Cincinnati Children's hosted the QUAD conference in October 2022 which was a combination of four conferences: The international organization for is Esophageal atresia, the Aerodigestive Society Conference, the Cincinnati Children's Airway course and the Cincinnati Children's pediatric dysphagia series. In this video series, we will summarize the key takeaway points from each session that has been held at QUAD 2022.
Today, we are here to talk about the cervical approach and the importance of ENT involvement with Dr. Alessandro de Alarcon, an ENT surgeon from Cincinnati Children's.
Host: Todd Ponsky
Type: video · 5 min · posted 2023-12-13 Canonical: https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779 ## Chapters - [0:00](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=0) Introduction and Conference Context - [1:14](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=74) Preoperative Workup and OR Setup - [1:47](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=107) Surgical Technique - [3:24](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=204) Case Example and Outcomes - [4:43](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=283) Summary and Conclusion ## Statements - "Cincinnati Children's typically uses a combined cervical and thoracic approach for esophageal atresia cases" — Alessandro de Alarcon (clinical) [0:49](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=49) - "Preoperative testing includes dynamic CT imaging, pulmonary function tests, microlaryngoscopy and bronchoscopy, and flexible bronchoscopy" — Todd Ponsky (clinical) [0:55](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=55) - "Intraoperative tools needed include a neck tray, MLB tray, and Maloney dilators versus NG tubes" — Alessandro de Alarcon (clinical) [1:15](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=75) - "Flexible bronchoscopy during the operation is key for visualization" — Alessandro de Alarcon (clinical) [1:21](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=81) - "Endotracheal tubes are often placed nasotracheally with the cuff positioned high, sometimes almost at the glottis" — Alessandro de Alarcon (clinical) [1:29](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=89) - "A NIM tube is used when possible to prevent potential injury to recurrent nerves or provide awareness when getting close to them" — Alessandro de Alarcon (clinical) [1:39](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=99) - "The surgical approach uses standard neck incision with subplatysmal flaps raised" — Alessandro de Alarcon (clinical) [1:55](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=115) - "Residual or regrown large thymus can be removed during the cervical approach as it is in the way" — Todd Ponsky (clinical) [2:01](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=121) - "Aortopexy and innominate artery pexy can be added at the same time as the cervical approach" — Alessandro de Alarcon (clinical) [2:09](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=129) - "In the lateral approach, surgeons work on the side of the airway to find the esophagus" — Todd Ponsky (clinical) [2:19](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=139) - "Pediatric surgeons find the recurrent nerve for the ENT team to help prevent injury" — Todd Ponsky (clinical) [2:23](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=143) - "The esophagus is mobilized above the level where the team aims to pexy" — Todd Ponsky (clinical) [2:43](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=163) - "Mobilizing the esophagus above the pexy level makes it easier to place sutures exactly where needed" — Todd Ponsky (clinical) [2:49](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=169) - "Stitches are sometimes placed in the trachea to pull it up and out of the way to visualize the posterior aspect where the spine is visible" — Alessandro de Alarcon (clinical) [2:54](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=174) - "A pulmonologist assists with visualization inside the trachea using flexible endoscopy through the endotracheal tube while stitches are being placed" — Todd Ponsky (clinical) [3:02](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=182) - "3-0 Prolene sutures are used for the tracheopexy" — Alessandro de Alarcon (clinical) [3:15](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=195) - "All stitches are placed before securing them down, and this is done under spontaneous ventilation conditions" — Alessandro de Alarcon (clinical) [3:15](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=195) - "The combined approach is valuable for complicated cases or patients needing additional operations for symptom relief" — Todd Ponsky (opinion) [3:24](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=204) - "Outcome measures include endoscopy follow-up, potentially PFTs when patients are old enough to perform them, and imaging" — Alessandro de Alarcon (clinical) [4:00](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=240) - "At 36 months follow-up, imaging may still show some tracheomalacia even when patients are symptomatically better" — Alessandro de Alarcon (clinical) [4:09](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=249) - "The field is still trying to learn exactly what measures should be used to define good versus bad outcomes" — Alessandro de Alarcon (opinion) [4:15](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=255) - "Potential complications include swallowing dysfunction and vocal fold paralysis" — Alessandro de Alarcon (clinical) [4:26](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=266) - "Otolaryngology involvement is important both in the procedure and during follow-up, and is easier when already built into the team" — Todd Ponsky (opinion) [4:32](https://library.globalcastmd.com/watch/quad-1-cervical-tracheopexy-with-dr-alessandro-de-alarcon-7779?t=272) ## Transcript Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hey everyone, I'm Todd Ponsky, and I'm a pediatric surgeon at Cincinnati Children's Hospital. And last year in October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination of four conferences, the International Organization for Esophageal atresia, the Aerodigestive Society conference. The Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia Series. In this video, we're gonna summarize one of the key takeaways from that conference, which was the importance of ENT involvement in the cervical approach in esophageal atresia cases with Doctor Alessandro Dialarcon. In Cincinnati we typically use a combined approach looking at the thoracic approach as well as with the cervical approach. Preoperative testing is important to understand what we're dealing with in the first place. For this, the group at Cincinnati Children's uses dynamic CT imaging, pulmonary function test, microlaryngoscopy, and bronchoscopy or MLB, and flexible bronchoscopy. But what about intraoperative tools? What do we need? You need a neck tray, and MLB tray, and Maloney dilators versus NG tubes in the operating room and you do it. The flexible bronchoscopy is really key and Placing your endotracheal tube is really important so they can look as you were doing the operation. They often like to do them nasotracheally and guide them exactly where they want them. And sometimes that means your cuff is super high and it's almost at the glottis. You just have to be aware of that. If we can, we like to use a NIM tube as part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're Getting close to them. Now that we understand the standard workup and OR setup, let's dive into the typical approach of Doctor Dialarkhan's team. It's a standard neck approach where we raise subplatysinal flaps. You deal with the anterior compression as needed. Sometimes they can assist with the thoracoscopic approach by removing some of the residual or regrown large thymus because it's right in the way. You can add things like aortopexy and mopexy at the same time. And then it really separate the straps and then expose the airway and find the esophagus. In the lateral approach we're on the side of the airway to find the esophagus. We as pediatric surgeons find the recurrent nerve for the ENT team which they try to prevent injury to. And then it's thinking about your approach to mobilize the esophagus and the experience of working with our team in Cincinnati, we have learned how to not be afraid of the esophagus. So being able to find it, to move it, to get it out of the way is really important. The surgeons work together to mobilize the esophagus above the level where they aim to Pi. That approach makes it easier to place the sutures exactly where they are needed. We will sometimes place stitches in the trachea to pull it up and out of the way so you can visualize that posterior aspect of where you see the spine. Our multidisciplinary team includes a pulmonologist as well, who is assisting in visualization inside the trachea with flexible trachea. Endoscopy through the endotracheal tube while the stitches are being placed. We like to use 30 prolenes and we like to place all the stitches before we actually secure them down, and it's important to do this under spontaneous conditions. This combined approach is really valuable for the complicated cases or those patients who need an additional operation for symptom relief. An example of a patient was one of ours who actually had already had a thoracoscopic approach to tracheopexy, had some of the dysphagia because of that torqued esophagus, and then we use that sort of combined approach to really get a really nice airway, and she's now symptom-free. Finally, what outcome measures are used to determine that the procedure was a success? And what follow-up testing should be done as we follow the patient through their recovery. It's important too to think about those outcome measures. So that means their endoscopy, a follow-up, potentially PFTs as they get old enough to be able to perform them. Imaging is needed. And when you look 36 months later, it may still look like there's some malaysia, but symptomatically, they're better. So it's important to pair that piece and understand that we're still trying to learn exactly what are those measures that we want to use to be able to say that they are a good outcome versus a bad outcome. And that managing complications is part of that piece to you, whether it's swallowing dysfunction or vocal fold paralysis. Due to those potential complications, it's especially important for our otolaryngology colleagues to be involved both in the procedure and during follow up, and it's always easier if it's already built into your team. To summarize, in this video we discussed the combined cervical and thoracic approach for esophageal atresia cases which included preoperative testing, intraoperative set up, and the importance of a multidisciplinary team for the best outcomes with Doctor Alessandro Di Alarcon, and this approach proves valuable for complex cases, improving symptoms and ensuring comprehensive care. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Globalcast MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. --- Not medical advice · citation policy: https://library.globalcastmd.com/ai