Tracheoesophageal Fistula with Dr. Daniel von Allmen
With Dr. Dan von Allmen · hosted by Dr. Todd Ponsky & Dr. Avi Schlager · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
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What the experts said
Cincinnati Children's has a multidisciplinary aerodigestive center including ENT airway surgeons, GI, pulmonary, general surgeons, nurse practitioners, geneticists, and dietitians
The aerodigestive center typically receives more complicated patients referred from outside through either esophageal or airway arms
Physical examination should assess for scaphoid versus full or distended abdomen and respiratory distress
The surgeon should personally attempt to pass the NG tube rather than relying on nursing reports, as tubes reported as not passing sometimes pass easily
Injecting air into the NG tube and obtaining a plain film helps visualize proximal pouch distention and assess distal GI gas pattern
Lack of visible distended proximal pouch raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression
Contrast studies can be performed if there is high suspicion of unusual anatomy, as long as the radiologist knows the esophagus may be obstructed
Echocardiogram is the most important preoperative study to assess cardiac anatomy and rule out right-sided aortic arch
Renal ultrasound and spine evaluation for tethered cord are needed but are elective and not necessary before addressing esophageal atresia
Conventional wisdom is to perform left thoracotomy for right-sided aortic arch
Left thoracotomy for right-sided arch is somewhat more difficult with the heart more in the way and harder proximal pouch mobilization
It is possible to complete the repair from the right side if right-sided arch is discovered intraoperatively, though some reports suggest higher incidence of swallowing problems
In a stable larger baby not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting 1-2 days
Should not wait a long time before repair due to risk of colonizing GI tract and soiling lungs
Oscillator ventilation does not make a significant difference in managing large fistulas with abdominal distention
Large fistula with distention tends to be a bigger problem in more premature infants with significant lung disease, where poor lung compliance drives air into GI tract
Treating with surfactant and improving lung compliance helps as much as changing ventilator type
Risk of waiting too long to make a decision in worsening distention can lead to emergency situation where child cannot be ventilated
For reasonably stable but worsening distention, would take child urgently to OR for right thoracotomy and fistula ligation
Bronchoscopic Fogarty balloon placement sounds good but is difficult unless expertise and equipment are immediately available
G-tube decompression may paradoxically worsen ventilation by making stomach lower resistance, allowing more air to go there instead of lungs
Laparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize severe cases, leaving in place for several days before definitive repair
For associated duodenal atresia in stable child, would potentially fix duodenal atresia first to avoid fixing esophagus upstream from obstruction
Both duodenal and esophageal atresia could potentially be fixed at same time if child is old enough and stable enough
Von Allmen changed practice to always perform intraoperative bronchoscopy after exposure to Cincinnati's complex patient population
Bronchoscopy documents fistula location, assesses for proximal fistula, and most importantly rules out laryngeal cleft which is easily missed
Many referred patients with multiple thoracotomies never had bronchoscopy and actually have laryngeal cleft
Second fistula occurs in approximately 1% of cases and can be very difficult to diagnose
High fistulas can range from trifurcation of carina (suggesting difficulty getting ends together) to very high fistulas potentially approachable through neck
Bronchoscopy allows guidance of ET tube placement by anesthesiologist based on fistula location
For fistula at carina (trifurcation), ET tube should be placed higher as it cannot pass the fistula; for high fistula, tube should be placed distal to fistula but not into the fistula itself
Extrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak
Dividing azygos has no morbidity, gives better access, and frequently guides to the fistula
Open azygos division is done by ligation and division; thoracoscopically can use energy devices or clips
Hook cautery can safely divide vessels if done slowly going up and down to ensure coagulation, learned from robotic Nissen experience dividing short gastrics
3mm surgical sealer is ideal device for this size patient and vessel
Spreading heel of right angle on ribs nicely shows extrapleural plane when going through intercostal muscles
Important to mobilize pleura up around apex of lung to have access for proximal pouch mobilization
After azygos division, identify distal esophagus and control with vessel loop, then dissect proximally to identify fistula site
Muscle-sparing thoracotomy can make exposure more difficult; has not seen significant morbidity from standard posterolateral thoracotomy
Standard teaching has been not to mobilize distal esophagus, but can actually mobilize it significantly especially laterally all the way to diaphragm
Must be careful with medial mobilization of distal esophagus due to blood supply concerns
Extensive proximal pouch mobilization gives the most length to get ends together
Thoracoscopic approach advantage is clearer visualization for proximal pouch mobilization
Proximal pouch dissection is similar to separating rectum and vagina - making two planes out of one without great natural separation
Risk of entering trachea during proximal dissection; must be very careful using blade cautery with light buzz and mostly blunt dissection with flat end of blade
Better to be in esophagus than trachea during high chest dissection; esophagus is thickened from obstruction
For significant tracheal defect, could perform sleeve resection as trachea is incredibly mobile, then place pericardium or autologous tissue between trachea and esophageal repair
Personal preference is 5-0 PDS - absorbable monofilament suture; not a fan of silk
Not a fan of myotomies as they potentially create even more dysfunctional esophageal segment; motility is already clearly abnormal in esophageal atresia
For cases too tight for primary repair, would ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for couple weeks, then return to put together
Traction or pressure is very strong stimulus to growth throughout cardiovascular system and lungs
For thoracoscopic approach, can place traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing return within a week for anastomosis
Would not do classic Foker technique with prolonged paralysis and sequential suture tensioning
Rusty Jennings and Foker published series in JPS showing 98% success getting ends together in primary atresia versus only 67% in secondary approaches after previous surgeries
Foker technique requires patients intubated and paralyzed spending weeks in ICU, which is probably worth it if you get good result
For thoracoscopic procedure, rotate patient past 90 degrees to allow gravity to move lungs out of way
Standard port placement: camera in center, posterior port inferiorly, anterior port superiorly
Uses 3mm instruments for thoracoscopic TEF repair
Important to do same quality operation thoracoscopically as would do open