Tracheoesophageal Fistula with Dr. Daniel von Allmen
With Dr. Dan von Allmen & Dr. Avi Schlager · hosted by Dr. Em Gootee & Dr. Todd Ponsky · StayCurrentMD
Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
More about tracheoesophageal fistula
same diagnosisDive deeper → Tracheoesophageal Fistula (23 items)Podcast
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What the experts said
Cincinnati Children's has a multidisciplinary aerodigestive center that includes 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 pathways
Physical examination findings in suspected esophageal atresia include assessment for scaphoid versus distended abdomen and respiratory distress
Personal confirmation of NG tube passage is important as some patients started on treatment for esophageal atresia are later found to have tubes that pass normally
Injecting air into the NG tube and obtaining a plain film helps visualize the proximal pouch and assess GI tract gas pattern
Lack of visible distended proximal pouch on plain film raises concern for either incorrect diagnosis or presence of proximal fistula allowing pouch decompression
Contrast studies can be performed when there is high suspicion of anatomic variants, with no contraindication as long as radiologist is aware of potential obstruction
Preoperative echocardiogram is essential 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 for right-sided aortic arch is to perform left thoracotomy rather than right thoracotomy
Left thoracotomy for right-sided arch is somewhat more difficult with heart more in the way and harder proximal pouch mobilization
It is possible to complete the repair from right thoracotomy even with right-sided arch, though some reports suggest higher incidence of swallowing problems
In stable larger babies not intubated, it is reasonable to wait until all resources are available in the middle of the day, even waiting until the next day
Prolonged delay should be avoided due to concern for colonizing GI tract and soiling lungs
Oscillator ventilation has not been found to make significant difference in managing unstable TEF patients
Air preferentially entering GI tract versus lungs tends to be a bigger problem in more premature infants with significant lung disease and poor lung compliance
Treating with surfactant and improving lung compliance helps as much as changing ventilator type in managing air leak through fistula
Risk of waiting too long to make a decision in deteriorating patient can lead to emergency situation where ventilation becomes impossible
For reasonably stable but worsening patient, approach is urgent right thoracotomy with fistula ligation
Bronchoscopic placement of Fogarty balloon in fistula is difficult unless expertise and equipment are immediately available
G-tube decompression may paradoxically worsen ventilation by making stomach lower resistance path, allowing more air to go there rather than to lungs
Laparotomy with vessel loop around esophagogastric junction at hiatus with gentle traction (Rommel tourniquet technique) can temporize unstable patient for several days
In stable child with associated duodenal atresia, consider fixing duodenal atresia first to avoid repairing esophagus upstream from obstruction
Both esophageal and duodenal atresia can potentially be repaired in same operative setting if child is stable enough
Routine intraoperative bronchoscopy is important to document fistula location, assess for proximal fistula, and rule out laryngeal cleft
Laryngeal clefts are easily missed and have been seen many times in referred patients who had multiple thoracotomies without anyone doing bronchoscopy
Second fistulas are very uncommon, occurring in perhaps 1% of cases, and can be difficult to diagnose
High fistulas can be seen bronchoscopically ahead of time and range from trifurcation of carina to fistulas potentially approachable through the neck
Bronchoscopy allows guidance of anesthesiologist for ET tube placement relative to 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
Extrapleural approach offers advantage of potentially limiting soilage of pleural space if there is postoperative leak
Dividing azygos vein has no morbidity and gives better access, frequently guiding to the fistula
For open repair, azygos is typically ligated and divided with suture
Spreading intercostal muscles with heel of right angle on ribs nicely shows extrapleural plane
Mobilizing pleura up around apex of lung is important to have access for proximal pouch mobilization
Distal esophageal segment is controlled with vessel loop to allow proximal dissection to identify fistula
Standard teaching has been not to mobilize distal esophagus, but it can be mobilized extensively laterally and to some degree medially with care for blood supply
Extensive proximal pouch mobilization is most important for gaining length to approximate the ends
Proximal pouch dissection is similar to separating rectum and vagina, making two planes out of one with risk of entering trachea if not careful
Blade electrocautery with light buzz and mostly blunt dissection with flat end of blade, staying right on thickened obstructed esophagus, is preferred technique for proximal dissection
Better to be in esophagus than in trachea high in chest during proximal dissection
Large tracheal defect would require sleeve resection, with trachea being incredibly mobile, and placement of pericardium or autologous tissue between trachea and esophageal repair
Personal preference is 5-0 PDS for anastomosis, favoring absorbable monofilament over silk or other sutures
Circular myotomies are not favored as they potentially create even more dysfunctional esophageal segment in patients who already have abnormal motility
For long-gap cases, approach is to ligate ends, tack both on tension to prevertebral fascia, close, let patient grow for several weeks, then return for anastomosis
Traction or pressure is a strong stimulus to growth throughout the body including cardiovascular system and lungs
Internal Foker technique uses traction sutures in proximal and distal ends brought out through crossed trocar sites with tension, allowing rapid lengthening within about a week
Boston series by Jennings and Foker showed 98% success getting ends together in primary atresia versus only 67% in secondary cases after previous surgeries
Foker technique requires patients to be intubated and paralyzed, spending weeks in ICU, which is significant cost but may be worth it for good result
For thoracoscopic approach, patient is rotated past 90 degrees to allow gravity to move lungs out of the way
Standard thoracoscopic port placement uses camera in center with posterior port inferiorly and anterior port superiorly
3mm instruments are used for thoracoscopic TEF repair
Thoracoscopic visualization is very helpful for mobilizing proximal pouch
Anastomosis is the most difficult part of thoracoscopic repair, requiring significant experience with minimally invasive suturing techniques
Clips are preferred for dividing fistula thoracoscopically, with less concern about them falling off esophagus than blood vessels
Hook electrocautery can safely divide vessels if used carefully with up-and-down motion ensuring coagulation
Spaghetti trick described by Martinez Ferro involves grabbing tip of proximal pouch and twirling it to show dissection plane
3mm surgical sealer is ideal device for this size patient and vessel size
Hanging stitch technique (first stitch brought out of chest) helps line up anastomosis similar to duodenal atresia repair
Vicryl ties down nicely but cannot use knot pusher for first stitch under tension as it will tear through esophagus; monofilament needed for knot pusher technique