Educational content from recorded physician discussions — not medical advice. Talk to your (or your child's) care team about your situation.
Video
Esophageal Atresia
39 min · Published Nov 2018
Video
Tracheoesophageal Fistula with Dr. Daniel von Allmen
Dr. Todd Ponsky · 45 min · Published Dec 2016
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Esophageal Atresia in Brief: Presentation, Workup, Diagnosis, and Treatment
Dr. Todd Ponsky · Published Feb 2022
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Thoracoscopic TEF Repair, Is It Really Better Than Open? Update Course 2018
18 min · Published Aug 2018
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QUAD #10 Pt.1: History of Thoracoscopic Repair of Esophageal Atresia (EA) & Tracheoesophageal Fistula (TEF) with Dr. Steve Rothenberg
Dr. Steve Rothenberg · 6 min · Published Jun 2024
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Thoracoscopic Repair of Tracheo-esophageal Fistula Tricks: Pediatric Surgery...
19 min · Published Jul 2017
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Intestinal Atresia Types Explained: Grossfeld Classification for Pediatric Surgery
1 min · Published Sep 2026
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Derivation and validation of the Pediatric Community-Acquired Pneumonia Severity (PedCAPS) score: A prospective cohort study
50 s · Published Sep 2026
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FETO for Late-Diagnosed Severe Congenital Diaphragmatic Hernia (CDH) at Cincinnati Children's with Dr. Beth Rymeski
4 min · Published Sep 2026
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Severe Congenital Diaphragmatic Hernia (CDH) Case: FETO Management & Unexpected Findings with Dr. Beth Rymeski
3 min · Published Sep 2026
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Fetoscopic Endoluminal Tracheal Occlusion (FETO) Procedure: Step-by-Step Guide with Dr. Beth Rymeski
4 min · Published Sep 2026
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Choledochal Cyst Types Explained: Pediatric Surgery Fundamentals
1 min · Published Sep 2026
What the experts said
Echocardiogram is obtained preoperatively to rule out congenital heart defects and determine aortic arch sidedness (right vs. left)
VACTERL workup includes renal ultrasound, vertebral X-rays, evaluation for imperforate anus, and sometimes assessment for VACTERL association
Preoperative bronchoscopy helps identify fistula location: mid-tracheal fistula predicts shorter gap, while fistula at carina predicts longer gap
Bronchoscopy can detect double fistula, though this is rare
Standard open approach uses muscle-sparing right posterolateral thoracotomy with extrapleural dissection to vertebral bodies
Azygos vein serves as anatomic landmark for fistula location during open repair
Small chest tube is placed in extrapleural space on water seal (not suction) and removed after postoperative contrast study
Retrospective study of approximately 100 patients showed no difference in complications between Vicryl and silk suture material
For thoracoscopic repair with knot pusher technique, PDS must be used rather than Vicryl to avoid sawing through tissue
Approximately 75% of EA/TEF patients are candidates for thoracoscopic repair
Complicated congenital heart disease is a relative contraindication to thoracoscopic repair due to longer operative time and cardiovascular stability requirements
EA/TEF repair is a 'one shot operation' where initial repair quality is critical due to significant complications from revision
Gap distance is the primary determinant of whether thoracoscopic repair can be completed; conversion to open is appropriate if ends cannot be approximated
Baby size under 2 kg makes thoracoscopic repair more difficult due to limited space and difficulty retracting lung
Proximal pouch mobilization is the most difficult aspect of thoracoscopic repair
Training fellows in thoracoscopic TEF repair is challenging with typical fellow exposure of 4-8 cases over training period
Thoracoscopic ports should be spaced widely and staggered (not in same line) for optimal ergonomics
Patient positioning should be more prone than lateral because esophagus is posterior mediastinal structure
High-frequency oscillating ventilator in operating room keeps lung collapsed during thoracoscopic repair, though baby shaking is a disadvantage
First stitch does not need to be tied tight; subsequent stitches are tied down tight once approximation is confirmed
Delayed primary anastomosis approach involves waiting months (up to 3 months) for esophageal growth before attempting repair
Esophageal growth occurs spontaneously over time; weekly bougienage does not necessarily promote growth
Bolus gastrostomy tube feeds may promote distal esophageal growth in long-gap cases
Given lack of good esophageal replacement options, surgeons should try everything possible (including long waiting periods) before proceeding to replacement
Even very small distal esophagus may eventually come together with delayed approach, though some cases ultimately require replacement
Foker procedure can achieve primary anastomosis but may require fundoplication and strictureplasty, resulting in 'long ride' for patient
Antenatal detection of esophageal atresia occurs in less than half of cases, identified by small stomach and polyhydramnios
Right-sided aortic arch can be successfully repaired through right thoracotomy without switching to left side, though technically more challenging
Recent literature (European Journal of Pediatric Surgery Volume 23) shows little difference in outcomes between open and thoracoscopic repair
Some recent studies (2008-2010) showed better stricture rates with thoracoscopic approach, though more recent data shows equivalent rates
Average attending pediatric surgeon performs 1-2 TEF repairs per year according to Maury Ziegler's data
Low-cost training models for thoracoscopic TEF repair have been developed, including one from Argentina presented at IPEG Beijing meeting
Wet clips are fast and reliable method for fistula division during thoracoscopic repair
Poll results show 35% of participants perform thoracoscopic repair while 60% perform open repair
Cathy Barsson at Northwestern developed bovine fetal tissue model for TEF repair training that does not require living tissue
This training model was used to teach 30 senior fellows from US and Canada and will be deployed at APSA and IPEG meetings
Thoracoscopic approach is very gentle for lungs, resulting in easier postoperative management, less pain, and smoother extubation
For thoracoscopic anastomosis, back row stitches are tied intracorporeally while front row knots are tied outside the lumen
Transanastomotic feeding tube passed after back row helps provide volume and guides needle passage for front row sutures
5-0 PDS with C1 needle is preferred suture for thoracoscopic repair; C1 needle has good curve and passes through 5mm trocar without damage
TF needle is also suitable alternative to C1 needle for thoracoscopic anastomosis
Stay sutures can be exteriorized through chest wall with hemostat to help bring gap closer before tying subsequent stitches
Dividing only 3/4 of fistula (rather than complete division) before anastomosis makes repair easier by maintaining traction
Minimal dissection of distal esophagus preserves blood supply and reduces trauma, even in long-gap cases
Long gap is defined as greater than two vertebral bodies distance on contrast study through gastrostomy
Gastrostomy tube placement is first step in long-gap management, allowing gap assessment via contrast injection and wire passage
Interventional radiology can pass wire up distal esophagus and inject contrast to identify GE junction location for gap measurement
160 endoscope can pass through slightly dilated 12 French gastrostomy tube to visualize and push lower esophagus
Cervical esophagostomy commits patient to esophageal replacement or substitution procedure
Modern approach to long-gap atresia favors multiple attempts at primary anastomosis before proceeding to cervical esophagostomy