdomen to look and see where the where the tube is, as well as to assess the gas pattern in the rest of the GI tract. I do the exact same thing. Do you ever use a more stiff tube like a A very small chest tube or no? I don't. I usually just use a reasonable sized replogal tube, and again, I think injecting air is a useful diagnostic because it's important to me when I look at those films to see that there's distention of what appears to be a proximal esophageal. Pouch. If I can't see a distended proximal pouch, then I worry. I worry that either one of two things either that the diagnosis is incorrect and in fact it is not an esophageal atresia, or that there could be a proximal fistula which is allowing that proximal pouch to decompress. Well, that's, I've actually never injected air. I think I might start doing that now. Have you ever injected contrast? I have, after seeing that, you know, a lack of proximal pouch visible on a plane film and having a relatively high index of suspicion that something else was going on, either that there was a funny history, they had trouble passing the NG or something. On rare occasions I have done a contrast study. I don't think there's any contraindication to doing that as long as the radiologist is aware of what you're looking for and that this job may very well be obstructed. Got it. OK. Let's say you're pretty convinced you pass the tube, it doesn't go anywhere. You inject the air, you see a nice proximal pouch, you see some distal air in the abdomen. What do you do before surgery? So it's important to rule out the other associated complications associated with the veal association. The most important one prior to taking the patient to the operating room is to get an echocardiogram, and the utility of that is, is obviously to assess the cardiac anatomy, but more as importantly, I would say is to assess to be sure that the patient does not have a right-sided aortic arch. OK, great. Do you feel the need for getting any other studies other than the echo? Ultimately, the patient will certainly need a renal ultrasound at some point. They'll need some evaluation of the we typically evaluate the spine for a tethered cord, but those are more elective, and I don't think they are necessary before addressing oesophageal atresia. Perfect. And jumping ahead a little bit, if there is a right-sided arch, how do you approach those patients? So having been in that situation, I think it depends on whether you figure that out before you're in the operating room or after you're in the operating room. OK, let's talk about before first. So conventional wisdom is that you should do a left thoracotomy as opposed to a right thoracotomy, and I think that faced with that, that's what I would do if, if the echo was pretty clear and suggest that there's a right sided aortic arch, I would probably approach it through a left thoracotomy. OK. Any technical pearls on on challenges with going through the left side. No, I think it is a somewhat more difficult operation. Obviously the heart is more in the way. It can be a little bit harder to mobilize the proximal pouch, but it's really the same operation in terms of identifying proximal and distal esophagus and pulling the ends together. So what happens if you find that in the operating room? And I've been in that position where the echo was reported to be normal, and in the right thoracotomy, the first thing I came to was the aorta. But I, in that case, it is possible to still complete the operation. There have been some reports to suggest that there's a higher incidence of problems with swallowing and such after that, but I think that in most cases it is possible to get the esophagus together and to have a good result. That's actually the one I've had. We did through the right side. And it was tricky, but that's why it is, you know, when talking to people, there's certainly a split on whether people go to the right or the left, especially if you find out intraoperatively. I would not close the right chest and reopen the left chest. If I were already in the right, I would fix it from the right. That's my point. That's a great summary there. So back to the patient who fortunately does have a normal left sided arch, and you go see the patient and They are doing great, stable on room air. And it's Saturday morning and you have a lineup of cases coming in. Do you do it right away that day because it's safe to wait another day or 2 days or 4 days? What's the, what's your take on that? I think that in a larger baby who's stable from a respiratory standpoint, not intubated in particular, I think it's perfectly legitimate to wait until you have all the resources that you would have in the middle of the day, and whether that's a Sunday, if the baby comes in on Saturday and the child's healthy. And looks good, then I think it's perfectly reasonable to do that case electively on Sunday or even Monday. I would not wait a whole long time because you worry about beginning to colonize the GI tract and soil the lungs. Well, let's take the opposite now. So now you, you see the baby and really having trouble, having abdominal distention, some tachypnea. This is they actually intubated the baby, so now all of this is getting even worse. How do you manage, not surgically yet, but how would you manage that baby prior to surgery? Would you, would you switch them over to an oscillator, keep them on a conventional ventilator? I've not found personally that an oscillator makes a whole lot of difference. I think if the child has a, has a large fistula, and typically it's actually, I believe this tends to be a bigger problem in younger, that is more premature infants who have more significant lung disease, and their compliance of their lungs is really what drives the The air into the GI tract as opposed to into the lungs. So I think that treating them with surfactant, doing whatever you can do to improve lung compliance probably helps as much as changing the ventilator from conventional to oscillator. OK, again, not really wanting to jump too far ahead, but I think we might have to to answer this question. So the baby is getting worse clinically and. Is having worsening abdominal distention. What are some kind of maneuvers that you can do before or in the operating room to help with this child's situation? So I think this is a difficult clinical scenario, and, and I think one of the risks is to wait too long to make a decision, and I've made that mistake myself, and then it becomes an emergency if you can't ventilate the child. So depending on where you are in that spectrum of ventilating but getting distended to crisis mode where you can't ventilate, that would for me determine my approach to the to the treatment. If the child is reasonably stable but getting more distended and more difficult to ventilate, then I would take the child to the operating room more urgently with a plan for a right thoracotomy and ligation of the fistula. A lot of the techniques that are described for controlling that intraoperatively, some of which I have, have no experience with, you know, one of the standards is, well, you just do a bronchoscopy and stick a A Fogarty balloon in there I think sounds good, but it's difficult to do unless you have the expertise and the equipment immediately available. You can do a G tube and decompress the stomach, which may or may not help. Decompressing the stomach may just allow that to become, in effect, the even lower resistance and allow more air to go there, making it even more difficult to ventilate. You relieve the abdominal distention, but you don't fix the flow of gas from the Trachea to the GI tract as opposed to from the trachea to the lungs. So have you ever opened the stomach and placed a foley through the transgastric? Of the esophagus. I have not done that, but what I have done is to do a laparotomy and actually put a vessel loop around the esophagogastric junction at the hiatus and then pulled that up to the essentially like almost like a Rommel tourniquet and to gently put some traction on that and you can, I've even put in a G tube and closed the child and left that in place for several days while we got the child stabilized and then. Took the child to the operating room, divided the fistula, and removed the vessel loop. That's a good sort of list of examples of things that can be performed in that tough situation. What about the baby that you get the abdominal X-ray and there's distal air but it looks like a double bubble and you're suspecting associated duodenal atresia does that change your management in any way? It certainly makes you think that you obviously have to think about which of these atresias are you going to fix first, the duodenal atresia or the esophageal atresia, and I think again it goes back to how stable is the child. If the child is very stable from a respiratory standpoint, I would potentially fix the duodenal atresia first so that when I fix the esophageal atresia, it's not fixing upstream from an obstruction. So would you ever consider doing both of them when you say first you're talking about the same operative setting, uh, or separate, a separate potentially a separate operation um you could you fix them at the same time? Uh, yeah, I don't see why not. I think that our pediatric anesthesia has gotten good enough and if the child is old enough and stable enough you could potentially do both procedures at the same time. I think typically they're staged. So Dan, let's move to the operating room. Do you always perform intraoperative bronchoscopy prior to your repair? I'll tell you that that is one of the things that I have changed in my management after coming here and having exposure to the patient population that we see, the complex patients that we see with the esophageal center and the neurodigestive center, and The airway surgeons here have convinced me that it is really important to do a bronchoscopy, and I think that you're looking for several things. One is that you can document where the fistula is. You can rule out, or you can at least assess. None of the tests are perfect, but you get a better assessment of whether or not there may be a proximal fistula. And equally or probably most importantly is to make sure that the patient does not have a laryngeal cleft, and that is easily missed, and we have seen that many times in patients who are referred who've had multiple thoracotomies. Nobody ever did a bronchoscopy and the child actually has a laryngeal cleft, yeah. What rate do you tell the parents is the chance of a missed second fistula? I tell them that it's very uncommon and they can be very difficult to diagnose, but that in perhaps 1% of kids there is a second fistula that we need to be aware of so that we can address that during the initial operation. OK, so I've had now a series of these fistulas that are very high. And you can see that bronchoscopically ahead of time. Yes, absolutely, and that's that particular anomaly is an interesting thing which I've also seen several times where the fistula is quite high and like everything else in embryology and development, it's a spectrum and so it can be everything from essentially a trifurcation of the carina, which gives you some idea that you may have trouble getting the ends together to a fistula that's quite high and potentially even approachable through the neck. Hi Doctor Alma, it's Avi. I was wondering what depth do you, uh, instruct or discuss with the anesthesiologist about placement of the ET tube? Do you ask them to sort of place it just high so it won't fall into the fistula, or do you try to main stem? Again, that depends somewhat because we do bronchoscopy on everybody at the time of surgery. We can guide the anesthesiologist in terms of placement of the tube. If the fistula is at the carina and it's essentially a trifurcation, then you might as well leave it higher because you're not going to be able to put it. Pass the fistula if the fistula is quite high, as the case that Todd just described, then you would be much better off to place the tube distal to the to the fistula, but you have to make sure that the tube doesn't go into the fistula, which is certainly a risk, but that's pretty obvious on auscultation. So Dan, I know you do this both open and thoracoscopic. Let's start with the open approach. Do you do this extra plural or trans plural? I do an extra plural approach and that's the way I was trained. I think it offers the advantage of potentially limiting any soilage of the plural space if there is a leak postoperatively. So I personally prefer to do an extra plural approach, OK. And you get into the chest, and do you routinely divide the azygu? I do. I think there's no morbidity associated with that, so dividing the azygus gives you better access. In fact, frequently will guide you to the fistula. So I would in most cases routinely divide the azygus unless I can clearly see the fistula above it. And how do you divide that fistula when you're doing it open with suture, I'm assuming, yeah, I usually ligate it and divide it, doing it open. I think thoracoscopically you can divide it with one of the energy devices or you can divide it with clips. And just from experience I've tried everything now. I've tried. I've tried actually hook cautery is the most common way that I do it when I'm thoracoscopic, which scared me the first time. It's just a matter of going really slow up and down, not taking it all at one time. I've tried the metal clips. I've tried the weck clips. The wet clips are a little tough because the instrument head is a little big, so sometimes it's tough to see as you're putting the clip across, but I'm confident on how well it holds. And recently I've used the 3 millimeter just right surgical sealer, which is a nice little trick. Yeah, I think to me that's sort of the ideal approach. I am not a big fan of clips because I worry about them falling off. It is amazing what you can divide with the electric cautery, with the hook electric cautery if you just get used to it, and I learned that doing actually robotic Nissans that you can divide the short gastrics in a teenager with the with the hook electric cautery. You just have to be, as you said, you go up and down and make sure that you've, you've coagulated the vessel, but I think the 3 millimeter sealer is a, is a great device for this size patient and that size vessel. OK, so still staying open here for now and then we can get on some dochoscopic pearls after. So tell me the steps of your operation. So with the patient obviously in the left lateral decubitus position we would do a posterior lateral thoracotomy, stay extra plural, and I think as you go down through the Intercostal muscles, I, I just take a right angle and put the heel of the right angle on the ribs and spread it and it very nicely shows you that extra pleural plane and then mobilize the pleural posteriorly to expose the azygous, which I really use as a sort of a guide to where I want to be. I do think it's important to mobilize the pleura up around the apex of the lung so that you will have access to mobilize the proximal pouch of the esophagus. Once that's done and the azyous is divided, then I identify the distal esophageal segment and usually control that with a vessel loop, which allows you to dissect more proximately up to identify the site of the fistula. You mentioned that little spread, the back of the hemostat. Any other technical pearls that you, I mean, let me actually ask you point blank, do you do, for example, a muscle sparing tchotomy? I have done them. I don't always do them. I think it, it can make the exposure a little more difficult. I know that there are potential advantages to that, I suppose, if you're, you're going to raise a Major League Baseball pitcher, but I think that I have not seen a lot of morbidity from a standard posterolateral thoracotomy. OK, great. So let's say you're trying to do your dissection, you're trying to get your two ends together. There's actually quite a big distance. Any tricks you use to gain distal length. Yeah, I think that we have learned that, you know, the standard teaching has been that you shouldn't mobilize the distal esophagus at all, and I think we've learned that in fact you can mobilize that segment a fair amount, especially laterally. I would mobilize all the way down to the diaphragm medially where you worry about the blood supply more. I think you have to be careful, but you can mobilize it to some degree. And then I think the important and the extensive mobilization you're going to get is from the proximal pouch. Identifying that usually involves, I just ask the anesthesiologist to push on the NG tube, which helps to identify the proximal pouch, and then dissecting in that area can be a challenge. I think it's one of the advantages of the thoracoscopic approach because you, because you can actually see that more clearly, but mobilizing that proximal pouch up as far as possible really gives you the length to try to get the two ends together. You know, hitting on that part you just mentioned, the proximal pouch, to me it seems similar to almost when you're separating rectum and vagina. It's, it's almost you're making two planes out of one. There's not a great separation between the two, and sometimes you can risk getting into the trachea if you're not careful. I completely agree, and I think that you have to be very careful. I personally like to just use a blade, electric cautery and with a little buzz and then mostly blunt dissection with the flat end of the blade, and I think that. That can help you and staying right on the esophagus, which is usually very thickened because it's an obstructed piece of bowel. I would rather be in the esophagus than be in the trachea up high in the chest. And so, but that dissection is, as you have described, very much like separating rectum and vagina. So let's say the worst happens and you end up with, you know, a larger than you would like hole in the trachea. Are there any tricks as far as if you can't bring the two edges together primarily? I have to admit I have not faced that problem acutely. It's usually possible to close the trachea. It would have to be a pretty significant defect in the trachea to not be able to get it together. You could do essentially a sleeve resection. The trachea is incredibly mobile. Another thing that I have learned from my ENT colleagues so that you could effectively do a slide to pull the distal trachea up to the proximal portion to cover that defect. And then I would put either pericardium or some autologous tissue between the trachea and whatever esophageal repair was possible if you had that big a defect in the trachea. I think. That's something that we can go into more on one of our subsequent ones, Dan, where the idea of putting tissue between the esophagus and the trachea, especially in recurrent TEFs, uh, is something that we'll, we'll see as a recurring theme. So you want to go ahead and put your anastomosis together. Do you have any preference on the type of suture you use for this? I personally use PDS. I probably use 50 PDS. I like absorbable suture. I like monofilament suture. I'm not a big fan of silk, uh, which other people use. People usevicro. I mean people use almost everything, but my personal preference is an absorbable monofilament, and PDS is my suture of choice. Perfect damn suture. Yeah, that's right. So, uh, Dan, let's say that this is a, we'll take two scenarios. One is a pureresia and the other is a TEF, or either of them. It's a TEF. Let's say you can't get the ends together. Do you have tricks to try to, to manage that patient when you can't get them together? There are lots of things that are described in terms of techniques to facilitate getting the ends together. Probably the most common thing described is the myotomies, and I personally am not a big fan of myotomy. I think it. Potentially creates an even more dysfunctional segment of the esophagus than already exists. The motility is clearly abnormal in patients with oesophageal atresia, and doing a myotomy just makes that problem worse. So I am not a fan of myotomies. You can do reverse flaps and such, but honestly, I, my approach to this is usually if I really try and I think it's going to be way too tight. Then I would ligate the ends, ligate the distal end after dividing the fistula, and then tack both ends on some tension to the prevertebral fascia, close and let the patient grow for a couple of weeks, and then return and put them together. What are your thoughts on, let's say for a pureresia on the Folker procedure? So I, I believe very firmly in the physiology of traction or pressure. Actually it's sort of the reverse, is a very strong stimulus to growth all over the place in the cardiovascular system in the lungs, and so I think that that that is a stimulus to growth. There's also probably some stretch, and I know there's a lot of argument over whether you're just stretching things or actually growing things, but I do think that that physiology works. The challenge is how do you operationalize that literally and if my approach is thoracoscopic, then what I have done is to put traction sutures in the proximal and distal ends and bring them out through trochar sites above and below so that they're crossed. Obviously this is a technique that I learned from. David Vanderzee and put tension on those and you get rapid lengthening whether it's growth or just stretch it's probably more stretch, but can usually go back within a week or so and put those patients together but I usually do the so-called internal folker, which is just Packing the ends on some tension to prevertebral fascia, or I would put some sutures in, but I would not do what is classically done or described by Dr. Folker, which is, you know, paralyzing the patient for a prolonged period of time and sequential tensioning of those sutures. I will tell you that there's so much debate on this, and I know that from experience people have strong feelings one way or the other. I will tell you that my Partner here, Bob Perry has now done, I think 5 or 6 of these, and all of them have worked great, so his results are different than mine. I think it must be in the way he does it, but I've, I've witnessed them and they've been spectacular outcomes actually you almost couldn't even tell that there was any stricture at all at the anastomosis after the Fokker. So somehow some people have great success with it, but not everybody, and I don't know why that is. And I think that's been the challenge with acceptance of that technique is because people's experiences have been so varied. But to me, I think credit to Rusty Jennings in Boston and Dr. Folker, who is the consultant there with them. They published a series a year ago or so in JPS looking at their results, and, and it was a very carefully well documented report of their results, and the data are striking if you Have a patient who has a primary atresia that you address, then in 98% of patients they're able to get the two ends of the esophagus together. In contrast, if it's a patient who's had previous surgeries and it's a secondary approach, then only 2/3 of those patients ever get the esophagus together. And in both groups there's a fairly significant cost to that in terms of what it takes. The patients are intubated and paralyzed, spend. Weeks in the ICU, which in the long run is probably worth it if you get a good result. So I would recommend to people that particular paper as a very well documented series from the people with the most experience doing it. I think that this deserves its own podcast where we can go into depth into some of the newer innovations that are out there and Complicated tricks that people have to getting these ends together. I know some are trying magnets and all sorts of new tricks, so we can get into that in a subsequent podcast. That would be great, which you have agreed to do, right? Happy to do it. So Dan, I know you do this both open and thoracoscopic, and there's definitely advantages to both. Tell me the basic setup on how you do the thoracoscopic procedure, how you position the baby, where you put your ports, for starters. Yes, sure. So as with most thoracoscopic procedures in the posterior mediastinum, I would rotate the. Patient past 90 degrees to allow gravity to help to move the lungs out of the way and then set up the standard port placement with the obviously the camera in the center and then a posterior port inferiorly and a more anterior port superiorly. I think allows you if the patient is ventilated well, it will allow the lung to drop away and give you exposure to the posterior mediastine. And do you use 3 millimeter instruments? Yes, OK. And regarding the repair, anything different than sort of the open repair as far as pearls, or I mean we had already talked about dividing the azagus. Any, any other technical pearls thoracoscopically? No, I think as with most minimally invasive operations, I think it's important to do the same operation or at least the same quality operation that you would do open and Frankly, I think that's one of the challenges with the thoracoscopic repair of a TEF is to actually sew the anastomosis. So in terms of dividing the azygous, I think you could use the sealer divider or sealer as we previously discussed. That's what I would use in terms of dividing the fistula. I would use clips for that, even though I'm not a big clip fan. I'm less worried about them falling off the esophagus than I am having them fall off a blood vessel. And then as we discussed previously, I think the visualization that you get is very helpful in mobilizing the proximal pouch. And then the anastomosis is the difficult part, and I think that's the part that requires the most experience with minimally invasive techniques, and it takes practice to do so I'm excited about the potential for some of the simulation courses because frankly these are not things that we get the. Opportunity to do that often and so there have been simulation courses designed to help teach people how to do this, which I think will be a great advantage for the trainees. Absolutely, I agree. And just to add a few more points, when doing the proximal dissection, Marcelo Martinez Ferro described a cool trick. I think he called it the spaghetti trick, where he grabs the tip of the proximal pouch and sort of twirls it on. Yeah, he twirls it up and it shows you that plane really nice. That's one little trick. I know that the group in Atlanta have talked about, and Avi can speak to this in a bit, they've talked about putting in a stitch, like a stay stitch that comes out of the chest where you put the first stitch between the two ends and it sort of holds it up in the air for you so you can put your subsequent stitches in that technique, and it's something that is done in duodenal atresia repairs and such. It just helps to line up the anastomosis. Exactly. That's a great analogy. It's very similar to the duodenal atresia. Taking the stitch, I've learned the hard way. I couldn't decide between Vicryl or or PDS or Prolean, and what I found is if you're going to use avicrol, which I think ties down really nice and tight, that's typically what I use. You can't use the knot pusher. Some people like to use the knot pusher for their very first stitch to bring the ends together so that it's since it's under tension, but that will tear through the esophagus. So I think you have to use a monofilament if you're using that. If you're doing all intracorporeal, I think it's safe and nice to use a braided suture. Taking the fistula, I agree using the clip is a nice way. I know that not everyone has access to clip appliers around the world, and a lot of people suture that that fistula closed, which is a nice option as well. I personally don't divide the esophagus all the way distally after I clip it, so I clip it and leave it, and I don't go to cut the fistula until I'm ready to place my first stitch, so it doesn't drop down toward the diaphragm. I agree that's a great trick that keeps you, saves you time wandering around looking for the distal esophagus. Yeah, absolutely. Yeah, one of the other nice things I think about the hanging stitch is that, as you said, as far as it's really sometimes challenging to sort of recapitulate the open surgery in the thoracoscopic version. And so because you can't set up your entire back row thoracoscopically and give sort of tension to all the parts at once, sometimes the hanging stitch can sort of help you. Let go of some of the tension as you lay in your first couple of stitches. So obviously it's not the same as having uniform tension throughout, but you do have at least some degree of proximation before you throw down your first couple of stitches. That's a great point, and I, I agree completely with that. To me, the important part, and I beat on our residents about this when they're doing this anastomosis, is you have to be able to see. You want to make sure that you incorporate mucosa on every stitch, and the hanging stitch, I think, helps, really helps to be able to visualize. The lumen of both the proximal and the distal end. Now Dan, I know we touched on this just a little bit earlier today, but when you do this thoracoscopically, do you have a preference as far as vent set up once again like oscillator versus conventional vent, or do you find that the lung for the most part doesn't really inflate that much to get in your way? I think it's more dependent on the anesthesiologist than it is on the type of ventilator, and you have to have an anesthesiologist who's comfortable with doing this and understands what you're trying to accomplish and is paying attention while you're actually doing the operation because they can either help you a lot or hurt you a lot with how they ventilate the child. It also, because we dope everybody beforehand, you can also position the endotracheal tube in a way that could help you ventilate more selectively the left lung. Yeah, that is a good point, and I know that I've even at Steve Rothenberg's course in Vail that he has every year, I know people were discussing the use of the oscillator, so you don't get huge lung distention, but I think that having some CO2 insufflation usually is enough to get the lung out of the way. And if you need to add an extra port to hold the lung down, that's OK too. Right, but I think that usually, and again this is with, with not just with TEF repairs, but thoracoscopic neuroblastoma resections and such, a little bit of insufflation where a little bit of time will collapse that lung as long as the anesthesiologist isn't fighting against you with positive pressure. That's a great point. They can tend to get scared and sometimes freak out a little bit when they see the shunting in the beginning, and if they just wait, things settle down. So let's get into the the routine patient postoperatively. When do you extubate? I know that some people worry about, especially me, that I want to make sure that the patient doesn't get reintubated. So how cautious are you with that? I agree it is a concern that the patient may require reintubation. However, I'm equally concerned that positive pressure is putting pressure on my tracheal repair, and I would much rather have the patient be breathing spontaneously to have, in fact, the opposite effect of a negative pressure in the trachea. So. My approach is that if the patient had good lung function going into the operation and the operation goes smoothly, then I would advocate extubating that patient as soon as possible, even conceivably in the operating room. OK, perfect. So let's say you've extubated the baby looks great. What's your post-op plan? Do you get an esophagram, and if so, when do you get it? I do honestly, I'm a little bit old school in that. I still get an esophagram. I usually wait for about 5 days. It's the kind of thing where depending on what day you do the operation, I certainly would not do it over the weekend, so I would either do it before the weekend. So I anywhere 5 to 7 days, I would get a contrast study. Before pulling the chest drain, and I tend to use one of those little TLS drains as opposed to a formal chest tube, especially if I've done an open extra pleural approach. So you're saying that after the esophagram, if all looks good, you'll start to allow PO feeds. Yes, all right. And you said that you leave a trans anastomotic tube as well. I do not actually. I again, a practice of mine that has changed based on our results from the Midwest Pediatric Surgical Consortium study in which the patients who Had a trans anastomotic tube had a much higher stricture and leak rate than patients that did not have that. Has that been published? It was, I believe, presented at the ABSA meeting and should be out in JPS soon. All right, so let's say you have an esophagram and you do see a stricture on the esophagram. When do you time your first dilation? Unless it's an incredibly tight stricture, I would wait several weeks before doing a dilation unless I was worried there was going to be a complete obstruction. But first of all, there's always reported a narrowing because the proximal pouch is always dilated, so it always looks like there's a narrowing at the anastomosis. As long as it's patent and contrast flows freely down the distal esophagus, I would hold off on. Uh, dialing it, dilating it probably several weeks if possible. Yeah, I typically would wait about a month if I could unless it was really tight. I'd have to go sooner. How often then do you dilate? We tend to be fairly aggressive with dilations here, so I usually dilate and then would wait a week or two and reststudy and then potentially dilate again and it's, you know, it's as with everything there's a huge spectrum. There are very tight strictures that are, are going to require many, many dilations, and there are kids who you dilate them once and they're fine, so. I personally, if the case goes well and the post-op study looks great, I don't get follow-up esophagrams looking for strictures. I just let the patient go and if they present with any symptoms suggesting they might have a stricture, then I would study them based on their clinical presentation rather than as a routine. That's a great point. I'm glad you mention that because I've wondered that myself if I'm getting too many esophagrams after my dilations. Do you use a balloon, Dan? Yeah, I think that again, having trained using bougie dilators, a balloon or radial dilation is, is less traumatic for the tissue, and so we prefer to use balloon dilators. We have an incredibly good interventional radiology group here and so we will frequently do them either in the bigger kids with our GI colleagues in the aerodigestive center or with the interventional radiologists. So you get your esophagram and there's a small leak. The child is not sick. How do you manage that? I would absolutely wait and do nothing. I would leave the drain in and usually that presents with some saliva in the drain, and I would just wait, and the vast majority of those close. It does, however, increase the risk that you're going to have a stricture post-op, right? And so your indications for going to the operating room would be what? The only thing that would make me go to the operating room would be if the child were getting sicker and if there was a wide open leak where you, you know, you had a large fistula or you had a large pneumothorax that you couldn't control. In the vast majority of cases, even if it seems to be a reasonably significant leak, it will heal, and then you can deal with the stricture post-op. OK, and do you wait one week between esophagrams for this? I usually do, and there's no magic to that, but I think I usually wait a week and as long as the child continues to do well, then we reststudy and it can get. A little bit arbitrary because I think there's sometimes there's a little outpouching where the leak happened and so whether or not that's actually still a leak or not, if you get a study in a week and there's a little bit of area there where it's not clear but there's nothing coming out of the tube and nothing goes any further than that, the leak is probably healed and I would probably take the tube out. OK, great. What about, you know, one of the things I think we don't do a fantastic job of pediatric surgeons is long term follow up with these kids. What do you do postoperatively for these kids as far as follow up? I think that first of all I would make the comment that that's a great point and it's interesting to participate in the International oesophageal atresia. A meeting that occurs every 2 years and to go and see the patients because that meeting is multidisciplinary, including even patients, and you see these patients who come back who are in their 20s or 30s or 40s and they talk about the long term issues that they have and we tend to follow patients until they're, you know, until they're eating well and then they're gone and at best until they're 18 and then we never see them again. So that is definitely something that I don't think we've done a good job at, and we have a lot to learn about the long term complications. I personally followed them for at least a couple of years, which is again probably not long enough, but if the patients are doing well, I would have them come back as they need as opposed to coming back on a regular basis. The biggest challenge with that group, I think, is typically problems with reflux or recurrent strictures. And the patients who have recurrent strictures and present with obstruction from a bolus of food, you see those patients and dilate them, and it's an ongoing problem. The patients that worry me more honestly are the patients who have ongoing reflux, and we don't know the long term impact of that on things like Barrett's esophagus and Potential long term risk for malignant change and those sorts of things. So let's say you have a patient that does have strictures that continually need to be dilated. When do you decide it's time to do an anti-reflux operation? If I have a patient who has a stricture that's been dilated 2 or 3 times, my next move would be to address reflux. Most of the patients we leave on anti-reflux medications when they are discharged from the hospital. I would argue that virtually all patients have some degree of gastroesophageal reflux. If they have a stricture that is not responsive to dilations, it dilates easily and then restrictures. I personally am very aggressive about doing a fundoplication on those patients, OK. And in patients with these poor esophageal motility, do you still do a Nissan? I do, but as with most Nissans, I make them loose and I make them short, so I usually use two or at most 3 stitches for the wrap and make sure that it is loose around the distal esophagus. And as we finish here, I'd want to know just briefly how you typically would manage a baby that's born with a suspected pure esophageal atresia. So I would just as a brief overview suggest that the approach we take here is usually placement of a G tube with some calibration of the length of the atresia, usually that's done with a distal catheter in the pushed up the distal esophagus and an NG tube or some other radio opaque thing in the proximal esophagus just to gauge the gap. I personally would wait just to see how close those ends come together over the next 4 to 6 weeks, and once they get within 2 vertebral bodies, I would just attempt a primary repair. OK, like I said, I think there's a lot that goes into that and, and we can go over that in a future discussion. Dan, I know that you're probably one of the busiest guys in the country, so I really appreciate you always being willing to do these and your dedication to these types of endeavors. So I hope you have a good rest of your day and hopefully we'll hear from you soon at one of these future podcasts. Great, thanks, Todd. I have to commend you on your commitment to education and putting these things together. So thank you very much. Thank you. Have a great day. We hope you enjoyed this episode of Stay Current in Pediatric Surgery. You can listen, watch, or read all content by downloading the Stay Current in Surgery app. Please send questions or comments to us attacurrent podcast@gmail.com. We'll see you next time.