QUAD #6 Slide Tracheoplasty for TEF, Otolaryngology Approach with Dr. Mike Rutter

Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hi everyone, this is Kim Pribben from Cincinnati Children's Hospital Medical Center. As we had mentioned before in our series, Cincinnati Children's hosted a quad conference in October 2022, which was a combination of four different conferences, the International Organization for Esophageal Atricia, the Air Digestive Society Conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia Series. And thank you for joining us today as we review several cases using a slide tracheoplasty technique for tracheoesophageal fistula repairs with Dr. Mike Rutter from Cincinnati Children's Hospital Medical Center. He is the director of the Aerodigestive Center and a pediatric otolaryngologist. This is looking At slide tracheoplasty as a method of repairing more challenging tracheoesophageal fistulas. Let's start with our first case. A boy with complete tracheal rings and a tracheoesophageal fistula. You've got a very tight ring segment with a fistula behind the ring segment, and you can see how narrow the distal trachea is. We went on and repaired both at the same time because we really didn't have an option, and that's after we repaired it. As you can see, there is a dramatic improvement. What is the best technique for such a complicated case? The technique is that we basically transect the trachea above and below the hole with a sort of a bevel, so we're not losing too much trachea. Use part of the trachea to repair the esophagus, slide the trachea over the top of it, quite often with a little interposition graft of periosteum. Let's move on to our next case. A 14-year-old girl from Sweden with a type 3 cleft repair with residual TEF. She's had thoracotomies, tracheal resections, flaps, because they couldn't get rid of the hole, they just left a T tube in place and, and she aspirates chronically. The case begins by finding the Hoer fistula, which can be quite difficult with an H-type TEF. This is done via tracheoscopy or esophagoscopy. Once you've found the defect, you can move on to the repair. And so this is a slight tracheoplasty technique, and you can see the bougie in the esophagus, we've transected the trachea above and below, and we're sewing this flap of trachea onto the esophagus, so the front wall of the esophagus is now gonna be a piece of trachea, just a a quick running suture technique with 4 OPDS. At this point, the distance between the trachea and the esophagus can be quite large. And so if you use nerve hooks and you just take your time slowly tightening up the multiple throws you've already done, it slowly comes together. Post-operative follow-up is important in these challenging cases. Serial esophagoscopies can give the surgical team a good picture of outcomes. Esophagoscopy, a month post-op. And you can see the suture line. Where we've sewn her trachea to her esophagus, and that front wall is actually a piece of trachea. She went back to Sweden, she's eating and drinking everything, she's got a really short trachea, and she's doing fine. Finally, our last case is a 4 year old female with a reoccurrent type C TEF repaired at birth, now with a reoccurrence despite several endoscopic attempts at closure. She was referred to us aspirating on high flow with a chest tube in place. And initial scopes, we've got a flex bronc on the left, we've got an EGD on the right, and you can see there's, there's a hole, and it goes to both the esophagus and to the mediastinum. There's suture material everywhere to the point you don't actually know where the lumen is in the esophagus. Using a team approach, the gastroenterologist was able to visualize from below by scoping through the G tube. So it wasn't continuity. She's had two thoracotomies, you couldn't mobilize her esophagus, and so we stabilized her initially by putting in an esophageal stent, bought her some time, that didn't fix the holes, but got rid of the mediastinal communication. Next, they turned their focus to repairing the TEF. Given the complexity of this case, a slide tracheoplasty open approach allowed for much better visualization in the operating field. You get fantastic exposure to the esophagus. We went transternal, transtracheal, and we took a little bit of tibial periosteum as a nice interposition graft. Periosteum is really good at protecting one lumen from another. Once structures are identified, the surgical team, which includes a pulmonologist for intraoperative tracheoscopy, must find the fistula. Looking in the chest, you've got an innominate vein, you've got an innominate artery, there's the trachea, you're opening the trachea, right where the fistula is, how do you know where to do that? A pulmonologist aids the surgeon by looking down the ET tube, which allows for additional visualization and identification of the fistula. They have now moved on to the repair, which includes transection of the trachea and esophagus, performing a slide esophagoplasty, placing the interposition graft, and closing the trachea. And then you're left with the sort of the trachea and you go and put your interposition graft behind the trachea and start sewing up the trachea. The patient was extubated the next day, esophagram and bronchoscopy were performed at one week. Amazingly, at 10 days post-op, the patient was back to eating ice cream. For challenging tracheoesophageal fistulas, a slight tracheoplasty can be a very valuable addition to the options available for repair. You're not gonna do this for everyone, it's just useful knowing that there are options available. In today's episode, we talked about slide tracheoplasty for repairing challenging tracheoesophageal fistulas. Our key takeaways are slide tracheoplasty is a valuable option for complex cases. Precise surgical techniques involving tracheal and esophageal transsection are crucial. Interposition grafts like periosteum can aid in successful repairs. Collaborative efforts, including pulmonologists, enhanced surgical precision, post-op, follow-up, and serial esophagoscopies are essential for monitoring outcomes. And remember, while not suitable for every case, knowing these options can make a significant difference in challenging situations. 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. Global Cat MD along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.