Aerodigestive & Esophageal Surgery - The Unsalvageable Esophagus & Cases

Kick off again and we're moving into what we've generously termed the unsalvageable esophagus. And so this will be much more. Uh, involved for both Todd and for Dan. And so looks like Bob's up, so. Shall we just launch in with a. Young man who's got a type C tracheoesophageal fistula, ligated day of life 1, and a long gap esophageal atresia, and he's now 4 months old. And so What we're going to try and do is look at a few different approaches for managing the long gap, and As you all know, this is an area that's, it continues to be fairly contentious. And so let's start off and just let's see what we've got. And so This is an initial scouting microlaryngoscopy, bronchoscopy. Little bit of tracheomalacia as basically everyone does, you can see it's ligated fistula, and so really nothing to find, we probed that, there was nothing down there. And This is his esophagogastroduodenoscopy, Phil's initially going in through his mouth. And really, you hit a wall fairly rapidly. There's a very short proximal segment of esophagus. And then this is the gap study. And It looks like we are running around about a 4 centimeter gap, so it's a, it's a long gap. Scope at the bottom, scope at the top, is that using a Hagar in the lower? No, this is, I think Phil's flex scope. Good. And oddly enough, I actually thought I'd recorded that, but I obviously messed it up. That's an important point is that some people believe that you have to use a scope to measure the true gap. I may not be at the end. This is from the bottom end. I just got completely disorientated. This is going up to the bottom going up, yeah, through the G tube, right? Some people will use a Hagar and, uh, and, and not actually be at the end of the distal pouch. Well, we do sometimes we do these in, uh, interventional radiology and with a catheter and inject contrast to make sure that you're actually at the top, but then it's not on stretch. Yeah, but you can use that to show that you're at the top and then you can push on it to stretch it. So it's just to document where the top of the pouch is it. And so we've got a pretty big gap in a pretty small kid, and this is really for both. Dan and um well, actually, shall we start off with you and Rusty too, who's also Rusty who's also right, so basically, how would you like to tackle that preferentially, right, so I've tried, I've tried, uh, I wouldn't say everything, but I've tried both, uh, ends of the spectrum, so I've Uh, tackle these initially upfront with the Folker technique, right, and we've also waited about 3 months or so and either done serial bouinage or nothing and just waiting a few months and going in and doing the repair once it's gotten to an appropriate distance that we feel that we can get the ends together. Got you. And then, yeah, so, you know, I think there are. A whole host of options, as you said for what works best in this particular case. Remember this child came to us at 4 months of age, so we sort of had the let's wait and see technique. I personally don't think that bougie andage does anything. Um, and so you either have to, you either have to try to figure out how you're going to get the two ends of these together primarily, Folker or, or, uh, other techniques. David Vanderzee, uh, described a thoracoscopic technique of Uh, grabbing these, uh, grabbing the ends of it and pulling sutures out and putting them on buttons, but not tightening them, sort of a la folker, um, but just waiting and only a short period of time, 3 or 4 days, go back, break up adhesions, pull on them again, leave the buttons there, and then you go back and put them back, put it together. The problem is for this child, is that this child had a thoracotomy and had the distal pouch tacked to the prevertebral fascia, so that's not going to go anywhere unless it's re-operated upon. And then the other thing is that that proximal pouch is very high, so it's hard to get from, or I was concerned that this would be hard to get from the chest. So the options really. Are some sort of esophageal replacement, um, and there are reverse gastric tubes or gastric pull-ups or colon interposition or small bowel interposition are, are the options, uh, versus the, you know, to focus this and try to stretch the two ends or grow the two ends to the point where you could close it primarily. What if this baby were a newborn, what distance would you need to see before you would feel comfortable going in? Let's say you grew it for 3 months. How many vertebral bodies? I mean, it's the book answer of two vertebral bodies or 2 centimeters about if you can get them that close, then theoretically you can get them together. What I've done is if I operate, if I, if you get them that close and I get it and I can't get it together, I put them on tension, wait for a week, and then re-operate on the child, and usually by then it's stretched enough, which is sort of a variant of what David Vanderzee described. So in the, in the lab we we presented this, we got a grant for this from IPEC. We and pigs right now are doing endoscopic fulkering essentially. So what we do is, uh, put, and actually this is Rayvine's original description where we pass a wire from the proximal to the distal pouch, pull it out through the G tube, pass an olive bead on one end, an olive bead on the other end, and we keep pulling the string and tightening them. Until we get the two ends together, the only problem is the pigs keep dying. So, so that's complication in our study. So, uh, what would be the, the ends come together. What would be the risk of having pressure necrosis at the site of that's exactly what we think is probably the reason that pigs were dying. And so, uh, we're working with uh Mike Harrison on our newest study starting now where we're using magnets. Um, that, uh, that won't be as under so much tension, under so much tension. The other thing is if we use the beads, we might loosen it, tighten it, loosen it, not always keep it under tension all the time, but we're very close. I mean, the ends really did go all the way together. Um, but I think it is probably the pressure necrosis, and we're trying to figure it out. I, I think that is going to be the answer, that somehow intra, intraluminally pulling the two ends together is going to be the way to do this in a minimally invasive sort of, uh, uh, keep the primary esophagus answer to this problem. Yeah, and much easier to repair on a dead pig, much less bleeding. So. This is what Dan did, which was a colonic interposition, and this is a view postoperatively. And so that's going through the upper anastomosis. Well, Phil, you should talk to this. I presume that's going through the upper anastomosis. You did it. It's a relatively short proximal esophagus, a proximal anastomosis with a little bit of suture, normal colonic epithelium with uh lymphoid aggregates that you can sort of see is where the light's bouncing off and eventually you get to the distal anastomosis, uh, which also looks quite good. Uh, it turns out that this was the initial. Exam, uh, 4 weeks I think after surgery, just by coincidence, I endoscoped him yesterday um and it looks virtually the same. We used a slightly bigger scope yesterday and I did decide to dilate the upper a little bit, um, but it's doing remarkably well. It looks great. The child is fine. But I think the As we said, there are lots of different approaches to this. This is not the standard colon interposition that goes from cervical esophagus to antrum of stomach. This is a segmental. Uh, as we all know, the, the long term complication of a, of a colonic interposition is that over time they become very tortuous and they can, uh, they, they don't drain very well. And the concept here is that if you Minimize the length of colon involved, there are two things. One is you hopefully reduce the risk that it's gonna become torturous over time. You also preserve the distal esophagus and so that the issues of reflux and that sort of thing, you could either are lessened or you could potentially treat with an anti-reflux operation at a, at the normal GE junction as opposed to having a big piece of colon plugged into the tru. And was this a 3 hole surgery, sort of abdomen, chest, neck? Yeah, and so that's the big downside of it is that it requires 2 anastomosis, one in the chest, one in the neck, typically, um, especially for this child that had a very short proximal pouch. So we were up in the neck and we virtually always do the proximal anastomosis in the neck, uh, but it does require a thoracotomy. So it's a, it's a fairly morbid operation in terms of actually doing the case, but it's. It's uh, it's one and done, and some of the other operations, some of the other techniques require multiple operations. Theoretically this is one and done. And if it's segmental, you're really obligated to be in the chest somewhere, presumably as opposed to running substernal if you were going all the way from the abdomen up. Right, because you want to preserve the distal esophagus, and so in any patient that has a reasonable amount of distal esophagus, we will preferentially do a segmental interposition as opposed to trashing the entire, the residual esophagus and doing an anastomosis to the stomach. And so you, you can't do that. Substernally, you have to do that through the native oesophageal bed. You know, the, the, the question, the whole big controversial thing is, do, are we trying too hard to save the esophagus? It's always saying, you know, we are always taught, do whatever you can do to save the esophagus, and some argue that maybe we try too hard to save the esophagus. I don't know. And certainly we, we are in the slightly unusual position where we see a lot of other people's problems. And so we see the numerator, not the denominator. We don't see everything that worked, but we sure see a lot of things that didn't work. It's hard, but I, I mean, I, my opinion is, yes, sometimes we try way too hard to to salvage the esophagus, and kids do much better. Uh, once you replace it to the point where frequently we get kids that have bad pulmonary disease because of chronic aspiration from either recurrent TEFs or strictures, and you know, the kids are ready to die from their pulmonary disease because we're trying to save the esop, the native esophagus, another one of those in the aura today, so, um. We just don't have the perfect, if you could get your pigs not to die, then we'd have the best way to put this back together. There's a question. Did you remove any of the proximal esophagus? We did not, no, it was end to end at the proximal esophagus and end to end at the distal pouch which I had to mobilize off the, you know, it was tacked to the presacral fascia. I'm sorry, the prevertebral fascia. So we mobilized that and may have lost a little bit with that scarring from the original operation, but basically preserved all of the native esophagus that was there, but it was a very long gap. It was, as you saw from the endoscopy, not a short colonic interposition, but I still believe it's better than taking the colon from the cervical esophagus all the way to the stomach. Endoscopically, it's a really short distal esophageal segment that's left, so it's interesting. I don't know what's Exactly happened to it after surgery, but it doesn't look as long now as it did pre-op. Well, when you mobilize these off of tension, they retract, and when they retract, they're much shorter than you think they are. Which may also help some of the colonic redundancy, I presume, right? I mean, so the idea is to minimize that redundant area and put a shorter and inner position in as you can and when that retracts it hopefully pulls it straight. And again, colons are not without their potential problems, which leads us into the next case. And so this is a 16-year-old girl, and again, another long gap without a TEF and actually had a colonicgan deposition when she was 6 months old. And did OK for quite a long time, the occasional food bowls and action. But when she was 12, started to have a lot of swallowing problems, needing multiple dilations and uh developed a both distal anastomotic stricture and also a stricture up at sort of her uh thoracic inlet. And she actually ended up getting part of her manubrium resected. And still continued to have a lot of symptoms. And so This is her initial EGD and and this is her equivalent swallow study. So again, distal or proximal esophagus with a fair amount of saliva in it, which is common only in the folks who have esophageal dys motility. Normally the esophagus is empty. Then you arrive at an anastomosis with something other than esophagus that's narrow but almost accommodates an infant sized scope. A pretty straight shot, so it's an easy dilatation, which has already been dilated over multiple years, multiple times without. So she had a small bowel, right, this is small bowel, not colon technically and with a bit of colon and a lot of small bowel if I remember. So and she's got, you know, a long segment that's really pretty skinny and scarred. And so, again, what are our options? Again, you've got to. Tight stricture at the sort of sternal inlet, thoracic inlet, and you've got quite a long segment that's been very resistant to dilation in a girl who's getting increasingly symptomatic. You know, it's probably worth going back to that for just a second. There's, there's a little bit of mystery in this, in that. Because the proximal esophageal pouch retains the barium, the contrast doesn't go through very well. It goes through at a trickle, and it turns out if you inflate the distal part of this, it actually opens up pretty well. It's not even narrow. Below the anastomosis, all anastomotic. Everything below that looks remarkably good. Interesting. So you get misled by these. It's a good point because you can be misled and there was a lot of concern that this stricture, this is a substernal position, as you can see from the study. So, uh, so her options to get to your question, Mike, and she had been multiple places for evaluation. We to continue to do dilations of this, to try, try to do a cervical approach uh to, to address the stricture which had already been tried once with resecting part of the manubrium unsuccessfully, um, or to take the entire thing out and start over again. And manubrial removing the manubrium is never as straightforward as it seems because your clavicles always get in the way. And, you know, you can take out a quite a long strip, but it's always a fairly narrow strip and you can take off the back of the clavicular heads. But it never is quite as satisfying as you think it's going to be. Never gives you the room you'd hoped for. It's not only that, but I think the problem that that I've had with strictures that occur at that location is they're very frustrating because you think we're going to go in there through the neck, we'll just make a low incision, we'll mobilize it, we'll take out the stricture and put it back together. The problem is you can't pull anything up. It's fixed behind the, behind the sternum. And so it's very difficult to get enough tissue mobilized that you can actually pull it up and do a reasonable resection, which is why we took the approach we did for her. So it's again a question, just does the. The proximal esophagus appears long on endoscopy, or is that an illusion? It was a pretty long segment of, of native esophagus, and then the anastomosis is down. Yeah, her anastomosis was at the maneuvering, yeah. Phil, are you suggesting that it would have been More effective to have done a retrograde esophagoscopy and injected contrast to get that contrast study. I personally, in this case you can't because she's got a duojunal segment coming up and her stomach's excluded, so I can't go backwards up hers would be quite tricky. So how do you distend the esophagus? You can put the scope in. And at the anastomosis and blow and put contrast through the scope as you do, but you can also put a balloon in and the wire guided balloons have enough space in them you can inject contrast with the balloon up and effectively do a pressure exam that way. But when I redid this um exam after she'd been repaired, um, it was just an anastomotic stricture repair, it was all totally wide open. OK, I think those are some important technical concepts for the radiologists to know about. Well, I know, I mean, I think it's very hard because you're, you're dependent on native poor functioning esophagus to effectively push material against what isn't very distensible and in some cases, in which in other cases it's very distensible and the contrast will just run down in a trickle. But then you're left with that impression as that's the only luminal space that's available, which isn't always correct, yes. Is there any, I'm assuming that stents don't work in, in scarred, uh, form strictures that are not fresh, um. You can potentially dilate it and steroid, inject it and leave it open, hoping it'll scar open by putting a stent in it, but esophageal stents are very much a double-edged sword. They can often cause as many problems as they fix, and we've had the occasional success and certainly a number of disappointments using esophageal stents, and it's also trying to find, you know, what would be the best stent, and we've got to, 1 or 2 stint videos coming up a little bit later on. So So this is what this girl had, which was a Well, in fact, I, I, I think I'll let you speak to that, John. You did it. So, um, she had the standard substernal pull-through in which the sternum, she'd never had any cardiac issues. She had never had a median sternotomy. So we elected to do a median sternotomy to address this stricture for two reasons. First of all, I didn't think that we could mobilize enough, uh, to get, um, to pull up the stricture to the point where we could. Uh, fix it and also because I was still concerned that we didn't know exactly where the stricture was anatomically and that the original perception, which as you rightly pointed out, we, we disavowed a little bit, was that the stricture was actually further down, distal below the mid portion of the sternum. But in doing that, we were able to mobilize this, it's a small bowel pull-up, we were able to mobilize the entire small bowel. There was a very dense cicatrix right at the top of the beneath the manubrium where this stricture appears on endoscopy. And there was no way that that was going to go away. It was like concrete, and so we were able to chip that out of there and then redo the anastomosis with fresh tissue with no scar tissue involved and close her sternum over that. We did take out a little more of the manubrium and a little of the back wall, as you said, to provide more space because I was concerned that it was somewhat constricted just because of space. So we're going to move in again, another long gap challenge. And so this is a boy who was a veal tracheoesophageal fistula long gap, had the tracheoesophageal fistula repaired, and then had multiple focal procedures over the next 10 months. And followed by eventually a primary end to end anastomosis, but continued to have a lot of problems with the anastomosis, with restructuring, needing multiple dilations. With the dilations, he had an anastomotic leak, uh, leak. Um, at some point he had a tapering procedure, I think that was during his 7th thoracotomy. I don't actually know what a tapering procedure is, um, maybe one of you clever pediatric surgeons can educate me, and, um, and still had up a stricture after that, and so came to us when he was 2 years old. I think the, the procedure was to taper the very dilated proximal esophagus because it had been chronically strictured and was very dilated compared to the distal esophagus, so it was just an effort to, Make the uh proximal esophagus more effective and match the distal, the diameter of the distal esophagus. So you're trying to structure the proximal esophagus so it'll match the, yeah, OK, I, I get that. And so, This is what we've got. Contrast goes down and to all intents and purposes hits a wall. And so this is what Phil gets to see. That would be the wall. That would be the wall in the proximal esophagus, there is a little hole through there. Maybe we'll get a wire down and safely guide a. Through the scope balloon dilator into an area so we're also watching on fluoro to make sure that the wire is going where we think it's going. Um, And then dilatation. Which has been attempted before, but ultimately doesn't result in retained diameter. They're able to dilate it and make what appears to be a hole. Comparatively speaking, compared to what you started with, and you can get down the rest of the esophagus to the GJ tube, but it doesn't stay open over time. And so a very tight, chronically recurring structure. And so again, We've, we've had a group of children who've had focal procedures that have ended up with very challenging anastomotic strictures. And again we have the same. Uh, nominate and enumerate a problem. We, we see problems, we don't always see the successes. By definition, they don't get sent to us. Um, but we've certainly seen several kids like this kid. And so Todd, um, Any suggestions as to where we might go with this? So I just to clarify, the stricture length was how long? Oh, it's very short, yeah. So, um, In the, I, we, I had a patient that had a, a, an anastomotic stricture, uh, great esophagus above. Actually, this was a child, um, that had a TE fistula type C, and when I did a thoracoscopic repair, I went to go past the NG tube. I couldn't get into the stomach. The patient actually also had a cartilaginous ring in the distal esophagus, which posed a problem because then you couldn't. You can't resect it at that time because then you'll have a segment of unvascularized esophagus. So we did a delayed, uh, thoracoscopic resection, which actually, um, which actually is a very feasible, uh, thing to do. Um, uh, the, uh, we went in, um, it was very distal, so, uh, um, we actually did a, um, a left-sided, uh, thoracoscopic, uh, distal resection. And um did a primary of the cartilage ring yeah yeah yeah um and the same thing can be with strictures it's a little more challenging because it's scarred in um but you can get the edges together and actually we use scopes from above and below to help identify where the stricture is thoracoscopically. Um, you can see the light from two scopes. You know where to go. You just divide and you do a primary thoracoscopic repair. Um, but, um, am I wrong? Is this, am I oversimplifying to think that you can do a resection and anastomosis? So this child had had how many thoracotomies? 7 socked in chest, 78 thoracotomy, that had a median sternotomy. It had a left thoracotomy. Yeah, I think all of his ribs were fused. He basically had a shield on one side. And the stricture is at what level? Oh, it's, there's only 2 or 3 centimeters of what looks like esophagus above the stenosis, and that segment of esophagus that exists looks terrible. When I would call Dan. I mean there's no good approach for, for, for accessing this. I mean, talk about going through the neck, um, maybe, I mean the question is where's it less, where's your, where's it less scarred? Where's your best access? I guess the neck is probably. Well, the problem was the, the stricture, like the other cases, you know, if you can't get enough, you can't mobilize you can't mobilize it, so you're not going to be able to get it back together, and the stricture was long enough that we were challenged with being able to get to the, to the distal part of the esophagus from the neck. So it was, it presented a A challenge of, OK, this child has already had multiple operations, whereas, as you said, where are we going to go back through to avoid as much misery as possible. Generate as little misery as possible and uh uh in the end, you know, you bite the bullet and you go back through and through what. We a right thoracotomy. So because he'd already had a, he said he'd already had a median sternotomy. Well, you saw the wires on the film, so he's already had a median sternotomy. It would have been great to say, well, let's just bypass this and do a substernal colon, but that was not an option. He'd already had a left thoracotomy and, uh, and, uh, the right thoracotomy was going to be difficult because of the fused ribs and the scarring, obviously from the multiple previous procedures, but. In the end, that's what she ended up doing. So he had done a colon, a segmental colon interposition. And getting in through the fused ribs was more an exercise of just chipping away, or yes, it was literally exercise because it was difficult to work, work through those, but, but you do and um. I think it's, it's very intimidating when you see the chest that looks like that and you could just look at this child and see this shield on the right side of his chest. But if you separate the ribs, we were able to get enough exposure to do it. But it's very difficult and it's, it's, uh, you can really beat up the lung because it's so scarred to the surrounding floor. And presumably a much narrower field of access just because things weren't spread very well, I would imagine, right? But again, it's very helpful as Todd alluded to, you put scopes in so you can see what you can see the light, you know, when you go to the light, which is where, so, just because I, I like talking about the, uh, the Disney World, uh, you know, land of Wonderland possibilities, but the other thing that we're doing in the lab, like I mentioned before, is for a very tiny stricture in a kid just like this that is prohibited to go back into the chest. Is a magnet on either end, and they, uh, the magnemosis magnets, they, they will snag each other and it will destroy all the tissue between them. So it's essentially a, uh, a stricture, stricture resection by just removes all the tissue and the two magnets drop into the stomach. So, but, but it has to be a very narrow stricture, yeah, and there's no mucosa. You're not creating any mucosal lining. You're creating a band of stricture, the scar tissue that you hope is going to stay open enough. I mean, I think you're you're wrong. I mean, I agree that's the limitation. You absolutely nailed what is going to be the limitation to that working is that you're not going to have a mucosalized. And they have to be very close. It has to be a very narrow structure. How, how far apart can the magnets be? So to link up when we just tried it in our last pig, um, just by taking two stapled ends of the esophagus and putting them on either end, there wasn't enough strength to keep them together. The ones we're doing next, next month is we're putting two magnets on either end. It gets, it gets tricky, but it's, it's only designed for exactly this situation when Getting in may make the, you know, may make it, uh, absolutely, you know, it may be really, really difficult to get in, but I mean, the magnomosis concept works if you, and I've seen it with a kid who swallowed a bunch of magnets and that stuck together and he had a bunch of anastomosis between different loops of bowels, you know, from all these magnets that stuck together. I mean they've successfully done gastroggenostomies without a problem. The question is, can we use it in the esophagus. Yeah, I think the length, the distance between the two is, is the biggest challenge. And, um, and then getting that mucosa line track because if it just erodes through and the ends don't pull together, they actually stay where they are and it just erodes through. It's, it's sort of a sea time. I have no question. So what do we know anything about function after that? The concern and my question is, is whether the kids are actually going to be able to swallow with a non-muscle surrounded. 2 they going to be limited to liquids and purees, are they actually going to be able to swallow solids? Almost like a biological stent in a way. It's exactly. But, but if it's short segment, I mean, even if it's not short segment, when we put a colon in there, I frequently use the left colon, which is backwards, and obviously for peristalsis, it's just an open tube, and they swallow by gravity, so. So I'm not, I think it's more the diameter of, of the lumen and whether it'll stay open or not in something that is pure scar tissue. So we're, these are obviously like the most horrid cases we could ever dream of being here, but let's go back to the more simple ones because there were some questions about. So esophageal strictures after, uh, maybe can we spend a minute on some of the more simple cases. So esophageal stricture after, uh, an anastomosis, there was a question here about the use of mittomycin. Uh, do you, do you use mittomycin routinely? Do you inject mittomycin in these strictures? Um, we typically use steroids and not mitomycin. Yes, and we're pretty much the same in the air, Kenalog, so yes, catalog. We went through a vogue of using mitomycin in the air. Way we started off at 0.4 mg per mil. We slowly stepped it up till I think we apexed at 5 mg per mil, which is this really pretty purple color. And anything it touches turns white and dies. And um, I mean, it does definitely do something, but it always made me extremely nervous about whether you might have some longer term consequences. And we found that our outcomes have been the same injecting Kenalog as they were using mitomycin. And so we, I haven't used mitomycin for a few years now, and haven't seen that my results are really any worse using steroid injection. And so we've drifted away from it without any science behind that. Phil should speak to it because he's the expert at this, but, but the other thing is, is not just using steroids, but combining that with a needle knife or some other method of opening the stricture more than just stretching the scar. If you actually cut the scar band and then inject steroids. But again, Phil, you're the expert on that, so that's something you should probably, I mean there's about as many ways to think about it as there are types of strictures and I think you have to individualize it, the soft, floppy, um. Uh, non-circumferential things stretch easily, but they don't necessarily stay open particularly well. Asymmetric, um, hard things don't stay open very well because the part that stretches isn't the part you need to break. So if there's a scar band that's visible that goes across the, um, from one side to the other, it's fairly easy to use a. Non-approved usage of a needle knife to cut the, cut the scar bands and stretch it a little bit and put steroids in it and try to prevent it from closing back down as it heals. It works quite well in the right circumstance. Um, I have a lot of concern about using. Um, cautery or needle knife than anything anterior in the esophagus and somebody who's had a previous TEF, but on the back wall or the sides, we've been pretty liberal about doing it, um, and it's pretty effective. Um. So, but I think you have to be fairly aggressive and um do the dilatations frequently enough so that the tissue doesn't have a chance to heal completely before the next dilatation if it's not staying open well. And while it's not directly esophagus, we've had the same philosophy with airway strictures. We tend to find that we're doing a lot more balloon dilations than we did 10 years ago. And increasingly, we're using a, a sickle knife or a laser to divide the scar, injecting a bit of Kenalog, and then dilating. And, um, The results are better than they were if we just dilated and particularly if you've got something that's thin or web-like, you've got a much better shot at actually achieving something quite worthwhile and the esophagus is not quite like an airway, but some of the concepts remain the same, and I think that's, you know, it's Phil's doing essentially the same thing that we're doing just in a different tube. Um You know, just going back to what you said, you know, there's uh David Vanderzee. Another thing that he's presented is this idea of putting a balloon down because you can open up the stricture, but maintenance of patency is the hard part, and he would have them blow the balloon up the balloon 5 or 6 times a day, and then the next patient would present, we actually tried that in him, and then that didn't work. And then we tried an interesting idea of Using a silastic tube that was hollow in the middle, almost like a stent, and we just kept upsizing it, um, and you leave it in, uh, and they could eat right through it because it's hollow, but it's a big selastic stent, and it's really, we would tie, we tied it to the G tube and then out the nose so it didn't move, um, for other reasons, we had to stop it because it was so high up in his throat, but because it was by his vocal cords, but. In theory, the issue is keeping it open because you know, you make that cut and it's just going to seal right back even so the question is how do we keep these open uh after we dilate them? And what we do in the airway, and I think Phil's saying the same thing, is that we try to redilate soon enough that the fibroblasts have had a chance to join hands. So in the airway, we do it weekly, and we usually do it 3 or 4 times in a row. And you're trying to end up, it's going to scar, you want to scar open, yeah, and so I just wanted to comment about using stents because that's ultimately the question we have access to stents that we're comfortable using in the esophagus that aren't necessarily designed for that, um, but that may ultimately be a bigger boon to this than anything else, and I think our Limitations in the past have been the availability of adult oesophageal stents for cancer palliations or 18 millimeter stents. They're just not practical, um, but we have stents that are 8 millimeters now that we can put in the esophagus that may be temporizing even for a young infant, um, and they're partially covered, so the risk is relatively small of migration or perforation or ingrowth. So I'm going to pull the audience while you're moving forward because I, I, I think that um. The, I was just studying on the adult general surgery recertification exam and every question is on the use of stents and I realized in pediatric surgery, at least among general surgeons, there's very little use of stents, and I think that this is absolutely something that we should be more aggressive with and learning how to do. I'm gonna ask anyone here if anyone's ever even used a stent. My guess is no. I think that. Pediatric surgeons. Well, the challenge, as always in pediatric surgery, is we don't have the right size small stents, but that's why I was saying, so it's pulmonary stents or it's biliary stents. Got a few coming up a little bit later. All right, good, good. Nothing's perfect, so. So we sort of briefly talked about what happened with this boy. He had a colonic deposition through the shield of his right chest. And um we knew his left recurrent was out. And so we were trying very hard to not ding his right recurrent because then we'd have to trach him. And um this is his just postoperative view. And again, this is Phil. A fair amount of granulation tissue around the sutures in the upper anastomosis, but certainly way more patent than it used to be. And so, uh, have there been any questions coming through we should tackle at the moment. We have, oh, this is a great question. Um, So, well, first of all, Adrian wanted to get clarification time between dilations, which is a week if we're gonna do it. Um, and, and by the way, I just want to hit on that again, that is, uh, that is not, uh, Most people don't do a week, that was a new concept for me by our pediatric gastroenterologist who said, we're doing this every week. I said, every week? It's crazy. No, every week. We did it every week and it really did, it does work. Um. Uh, there was a question here about, and I also say that if you are doing the weekly dilations and you're starting off dividing scar tissue, say using a needle knife, you don't need to do it the second or the 3rd time because the whole aim is that you've opened it the first time, you've broken the scar band, you're now keeping it open with dilation, you don't necessarily keep needing to attack it with a needle knife. Um, although using, uh, balloon dilation, I'm just curious what the audience, you know, again, I was always taught, uh, with bougie dialers, either like a tucker, Mahoney or savory, and then, you know, but radial dilation is probably better using a balloon, and I've gotten very good at those lately. Uh, but, uh, uh, so, but that's another thing is, is, you know, exactly how we do it. And I found that when we use the dial, the balloon dilator, it actually sometimes can crack. The, the scar without having to use a needle knife, uh, at least in this next case it did. So the other question, um, which maybe, and I'll leave this up to you guys to decide if you wanna put this off later because this is a great topic and I've always wondered this. And Dan, I actually asked you this question on our next patient as well is when they have reflux and they have a stricture, it's very tough because, um. Well, first of all, what's the timing, the first question was the timing of doing a reflux anti-reflux procedure in a patient that has a stricture? Question number 1. Question number 2 is, if it's someone that you're debating that you may be doing a replacement on or uh some problem with this non-healing scar, non-healing scar, it's not healing with all that keeps coming back, you may have to do it in the interposition. Do you wanna, you don't wanna necessarily do your reflux operation before, but that might be making it not heal. So the question is, What do you do first? Do you try first an anti-reflux operation, but you don't want to use up your stomach that you might be going through? What's your strategy? Well, my Our approach, I think, is that in patients who have re recalcitrant strictures that have reflux is to treat their reflux before considering doing anything. But doesn't that eliminate the, does that make, does that not eliminate, I know you're not a pull-up guy, but if you are a gastroc pull-up guy, which, by the way, I don't know if you wear pull-ups, but, uh, by the way, 30%, 30%, 30% actually 30%. Well, let me put it to you this way, 60% of the audience does some sort of gastric replacement divided between pull-up and reverse, reverse gastric, OK, so that's a substantial amount of the audience that might have concern about doing an anti-reflux operation in someone that they have a high likelihood of having to do some sort of esophageal replacement. So that's why I don't do, no. As we all know, there are a lot of ways to approach this, which means none of them are perfect or everybody would do the same thing. So I don't think there, there is the right, the perfect answer. I do think. In my practice, our approach is to do to treat the reflux if there's a recalcitrant stricture. Can't you treat it medically to get the same effect just temporarily or no? I don't think so. So you can turn off or reduce their gastric acid production, but you can't stop the reflux without mechanical barrier, um, and because there's other irritating stuff in that, um, I think some people do better with surgery than medicine. So you think a non-acid reflux. Uh, maybe just as, uh, or maybe, uh, maybe enough, enough to prevent, uh, healing of the earth, to prevent the more likely if you've had a heller and you're refluxing bile or something like that. Well, that would require a pyloroplasty or something to disable the pylorus, which is not typical. I. I don't know the answer to that. I mean, it's a good question. Can you treat it medically temporarily? But I think the response is, I mean, how do we treat reflux normally if medicines don't work, then we do an operation. And I would take the same approach. If there's a stricture and you think there's still significant reflux, then you treat that with an operation, and my operation would be probably some sort of partial. Likely either a very loose Nissan or a partial wrap because of the because of the esophageal dys motility. You do a Nissan for these patients, right? I mean, if it were a type C that has a stricture that just keeps recurring, easily dilated, thin, short stricture, and has documented reflux, my approach to that, my next thing to do would be a cent. OK, I think you have seen a few kids who've had the sort of Feeding GJ draining G as a temporizing measure as well. Just to buy time while you. Deal with their esophagus, right? I mean, so. These are all things that we've, so then there's a, go ahead, there's always some asset even in my experience, in my experience, I agree. I think this since this is a surgical audience, it's worth remembering or learning if you didn't know that in the last couple of years it's become quite clear that patients who are born with tracheoesophageal fistulas, especially if they have bladder, are at much higher risk for developing eosinophilic esophagitis, non-acid. induced inflammation of the esophagus, which by itself is scar forming, stricture forming disease untreated. So recognizing it, managing it, preventing it, um, is absolutely worthwhile as part of this, um, and we have several patients who have both reflux and eosinophilic esophagitis and oesophageal strictures after TEF. So you have to manage all the parts of it to get, to get it to work ultimately. Would you ever do screening biopsies on these kids, and if so, when? So I, if I can get through a stricture in a baby who's been treated for a tracheoesophageal fistula, biopsy the esophagus as part of the routine exam, um, because we need to know the answer to that question. And the treatment just for everybody because you are an expert in this for esophageal, uh, for eosinophilic esophagitis. So the management in an infant is easy. It's an elemental formula, you're probably tube fed anyway. And they should be on an elemental diet. It's much easier than doing anything else, and 95% of the time it's effective. Um, so you can manage the eosinophilic part of it. Um, you still have to manage the reflux part if they have it. I always tease our gastroenterologists that it's impossible to remove the endoscope without bringing out tissue with it. It's no reason to tease. That's right. It should be, yeah. I've developed this theory that if you've got mucosal disease, all you need to do is remove all the mucosa. You've got no disease. A lot of biopsies, biopsies. There was just one. Comment. Um, so the next case, by the way, is my complication that we're going to talk about. So I'm doing as much as I can to delay getting the next case. I'm going to go through all the questions, complication as well. Why you got to share the wealth. There was a question about this is a good question. Uh, probably for, for, well, I guess everybody here, but I've used an esophageal stent and it compressed the adjacent airway and had to be removed almost immediately. Have you? Yes, it's a risk, and again, the single word of advice is if you put in an esophageal stent, have a quick look in the airway when you're done. And if it's squashed, take it out. It's sometimes the size of the stent, sometimes it's the position of the stent. Most of the time it's not relevant. But in some kids, it very much is. And again, it's very easy to have a quick look at the end of the procedure and see if your airways compromised. One of the things that that I'd point out here is if you look on a CT scan. Many of these kids Their big, poorly functional esophagus will lie immediately posterior to the trachea, which is malasik. And so any distention of the, of the esophageal lumen will compress the trachea. And one way to test that before you stick a stent in there would be what, what uh Mike does is put an endotracheal tube in there and blow up the balloon. And I, and watch with a bronchoscope and see what happens. Other children, if you look at their CT scan, the esophagus goes to the left of the trachea. And even though they have significant tracheomalacia, the esophagus itself doesn't interfere with the trachea. It may ding the posterior wall of the left main bronchus, and I see that fairly frequently. But not the trachea itself. So you can get a clue from the CT scan beforehand whether you're gonna have trouble with that. I see a fair number of children who've had esophageal atresiati fistula, where the esophagus is immediately posterior, and when the kids get to be 2 or 3 and they like to eat great chunks of food and swallow it whole, they get into respiratory distress. Wow. We also see it with um chronic oesophageal foreign bodies, um, classically the penny. And typically for a chronic one, they come in about 6 weeks later. And they come in with a diagnosis of asthma, and the current protocols, if you've got asthma is you don't take a chest X-ray, you just treat it or bronchiolitis, yeah, and they don't do very well with bronchodilators and uh someone eventually takes the photo and eventually the penny drops, so to speak, and you see the foreign body and there's a lot of posterior bulge from the inflammation usually at cricoharyngea, so upper trachea. And you know you, you just pull the penny out and everything gets better, but it's amazing how long some of these can live there. We've had a few with holes in the penny because it's partly dissolved. Oh my God, we've had some with mediastinitis too more interesting. Yeah. So this is a boy who had a again a type C with an esophageal a treasure and a very proximal fistula, or should we not say what he did?shall we show you what we Found when he wandered on up, down, which, yeah, down, I knew that. So Again, quick check for a cleft just because we kind of do it as a mandatory thing and kids with any sort of aspiration history. And his trachea is not bad, but he's got this divot where he used to have a fistula. And again, being suspicious by nature. We gave it a good poke around. And this is trying to make sure there's still not a fistula there, although nothing suggests that there should be. And again, as you're doing this, the aim is to probe it but not push so hard that you create a fistula. That's always embarrassing. And again we're using a bugby as a probe, and he's got this little pocket that goes nowhere. It's also nice to use a small flexible bronchoscope, go into the pocket in the flight, and it really distends it so you get a really good view of what's in there and you can use a little bit of saline to wash out any secretions or whatnot and get a good clear view. Of the mucosa, it sounds to me like, and I know you're joking, the fiber optic bronchoscope, the flexible bronchoscope needs to be in the pediatric surgeon's armamentarium, or you need to work much more closely with the pulmonologist to help. Yes, yeah, it's a useful tool, yeah, and the more you use it, the better at it you'll get. If you only use it once or twice a year, you'll never be good with it, which is me, right, exactly. And so this is what we've got for proximal esophagus, that's his larynx off to the left just here, so that's a narratinoid there, and simply put, you really don't have a proximal esophagus, there's just, Very little and you hit the wall with this, uh, little feeding tube going through it. So you've got about less than 1 centimeter of proximal stump, so it's really high. And then we'll jump to the EGD. And again, when you pull that little tube out coming from below, this is the top going down and then we'll go bottom up. And so now we're in the stomach about to go bottom up. So very short segment at the top. Now we're just about to, I think, is this you going into esophagus now, Phil? Looks like it. Yeah, this is from below. Looks like he's got a little esophagitis, not that I would really can tell. Well, I'll tell you, he does. That's another problem, yeah. He's got esophagitis because in order to, so he had his whole esophagus. It wasn't that he was missing an esophagus. So in order to mobilize his esophagus to get the two ends connected, we mobilized the GE junction. So we essentially created a hiatal hernia in him. Uh, which is yet another problem, um, and I've been resistant to repairing that because I thought we might and we still might, and the question is, you know, do we ever need to use his stomach, um, which is why I've been resistant to doing a, an anti-reflux operation on him. Um, but the problem is, and just for the audience, I'm curious here now, so now you have a stricture almost at the level of the vocal, almost at the level of, you know, what is it, a centimeter, not even below the epiglottis, um. Yeah, I mean, his stricture is 1 centimeter out of the hypopharynx, I mean out of the that's in the back of the throat. But you have, but he has his entire esophagus. So do you want to replace his esophagus, do a gastric pull-up? Uh, is there any other modalities you would use to help get rid of the stricture, um, or do you do an interposition? That's the question. And you should poll the audience too bad we didn't think of that earlier because we so here we go, we've got a. Basically, his, his esophagus isn't bad, he's just got this incredibly tight stricture at the top of it. It's not a particularly long, but it's extremely tight. And this is just an air bubble in the contrast. But you've got basically uh, you know, pretty good esophagus below a very tight stricture, and the strictures about as high as you can get. Which Brings us to the uh who wants to do what to fix it. Uh, so it'll probably take a few minutes to get poll results, but, um. So, um, while we're waiting for them, um, I mean, this goes back to the question, what are the pros and cons? If you, so, so, patient's yours now. So what I mean, you have, you have things that you like doing, but if you were to be totally unbiased, what goes through your head discussing the pros and cons of each of these uh options? First of all, let me ask you, you saw the patient, did anything go through any of your heads about a better way to get the stricture to open? Did you try that first? Is there anything that wasn't tried? We did, we Phil, you dilated it. I did dilate it and we looked at it to see if this would be amenable to a needle knife incision, but it's, you know, it's long. The needle knife is much better for a very short, well defined unilateral, usually, or, you know, some partially circumferential scar band where this is uniform and way longer than I would ever cut. The needle knife, and dilatation's already been attempted without success. And we had a pretty good idea of the, the history coming in, and it wasn't an optimistic history in terms of doing anything to that stricture that was going to make it stay open. unless a stent, which you can't really do in the back of the throat very easily. That would have been in his pharynx. It would have been in his pharynx, which is what happened to us when we tried that silla. A tube he was choking on it, right? So that's the concern. So, so someone in the audience wrote a better attempt at dilation and, and for whoever you that you have an answer from, from Rusty Jennings, but for, for any of you that, uh, that, that wrote, someone wrote a better attempt at dilation, I'm curious what, uh, else might be a good approach to deal with the stricture. We have a bunch of, a bunch of comments here, um. Uh, Adrian, I'm gonna get to your case, you know, in a second. Uh, it's about the dilations. Um, Rusty Jennings says, I would pull the stomach down and do a Nissan 1st. 6 weeks later, resect the stricture to normal tissue. Very good point. Um, it's a great point, and it's exactly the conversation we had before about what do you do. I think the difference with this case for me is the fact that there is no proximal esophagus, and this is a very long stricture. And so having had multiple operations on the cervical esophagus, and I was, I was personally not convinced that we were going to be able to make this stricture go away with an anti-reflux procedure. And in fact we put more attention on it and then if you have To resect that stricture and pull the distal esophagus up, you would either have to undo your Nissan and redo what you did, which is mobilize the hiatus, or you were never going to get enough length to get that back together. Yeah, because you, it's sewing to the pharynx, basically. So now another person says the same thing. I would do a laps and then wait 3 to 4 months before a right thoracotomy to resect the stricture and reastomosis of the esophagus. So that's another thing, by the way, get to it. No, no, but the idea of the idea of resection and primary anastomosis, but I have a, uh, I have a feeling that that would be tough to do. Um, when you went in there and you resected the stricture, did you consider putting the two ends? Would, would you, were you able to get the two ends? I absolutely did. I, I abs I was. Surprised at how much. Distal esophagus, I was able to mobilize up high and you could potentially have sewed that it would have been tight. But you'd already tried that several times. And it was a, by the way, uh, gorgeous anastomosis. I mean, we were patting ourselves on the back saying there was no tension, uh, came together easily. Clearly I had ischemia because it was 100% a technical issue, whether it was ischemia. I don't know that it was because I mean, as you know, you, it's not the first time you've done this. As a good surgeon, you do it not once but twice, and it, as you said in the operating room. When I did it, it didn't look, I mean, it was tight. It was going to be tight, significantly tight. We even, I think you even came in the room when I was doing it. We talked about is this worth trying to close primarily, and it was the fact that it had been tried several times before. I didn't want to just repeat the same. Attempt and get the same result, which is either a leak or a stricture or both, right, right. Can the pulmonologist ask a naive question? Well, I think most pulmonologists. OK. That was the line. OK, yeah. Where did we get him from? Um. What about the cricopharyngeal? If you, if you have all this stuff up here, you have no cri cricopharyngeal function. How is a kid ever going to swallow? How is he going to protect his upper airway? Is he not going to be turned into a constant aspirator? So what would be your, what's your Solution. I don't have a solution. That's why I'm asking the question. Well, he might be. And so the only solution to that would be to do a spit fistula on the kid if you're saying that there's no. And a lot of kids have replaced esophaguuses and most of them don't aspirate, even if you've got a trashed cricoharyngeis. So, and in fact, in a lot of kids, we've got one coming up where, uh, you know, we, Do a cricopharyngealyotomy and so that doesn't need to be the ultimate safeguard, OK, and so a colon interposition to the child with no esophagus into the pharynx. We've got another one coming up. I'm not looking forward to that. Yes, no, me either, but, um, and those that child is able to swallow at least saliva and stuff so that she does not aspirate. So all of the common, every person that's commented said that they would do an anti-reflux operation. Uh, this person says, uh, uh, they would do a coli, which, by the way, is what we talked about today as well. I mean, I'm going to have to do an anti-reflux operation on him. And the question is what operation? It's gonna probably, you know, if I wait long enough, I may be able to mobilize it back down, but I think I'm probably gonna have to do a colis on him because I don't think I'll be able to get enough. His G junction's up in his chest. Yeah, although in that contrast study it's not that high up in the chest and he's got a lot of normal distal esophagus, and I bet you'll be able to pull that down and do a wrap, and it's a little looser now that he's had a little something shoved in above it. Well, we talked about that, but I don't know if it's going to help because I think it's still all stuck. It's going to be stuck up high, although I was, it was remarkable how mobile his distal esophagus was. It just I did not think in the operating room we were going to get close enough to have a reliable anastomosis, and it had been tried multiple times. And if you pull it down and do a Nissan first, which I think everybody who said that, it's a very It's a very reasonable thought, but that's going to make that that upper part even harder because now you're putting what I did. Yes, exactly. That's exactly right. You're undoing what you did to put more tension on it from below, so. Again, none of these kids are simple kids. Uh, it's a different, uh, a different approach. I have another question, but I want to do it after you show this because it's a question post-op there. Yeah. Oh, let me try that again. So, uh. And so this is just um Showing in some senses the combined approach that we tend to use, because these are quite long and somewhat tedious operations, particularly when, you know, you're, you're going into a, a sort of a, a repeat battlefield. And so we tend to do a two field approach. So, that's Dan on the abdomen, I'm up in the neck. And We're working simultaneously for a few hours and so I exposed the esophagus, I made sure that we looked after the recurrent laryngeal nerves. I actually took out most of the thymus and got down beyond the nominate artery, and while Dan's getting things going in the chest, I can tell you that's actually the fellow because I'm not an LSU fan. I was wondering who was that. He's got an LSU Tigers hat on, so that wasn't me, but, but I was in the room, and I'm sort of, you know, I'm, I'm feeling mildly offended at this point because there are things going on on that belly that I do not understand and do not appreciate. I'm much happier up in the neck. But this, this combined approach has been very useful for some of these complex cases because one of the risks for these kids is they spend a long time in the operating room and it has been very, uh, it's great to have great colleagues who have expertise, you know, to their. Dissecting out the neck is great because it saves several hours. It literally saves several hours of surgery. So when you went into the neck, did you, this lies right under the clavicle. Did you ever consider resecting the clavicle? No, because once we got the esophagus dissected out, I could mobilize normal esophagus way above that. So I'm not sure what resecting the clavicle. I'm wondering if that's contributing to the It's an, well, the answer is no, I don't think so. Not technically the case, but post-op, post-op. What was interesting is how lateral this esophagus was, and I think it was because he had had a spit fistula and then had a reastomosis, but the esophagus was not in the normal location at all, which made us worry because his, his recurrence worked fine. And so, you know, that made that part of the dissection. A little more difficult because it was a very scarred and b, we didn't know where to, you know, finding the recurrence was not as straightforward as you might think. And I'm just going to put the still image or a little bit of video here showing just how tension free that is. It is amazing. And that's, you know, it's what part of the colon is that on this child, what I do is when I open the abdomen, I assess the marginal artery and I pick whichever side I think it's a better artery where the vessels are better. In this child, it was on the right side, so we used his. The plan was to use his right colon, go into his chest, and do a segmental colon interposition from way up at the pharynx, uh, to the esophagus. What we found in the operating room is that as we've discussed multiple times, I can immobilize the esophagus, the normal esophagus into the neck, and there was no reason to go in the chest, which is great because he'd had multiple thoracotomies before and it was redo, redo, thoracotomy. There was, so there was no reason to do that. I could do just a short segmental. The plan was a short segmental colon interposition just to bridge that gap, to take the tension off it in the neck. And in order to get it there, uh, rather than going through the right plural space. The native, you know, through the esophageal hiatus, which had already been dissected out and such, I actually ended up, once we discovered we only needed a short segment, is to use the substernal tunnel so that we completely avoided a thoracotomy and just brought this short segmental colon interposition up into the neck. So Dan and I were able to shake hands across the skin's thorax, uh, you know, we'd dissected out the thymus and got down beyond the nominate, primarily for the exposure. But by the time Dan was coming from the bottom up, we realized we were really pretty close and it wasn't too difficult to connect and that was tension free enough we could have anasomized it to his nasopharynx if we wanted to so not everyone mobilizes that well as you, as you'll see, but, um, uh, but it is amazing how high you can get a colon in a position to go, and we've had. A number of kids with essentially no esophagus left and sewed it to the pharynx, yeah. And he did have some small problems post-operatively. So he had a leak from the proximal esophagus. We took it up as high as we could and it was still bad. I mean it was just bad tissue and it was very strictured. It was scarred. It was hard to find. It was more mucosa by the time you got to it than anything else. So not surprisingly, he leaked from the cervical part, although that ultimately healed, and he, he had a little side trip to the You know, with a bout of sepsis, which is probably related to his line. Then we got this study which shows his colon interposition, which I had this great idea to make a nice short colon interposition. The problem is I didn't make it short enough. And so he's got this little redundant segment of colon, this big kink in it which is redundant colon. It's a very short segment, and it's still kinked. I mean, it's really obscene. And he's got a little bit of a stricture on the distal anastomosis, so things back up some of that is contrast because Phil could actually drive his scope through there. Oh no, this is, this is this, you've got to go round that sort of uh. Phil had to go around the corner and down. And it looks narrow with the contrast going through the same side that scope went through that, so interesting, so it's all. And in fact we can show that. And so To stop the leak, Phil actually put in a stent, and this may not be a bad juncture to talk about esophageal stents, and so this is through the top anastomosis, you're into, that's the anastomosis right there. And now you're into into position, you can sort of see colon slime. I always feel slightly offended by that. Who And then Phil's got to take a bit of a turn to get through here. It's just got this redundancy. And it's, it's hard to catch it on video because it was, it was almost by and get all the slime out of the way so I could see. And it's worth just watching the rest of this video because this also shows Phil putting in one of these covered stents. And this is a, a still photo of the covered stent afterwards. And as the covered stent is coming out tomorrow, we'll have to let you know how it worked. So, as we're watching the video, um, Let's say he gets through this and does OK. Hopefully he's going to get through this. What's the, what is the what is your management for us? I don't want to jinx us. That's why I'm saying it that way. Um, I'm not saying when exactly, but let's, so, uh, what is the, what, what, how do you deal with redundant interpositions as the patient grows? What is the usual? Um, I'm assuming usually you have to go intervene and resect some of the interposition. Yeah, and you can do, I mean, you obviously, you worry about the blood supply, but you can, uh, you can do that, and it's, here's the picture of the stent inside the stent. That's great. It's funny that that's that's a covered stent, yeah, this loopy thing, if you grab it and pull it concertine is the top of the stent, so you can pull it back. It collapses I think that's the technical term the company said to use, and, uh, and you can actually go down and see the end of the stent is just proximal to GE junction really. So, um, You, first of all, does it neovascularize? I wouldn't count on that. OK, I don't know the answer, but I've never tried that experiment and I hope not to. I think that what happens is that you start with this little tiny marginal artery, and I always like to see the little tie on the end, you know, pulsating to make sure there's some flow there. And to be honest, when we scoped him, my most The most important thing I saw was bright pink, healthy looking colon because now I can fix, you know, I have a nice viable piece of tissue there that will bridge the gap between native esophagus and the pharynx. Now I just have to make sure it's right, and this may fix it, it may not, but I know I have viable tissue up there. In terms of shortening it, you can do, um, you can. Either redo, you, I guess you would probably redo, I would prefer to redo the distal anastomosis because the proximal one was very difficult because we didn't have esophagus to sew to, um, and in the same way that you create this segmental interposition, it involves just dividing the little branches on the wall of the esophagus and shortening it, leaving the vascular arcade to the distal end, which obviously is high as you want that to be as high as you can get. So I just didn't make this one. I thought I made it short enough and I didn't make it as short as it looked in the operating room. It looks twice as long. Is it, is it too gross of a statement for me to say it's better to err on the side of too long than too short? Well, that was my intention. I don't know, but we'll see how this works out because my concern was to make it, I didn't want to make it too short and I wanted to give him something to bridge. That for whatever reason he does not heal his esophagus and he never would have healed esophagus to the stuff that we sewed to at the top. It just, it would have been under tension and it didn't even heal when there was no tension and it was a very well vascularized thora. I want to point out the complication that I had that we brushed over, but I want to point out a trick I learned I learned from my mistake when I did the spit fistula. It's not as simple as divide and, and bring this up. You, I learned from that, you really have to mobilize the esophagus when I was all the way down to the diaphragm pretty much to separate it away from the trachea cause it will refis your distalline will find the trachea. I never knew that. I thought it was a matter of dividing it and dropping and dropping, and I did dissect it a few centimeters, but you really have to apparently totally mobilize the distal esophagus if you're going to be doing a spin. I can tell you immobilized the proximal too because it was way the hell out to the right side of the neck when we went in there. It was quite impressive. Yeah, yeah, we mobilized. Oh, you immobilized. Oh yeah, so we were thinking, what the hell is that? It worked out it was esophagus. So. So here's a challenge. And um now the other thing that this shows is you see there's almost a very slight waste just there minimally that's where the redundant kink in the colon is repositioned itself and there is a chance that it may now stay scarred open and that little kink. Maybe will not be as an issue. I mean, yeah, that's, that's a statement of hope more than anything, but that would be useful. General question, let's say this is a question for you, that this proximal anastomosis fails. Now we're up even higher now than we were before. At a certain point you can't. What do you do? What do you do when you get up to, I mean, we have, so we have done a case where Mike put his fingers in the kid's mouth, pushed him down into the bottom of the hypopharynx, and just pushed, and I cut down on his fingers and sewed the colon. Wow, so you can go go up higher. You can always go higher. That's, I mean, I sort of felt like we're running out of space to tie so to, but there you were. I mean there, there was essentially, there's virtually no esophagus, right? It's approximate hypopharynx. Yeah, it was to the background noise of don't cut too deep now. Yes, yes, yeah, yeah. And so, again, This is. Um, slightly more interesting boy in a lot of ways, and so this guy is, he's 16. Completely mentally normal. He's at school. He's got an interesting history. He's had a pure esophageal treasure. It was repaired at 6 weeks. It's strictured. He got dilated, well, at least 30 times, probably more, until it ruptured when he was 4. And he got a thoracotomy, chest tubes, stents, and. That continued to be the theme for the next decade until after one of the stent placements, he started coughing a lot and turned out to be aspirating with a hole into his trachea, which was repaired with a muscle flap. And so at this point in time. He comes to us, he can't swallow his saliva. He wakes up every 3 hours at night, sits up, coughs out a large amount of mucus, and goes back to sleep again. He's GJ fed, and this is a normal kid. This is a guy who's doing pretty well at school. He's pretty skinny, and he's got a very compromised lifestyle, and he's actually not really having pneumonias, but he's clearly chronically aspirating. And so let's have a look at some of the initial images. So again, we'll, so can I stop you? So, so your first study in a kid like this is to do a scope, not an esophagram or I think we did we get the esophagram first or second, I don't remember. When a patient, a complicated child like this, this is not the routine TEF. This is a complicated patient who's had multiple operations. They come for an evaluation, and the evaluation usually involves multiple tests, usually a swallow, high res CT, high resolution CT scan of the chest. And then they go to the operating room and the four of us go to the operating room together and we do the, sometimes there's 2 scopes, as you may see in this one, sometimes it's, but the standard approach is an MLB, a flexible bronch, and an EGD. And then to just try to sort out exactly what the anatomy is because they've had so many procedures it can be very complicated and I usually do a contrast exam through the scope with fluoro at the time. So sometimes many of them have had some sort of contrast exam awake, but I always do it before I try to do anything endoscopically or replace a wire. I always do a contrast exam to the scope. I have to tell you, I'm sorry, this is so cool that you have this team here. I mean, that's, I just don't know. of any other places that have it, and I'm sure there are, but it's, it's just, uh, that's, this is the, this is the 2nd time today. I mean, that, you know, this morning's was on intestinal failure, and the big thing that was a take home was that actually they've shown decrease in mortality from team approaches in, in intestinal failure patients, and I don't think most places do this. I mean people operate on islands and silos, and that's how, and that's. Why they're not getting the same we all learn from each other, and it's also very, uh, very liberating to say there's somebody who can do a neck dissection faster than I can and you know, has a better chance of preserving the nerves and, you know, do the scopes and such. It's just, it's, it's great. It's safety in numberstaneously just saves time. These are not short cases. And uh the other nice thing is, um, for the families, because a lot of these families have been through a hell of a lot. It's actually kind of nice, the four of us, you know, we hunt in packs, we walk out together, we meet with the family, and we present the sort of combined information and the plan, if you like, of this is what we've got. These are some of the challenges. This is what we think we should do. And it's sort of, you know, very much a collaborative approach. And um, you know, we don't always get everything right, but it's uh often useful to, you know, as you'll see here, we've start off with the initial, Rigid bronchoscopy, so typically we do a flexible bronchoscopy, then a rigid bronchoscopy, and then an EGD. As the sort of baseline evaluation, Bob's already gone in, you can see all the goo down there from where he's been washing things. And um then I'm actually going in the upper esophagus here with a rigid scope, putting an anesthetic blade into the upper esophagus, and it's, you know, it's, it's got a problem. And then I'm, what I'm doing now is I'm putting in an endotracheal tube in that upper esophagus. To blow air to see if anything's blown out all those holes in the trachea, because there's holes in several parts of that trachea. So Tube in back into the airway. That is a little divot that means nothing, it turns out, and at cricoid, it really shouldn't. And then we're going down to pump air in and you can see this is the balloon of the endotracheal tube there, you can see the tip of the tube as you wiggle it around. Now we're putting pressure in, and I can't get any of these to blow air from the top. However, But your balloon, your balloon was below that point. The balloon was proximal to all those holes at that very severe stricture. All right. And so what Phil, so Phil's looking at the upper stricture there. And it's, you know, it's a small hole. And then Phil's going bottom up, so this is through the stomach now he can blow air correct. And what we found was that there was tracheoesophageal fistulas connected to the distal esophagus, not so much the proximal esophagus, and it looked like the esophagus wasn't in continuity. OK. Well that's the that's the that's the stricture, that's the stricture from the bottom end looking up and one of those holes, those are fistulas, yeah, there's, there's several of them, not all of them go to the airway, but some of them do. And so this kid's got a bit of a problem. Now, he's, let me just think for a second. So he's had. The original repair and he's had that muscle muscle flap repair he's had two operations and Multiple endoscopic procedures and so let me go back and just work out exactly what he had. The only 2 hours he's had 30, yeah. So a hootomy and then another hootomy, so he's had at least 2 opens. And so we've got. A bit of normal esophagus, a stenosis that's probably complete. You can see a hole, but I'm not sure it actually goes anywhere. You've then got At least 2 holes that connect to the esophagus from the trachea to the distal segment of the esophagus with quite a long segment before you hit the stomach. I have a question for Phil. And then I'm gonna turn it because I know you guys all know so I'm the only one here that doesn't know the story so like you have a problem with this so far. I feel like I'm taking the oral boards here. Um, looking at that stricture, well, this, this is the stricture that This is still the same stricture that's been dilated 100 times, so that, that needs to be resected. There's no chance of any endoscopic therapy for the stricture. If you resect it, that's not going to work. You're going to lose the back of the trachea. It's really those holes are correct, right. And even if we could do some sort of novel because it's, it was a, it probably actually we don't know the, the, the length of it because you couldn't get the scope unless you use radiology to see we scope scope from a scope and so what was the distance of the street, not that it matters really, but I don't remember centimeter, so it's going to be a resection and um you're going to have to put, I mean you're going to have. It looks like you're going to have almost like a 2 to 3 centimeter. Area of resection, you're gonna have a huge whopping tracheal defect then. Yes, that was the problem. So that's when I will call you, right? Why is my telephone so call a friend you approached through what and then again, what approach do you take now if you're gonna be doing a trach court now where this is um. Proximal trachea, this is, this is all above just like to the level almost down to the carina. Yes, yes. We also do a trachea reconstruction. We didn't actually, so. And I know this is just really quite unfair because you don't know what we did, but So this is a post-op flex bronc. And The trachea hasn't been operated on, and this is Bob doing his upside down thing again. Because I can get a sharper angulation. And There's a hole the fistula. But it's not a problem. But you're not telling me what you did. Yes, so what we did. Was, well, Dan, you're up for this. You've got to explain this. Our, our assessment was exactly your assessment, which was if we tried to resect this, first of all it would be, he'd only had two thoracotomies, but he had had leaks, and I mean he, his chest was ugly. And, but a bigger problem was the fact that he had these multiple holes in the trachea and and would leave an enormous defect in the posterior wall of the trachea to the point where our assessment was that would potentially not be reconstructible. And so our approach was We elected to bypass the esophagus, leave the esophagus in place, do a substernal colon interposition up to the cervical esophagus, dissect the cervical esophagus down as far as we could to the stricture, just divide the esophagus there, put the colon in a position substernally all the way down to the stomach, redo a Nissan to reduce any risk of reflux into the residual proximal esophagus, but we didn't, you know, I didn't think all he would have would be esophageal secretions, correct. Right. Exactly, and theoretically there shouldn't be much in the way of esophageal secretions, right? And you could you devascularize that esophagus or no, not really. Well, we didn't want, I didn't want to. I mean, I, right, right, because then you'd have, right, I didn't want the esophagus was basically making up the posterior wall of the trachea, so I did not want to do that, but I didn't want him to. Reflux into it. That hole was actually very useful because the native secretions that are produced in that residual esophagus now have a place to go instead of forming a mass lesion. Yes, so we essentially wanted that to stay open so that he wouldn't get essentially a mucocele in his chest, right? Yes, very important, yes, so. I don't know if you have post-op studies, but he, um, he actually did remarkably well, which was very, yeah, uh, it was nice because this cicada had not been able to eat for 4 years. And I, one of the teaching points for me was we did this, we got a contrast study. It looked great. The esophageal replacement was great. Everything was patent, and you go up to his room to see him and he's still spitting in a cup. And I thought, jeez, you know, we haven't fixed him at all. And he actually, even though we had a study that showed it was fine, and we sent him home and he came back for a follow-up, and he was from a distance. He came back from a follow-up and his mom came in and she was kind of beaming and she said, well, on the plane on the way here, he was eating pizza. So it was really just a learned behavior that for 4 years he was spitting. So I, and we've seen that in several kids now where it takes a while for them to learn how to swallow again. In fact, he's had his G tube out now, hasn't he? So he's fully oral now. He's ecstatic when he comes back to see us too. He's got, you know, you know, he does have, he's got unsurveilable esophagus, but I don't know if that matters. Well, right, and it's a concern. And so I, you know, this, we thought that the safest thing to do for him was not to try to take his esophagus out and just to bypass it, but that doesn't mean he's not going to have problems in the future either with his colon interposition because he's got the full length colon interposition. Uh, or from his residual esophagus, and so it's, and it's a challenge to think about how to follow him, and so we CT'd him and to make sure he didn't have a mucousy going in there, um, but he so far has done very well. Have you ever done a bypass of the esophagus, is that, I mean, it seems to me, I've never even thought of doing that, um. It seems to me a great idea in this kind of bailout situation. Well we just damage control. It was, we are right. He was either going to stay the way he is, you could give him a spit fistula and say you're going to have a spit fistula for the rest of your life, um, but in our assessment, and this is a great, you know, you can only tell in retrospect if you made the wrong decision, if you tried to resect this and you didn't have enough trachea to put back together, that's a disaster. And so we elected. In this case, to leave, to accept the potential long term complications of leaving the esophagus in place, and it's great that he can eat and that's wonderful and all that stuff, but it's better than killing him by trying to take out his esophagus. I just, I mean, I think this is great. I'm curious, is there anyone in the audience that Is there anyone in the audience has a problem with this that thinks that this, that they would have done this differently? I'm very curious if anyone has any other options. Let me ask you a question while we're waiting for that because there's one comment, but is there, can you, uh, do tracheal reconstruction with biologic materials or, or no? Does it not work that way? The future will be doing tracheal homografting where we've pre-epithelialized and so there's been a few cases done around the world. There's an awful lot of controversy at the moment. And we've, I've actually got about 6 kids waiting for that sort of operation. And I don't think it's ready for prime time, so I'm not doing them yet. But kids who need a new trachea. I've done about 12 homographs, putting in a dead trachea before, and it's not much fun. And it's a tough few months afterwards. So eventually the idea that this is a lot of work's being done in about 8 different units around the world, probably London's leading it at the moment. And um this for tissue engineering tissue engineering, and so either you can use a dead trachea that you put in a pocket, let it sit there for a while, then inject the hollow space with some of the patient's cilia ciliated epithelium that you've grown, and then roll it into the airway, and that's probably not a bad option, um. No one's quite got the secret source. It's just not quite there. And although there's been, you know, blazing publicity about several cases, if you follow some of them through, the longer term results weren't always glorious. And um at the moment, probably the best science is coming out of London. It's close. It's not there, but it will be, but it will be there. I mean, it's going to be the future. I'm just not convinced it's the present. Uh, Adrian, you asked about how far out he is from his colon at present. Is there a specific question you had or you're just curious? He's he's 2 years out, um, and we've followed him. Initially every 3 to 6 months or so and then we've seen him probably at a 6 month interval and because he is from a long way away, we keep in touch with him over the phone, but we actually have brought him back for several reevaluations to have to be scoped just to make sure that this wasn't going to be a problem. We get a CT scan to make sure that there's no mass accumulating in the chest and that he's not got some mucocele accumulating in the chest. Interestingly, that tiny hole, if we really needed to, we could dilate it and put a telescope through it. And so we can, if we were very motivated, we could, you know, do a surveillance look. Rusty Jennings says, I have treated several, uh, kids like this, some worse. Um, separate the trachea and the esophagus, OK. Posterior tracheoplasty, OK, and, uh, posterior tracheopexy, resect the esophageal stricture. Rotate esophagoplasty, and you can use bovine pericardium for the posterior trachea. Do you want me to go through those again? Yeah, OK. Potentially doable. Um, the bovine pericardium works great when it works, but if it doesn't work and we see this more with the complete tracheal rings kids who, um, have had that done, when it doesn't work, things can, you know, get. Quite literally, you can end up with a hell of a big hole. And so, um, but, you know, yes, uh, you know, the, the concept of that is fine. Again, there's more than one way to skin the cat. Posterior tracheopexy. I, I, I won't presume to speak for Rusty because he's the expert on this, but he, uh, has described this technique of, of, you know, it's essentially the reverse of an aortopexy, um, is, and Rusty, please. Uh Chime in if this isn't correct, or please let us know exactly what you mean by a posterior tracheopexy, but it's essentially Pexing the the trachea further posterior. What to the spine? I, I'm not going to try to describe the technique. Rusty is the expert he'll clarify. Um, Adrian says I would have at least looked in his chest to see if it could be mobilized. It would have not resected any common tracheal wall. If the 5+ centimeters of esophagus that was missing. Um Was missing, then you could have her placed in in position. I worry about the long term function of the colon. Very tough surgery with risks, but I think he has a long road starting in 2 to 3 decades. And then let's discuss that and then Rusty answered. Uh, all I have to say now, he says, move the esophagus to the right chest. And attach the posterior trachea to the anterior spine. That's what I thought. Yeah, we've seen some kids who've managed to auto do that where they've had a constant congestion and they come in with no esophagus, no stomach, no back of trachea, and, uh, we've actually, you know, we don't have the time for it, but we've got a lovely video of, uh, a flex scope going down trachea. Behind the pericardium, which is this nasty gray color, down to diaphragm, and uh because there's no esophagus there anymore and no back of trachea, and he scarred his trachea to his spinous ligament and effectively sealed off his trachea without needing anything else done. Um, he still needed a colon into position to swallow, but, uh, he fixed his tracheal defect, effectively, you know, what Rusty's saying. And so, um, We are close to winding this up. I don't think it's worth doing any other cases. Are there any other questions that we've got? I think, um, what's good to do, um, and I hate to put you all on the spot, is we've been talking now for a while. What sticks out in your head is like the, the takeaway points, the big points that were addressed today for, for summarizing. I know for me it's the team approach. I think the bug be is something that's important. I like the idea of blowing the use of an endotracheal tube in the esophagus, um. Uh, these are some of the, the, the big, you know, the whole advantages of the colonic interposition. Those are some of the big take home points that I've brought home today. I don't know. Yeah, I think those are all really important things. I think I would reiterate the team approach because it all, it is dependent on all of us to have a full understanding of the child, and we're very often dealing with kids with multiple comorbidities affecting systems outside the respiratory tract or their GI tract, um, managing the families as well, um, especially when they're from a distance. It all works better when we all work together. And the 3 of us are in the room at the same time watching what the other guy is looking at. That's powerful. Also, the other thing I would add is go read Aesop's fables. Look, look before you leap. Every year we get a kid or two who's had a thoracotomy, uh, gone on bypass, had his cardiac defects repaired, and then they decide to look in the trachea after they've closed the chest, and guess what, he's got complete tracheal rings. Mhm. Yeah, I think that. I think every time we discuss this in these kinds of cases, I'm impressed by the fact that we don't have the right answers yet, so you need to get your pigs to live, or we need to get some tissue engineered esophagus or something, you know, there are lots of different approaches to these very difficult patients, and I don't think you can say any of them are right or wrong. It's if you can keep the patient alive, then it's a good answer. If you can give them a better quality of life, that's a better answer. It is never, we still don't have the right answer, and these are just incredibly difficult problems that That we have to continue to work on trying to figure out how to perfect these techniques or develop new techniques is probably really the answer, um, but we're just not there yet. So, so this is great and we're, it's the team approach is awesome. We need to continue to evolve. Yeah, this is a game where complications are almost inevitable. And it's not that you can eliminate them, you can minimize them, but then it's the team approach trying to work out how to manage them, and that can be both preoperative as well as postoperative. Often it's anticipating what could be a problem with, uh, you know, if you like, all of the components of the team trying to contribute to that. So I, I wanna say one last comment and I'm gonna just have Adrian say it for me. Uh, I, it's been a real pleasure being here today and it's been an honor how much I've learned in one day, but Adrian says absolutely amazing webinar, some amazing cases with excellent skills that you all brought today. I'm happy that you all are there for us when these cases get beyond the norm, and I wanna echo that. It's been a true honor listening to this today and uh. Uh, I, I hope, uh, I hope the rest of the world, you know, this, with this archive will be able to watch these over and over and, and learn from this and we can do more of these in the future. And again, thank you, Todd. Thank you, Phil. Thank you, Dan. Thank you, Bob. That was a lot of fun and hopeful. If, you know, even if there's one or two little gems that come from this, then it's worthwhile. So thanks for putting all the work into this. OK. All right. Oh well, uh, that's it for today. Uh, good morning, good afternoon and good evening, and we'll see you next time from Cincinnati Children's.