Tracheoesophageal Fistula Repair
What the Examiner Expects
Surgical repair of a tracheoesophageal fistula with or without esophageal atresia, the most common congenital esophageal anomaly. The examiner expects you to classify the Gross types (A through E, with Type C — proximal atresia with distal fistula — comprising 85% of cases), describe the diagnostic workup (failure to pass NG tube, coiled tube on X-ray in the proximal pouch, check for air in the stomach — if present, a distal fistula exists), screen for associated anomalies (VACTERL — echocardiography is mandatory to assess cardiac anomalies and determine aortic arch laterality, which determines the side of thoracotomy), and describe the repair through a right posterolateral thoracotomy (or thoracoscopic approach): division and closure of the fistula, and primary end-to-end esophageal anastomosis.
Key Examiner Focus Points
- Type C (proximal atresia + distal TEF) accounts for 85% of cases
- Diagnosed by inability to pass an NG tube; X-ray shows coiled tube in proximal esophageal pouch
- VACTERL association: Vertebral, Anorectal, Cardiac, TEF, Esophageal atresia, Renal, Limb anomalies
- Right posterolateral thoracotomy: divide the fistula, primary esophageal anastomosis
- Echocardiography BEFORE surgery to identify cardiac anomalies and confirm aortic arch side
Common Curveballs
The gap between the two esophageal ends is too long for primary anastomosis (long-gap atresia)
Long-gap esophageal atresia (> 3 cm gap) cannot be repaired primarily. Options: delayed primary repair (place a G-tube, perform serial Foker-style elongation sutures), or esophageal replacement with gastric pull-up, jejunal interposition, or colon interposition at 6–12 months of age.
Postop anastomotic leak with mediastinitis
Obtain contrast study to confirm. Contained leaks may be managed with NPO, broad-spectrum antibiotics, and chest tube drainage (already placed). For significant leaks with sepsis, re-exploration with repair and reinforcement (pleural or intercostal muscle flap) may be needed. Esophageal diversion is a last resort.
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