How is surgical repair of tracheoesophageal fistula (TEF) performed?

Updated: Nov 07, 2018
  • Author: Sat Sharma, MD, FRCPC; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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Answer

Note the following:

  • Timing of the operation and the choice of surgical approach in congenital TEFs are crucial. Make decisions based on the size and condition of the infant. Most infants are recommended to undergo primary care; however, a staged repair several weeks following birth is recommended for infants who are premature and have severe respiratory distress syndrome. The presence of other severe comorbidities, such as aspiration pneumonia, congenital cardiac disease, or other life-threatening conditions, should also delay the primary repair. Tracheostomy is required only if planning a staged repair. Infants who have severe respiratory distress syndrome may require the use of a Fogarty balloon catheter to obliterate the TEF while awaiting surgery.

  • The repair is performed via right thoracotomy in the left lateral decubitus position, and the head of table is elevated to avoid gastric reflux. A posterolateral thoracotomy incision is made through the fourth intercostal space, and a retropleural exposure is obtained. During the dissection, the azygos vein is divided and the vagus nerve is identified. The distal esophagus is identified and dissected distal to the TEF. The fistula is divided and closure is performed with stay sutures. Dissection is carefully performed to avoid interruption of blood supply or the branches coming off the vagus nerve. Tracheal suture line may be covered with a flap of mediastinal pleura. Prior to esophageal anastomosis, the proximal pouch of the trachea is mobilized.

  • If a fistula lies between the esophageal pouch and trachea, it is divided and closed. The esophageal anastomosis is performed in 1-2 layers and is covered with mediastinal pleura. A nasogastric feeding tube is placed through the esophagus into the stomach prior to the chest closure, and a chest tube is placed in the retropleural space.


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