Interesting Case Presentations Part II: EA/TEF

Hybrid thoracoscopic-endoscopic approach with transillumination is essential for localizing distal esophageal strictures that are not visible thoracoscopically

Distal esophageal cartilaginous rings should be resected rather than dilated, as dilation is ineffective

Upper pouch fistulas or H-type fistulas are very difficult to see and can be missed even by experienced endoscopists, requiring repeated investigations

Contrast studies should be used in addition to bronchoscopy when evaluating for fistulas, as what may be missed with bronchoscope could be picked up with contrast

Thoracoscopic approach is feasible even after previous open thoracotomy on the same side, with adhesions being manageable

Esophageal flap repair can convert a grade 3 laryngotracheoesophageal cleft to a grade 2 cleft, allowing for safer subsequent endoscopic repair

Rapid spillover of contrast into the trachea with less than 1 millimeter of contrast should raise suspicion for laryngotracheoesophageal cleft

During bronchoscopy, one should attempt to separate the posterior commissure of the vocal cords to identify a laryngotracheoesophageal cleft

For right-sided aortic arch with EA/TEF, left chest approach is easier because the aorta is out of the way

Right chest approach with right-sided arch is feasible but can cause bradycardia when retracting the lung

For patients with CHARGE syndrome and swallowing problems, if esophageal replacement is required, colon interposition is preferable to gastric transposition because the stomach can remain in the abdomen for gastrostomy feeding

Thoracoscopic approach allows better protection of the recurrent laryngeal nerve during H-type fistula repair because all manipulation is under direct vision

Flexible bronchoscopy through an endotracheal tube will miss proximal fistulas because the tube is positioned too far distally

Rigid bronchoscopy provides better examination than flexible bronchoscopy for identifying fistulas

Post-pneumonectomy syndrome is a risk in young patients with esophageal lung, potentially requiring placement of tissue expander to stabilize the mediastinum

The younger the patient undergoing pneumonectomy, the greater the risk of post-pneumonectomy syndrome