QUAD #1: Cervical Tracheopexy with Dr. Alessandro de Alarcon

Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. Hey everyone, I'm Todd Ponsky, and I'm a pediatric surgeon at Cincinnati Children's Hospital. And last year, in October 2022, Cincinnati Children's hosted the Quad conference, which was a combination of four conferences: The International Organization for Esophageal Atresia, the Aero Digestive Society conference, the Cincinnati Children's Airway course, and the Cincinnati Children's Pediatric Dysphagia series. In this video, we're going to summarize one of the key takeaways from that conference, which was the importance of ENT involvement in the cervical approach in Esophageal Atresia cases with Dr. Alessandro Dialarcon. So at Cincinnati, we typically use the combined approach. We're looking at the thoracic approach as well as with the cervical approach. Preoperative testing is important to understand what we're dealing with in the first place. For this, the group at Cincinnati Children's uses dynamic CT imaging, pulmonary function tests, microlaryngoscopy, and bronchoscopy or MLB and flexible bronchoscopy. But what about intraoperative tools? What do we need? We need a neck tray and MLB tray and Maloney dilators versus NG tubes and the operating room and you do it. The flexible bronchoscopy is really key and placing your endotracheal tube is really important so they can look as you're doing the operation. They often like to do them nasotracheally and guide them exactly where they want them. And sometimes that means your cuff is super high and it's almost at the glottis. So you just have to be aware of that. If we can, we like to use a NIM tube, that's part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're getting close to them. Now that we understand the standard workup and OR setup, let's dive into the typical approach of Dr. Dialarcon's team. It's a standard neck approach where we raise subplatismal flaps, you deal with the anterior crest as needed. Sometimes they can assist with the thoracoscopic approach by removing some of the residual or regrown large thymus because it's right in the way. You can add things like aorta pexi, on pexi at the same time. And then it really you separate the straps and then expose the airway and find the esophagus. In the lateral approach, the pediatric surgeon stands on the side of the airway to look for the esophagus, while the ENT surgeon looks for the recurrent laryngeal nerve. And then it's thinking about your approach to mobilize the esophagus. And the experience of working with our team in Cincinnati, we've learned how to not be afraid of the esophagus. So being able to find it, to move it, to get it out of the way is really important. The surgeons work together to mobilize the esophagus above the level where they aim to pexi. That approach makes it easier to place the sutures exactly where they are needed. We will sometimes place stitches in the trachea to pull it up and out of the way so you can visualize that posterior aspect of where you see the spine. Our multi-disciplinary team includes a pulmonologist as well, who is assisting in visualization inside the trachea with flexible tracheoscopy through the endotracheal tube while the stitches are being placed. We like to use 3-0 prolines and we like to place all the stitches before we actually secure them down and it's important to do this under spontaneous conditions. This combined approach is really valuable for the complicated cases or those patients who need an additional operation for symptom relief. An example of a patient was one of ours who actually had already had a thoracoscopic approach to traxi, had some of the dysphagia because of that torque esophagus. And then we used that sort of combined approach to really get a really nice airway and she's now symptom free. Finally, what outcome measures are used to determine that the procedure was a success. And what follow-up testing should be done as we follow the patient through their recovery. It's important too to think about those outcome measures. So that means their endoscopy at follow-up, potentially PFTs as they get old enough to be able to perform them. Imaging is needed and when you look three, six months later, it may still look like there's some malacia, but symptomatically they're better. So it's important to pair that piece and understand that we're still trying to learn exactly what are those measures that we want to use to be able to say that they are a good outcome versus a bad outcome. And that managing complications is part of that piece too, whether it's swallowing dysfunction or vocal fold paralysis. Due to those potential complications, it's especially important for ourology colleagues to be involved both in the procedure and during follow-up. And it's always easier if it's already built into your team. To summarize, in this video, we discussed the combined cervical and thoracic approach for esophageal atresia cases, which included preoperative testing, intraoperative setup, and the importance of a multi-disciplinary team for the best outcomes with Dr. Alessandro Dialarcon. And this approach proves valuable for complex cases, improving symptoms and ensuring comprehensive care. Thank you for watching this video. Don't forget to subscribe to the Stay Current MD YouTube channel. Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.