1 00:00:00,000 --> 00:00:08,000 Global Cast MD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe. 2 00:00:08,000 --> 00:00:13,000 Hey everyone, I'm Todd Ponsky, and I'm a pediatric surgeon at Cincinnati Children's Hospital. 3 00:00:13,000 --> 00:00:22,000 And last year in October 2022, Cincinnati Children's hosted the Quad Conference, which was a combination of four conferences. 4 00:00:22,000 --> 00:00:34,000 The International Organization for Esophageal Atresia, the Aerodigestive Society Conference, the Cincinnati Children's Airway Course, and the Cincinnati Children's Pediatric Dysphagia Series. 5 00:00:34,000 --> 00:00:49,000 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 D'Alarcon. 6 00:00:49,000 --> 00:00:56,000 In Cincinnati, we typically use the combined approach, looking at the thoracic approach as well as with the cervical approach. 7 00:00:56,000 --> 00:01:00,000 Preoperative testing is important to understand what we're dealing with in the first place. 8 00:01:00,000 --> 00:01:12,000 For this, the group at Cincinnati Children's uses dynamic CT imaging, pulmonary function test, micro-laryngoscopy, and bronchoscopy or MLB, and flexible bronchoscopy. 9 00:01:12,000 --> 00:01:15,000 But what about intraoperative tools? What do we need? 10 00:01:15,000 --> 00:01:21,000 We need a neck tray, an MLB tray, and Maloney Dinolytors versus NG tubes in the operating room when you do it. 11 00:01:21,000 --> 00:01:29,000 The flexible bronchoscopy is really key, and placing your endotracheal tube is really important so they can look as you're doing the operation. 12 00:01:29,000 --> 00:01:34,000 They often like to do them nasotracially and guide them exactly where they want them. 13 00:01:34,000 --> 00:01:40,000 And sometimes that means your cuff is super high and it's almost at the glottis. You just have to be aware of that. 14 00:01:40,000 --> 00:01:47,000 If we can, we like to use a NIM tube as part of trying to prevent potential injury to recurrent nerves or at least make you aware when you're getting close to them. 15 00:01:47,000 --> 00:01:55,000 Now that we understand the standard workup and OR setup, let's dive into the typical approach of Dr. Deallercon's team. 16 00:01:55,000 --> 00:02:01,000 It's a standard neck approach where we raise subplotisinal flaps. You deal with the anterior compression as needed. 17 00:02:01,000 --> 00:02:09,000 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. 18 00:02:09,000 --> 00:02:13,000 You can add things like aortapexia and omopexia at the same time. 19 00:02:13,000 --> 00:02:19,000 And then it really separates the straps and then exposes the airway and finds the esophagus. 20 00:02:19,000 --> 00:02:29,000 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. 21 00:02:29,000 --> 00:02:33,000 And then it's thinking about your approach to mobilize the esophagus. 22 00:02:33,000 --> 00:02:39,000 We've had the experience of working with our team in Cincinnati. We have learned how to not be afraid of the esophagus. 23 00:02:39,000 --> 00:02:44,000 So being able to find it, to move it, to get it out of the way is really important. 24 00:02:44,000 --> 00:02:49,000 The surgeons work together to mobilize the esophagus above the level where they aim to pexie. 25 00:02:49,000 --> 00:02:54,000 That approach makes it easier to place the sutures exactly where they are needed. 26 00:02:54,000 --> 00:03:02,000 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. 27 00:03:02,000 --> 00:03:15,000 Our multidisciplinary 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. 28 00:03:15,000 --> 00:03:21,000 We like to use threoprolenes and we like to place all the stitches before we actually secure them down. 29 00:03:21,000 --> 00:03:24,000 And it's important to do this under spontaneous conditions. 30 00:03:24,000 --> 00:03:33,000 This combined approach is really valuable for the complicated cases or those patients who need an additional operation for symptom relief. 31 00:03:33,000 --> 00:03:43,000 An example of a patient was one of ours who actually had already had a thoracoscopic approach to tracheoplexy, had some of the dysphagia because of that torqued esophagus. 32 00:03:43,000 --> 00:03:49,000 And then we used that sort of combined approach to really get a really nice airway and she's now symptom free. 33 00:03:49,000 --> 00:03:54,000 Finally, what outcome measures are used to determine that the procedure was a success? 34 00:03:54,000 --> 00:04:00,000 And what follow-up testing should be done as we follow the patient through their recovery? 35 00:04:00,000 --> 00:04:02,000 It's important too to think about those outcome measures. 36 00:04:02,000 --> 00:04:08,000 So that means their endoscopy follow-up, potentially PFTs as they get old enough to be able to perform them. 37 00:04:08,000 --> 00:04:09,000 Imaging is needed. 38 00:04:09,000 --> 00:04:15,000 And when you look three, six months later, it may still look like there's some malacia, but symptomatically they're better. 39 00:04:15,000 --> 00:04:25,000 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. 40 00:04:25,000 --> 00:04:31,000 And that managing complications is part of that piece to you, whether it's swelling dysfunction or vocal fold paralysis. 41 00:04:31,000 --> 00:04:40,000 Due to those potential complications, it's especially important for our otolaryngology colleagues to be involved both in the procedure and during follow-up. 42 00:04:40,000 --> 00:04:43,000 And it's always easier if it's already built into your team. 43 00:04:43,000 --> 00:04:50,000 To summarize, in this video, we discussed the combined cervical and thoracic approach for esophageal atresia cases, 44 00:04:50,000 --> 00:05:00,000 which included preoperative testing, intraoperative setup, and the importance of a multidisciplinary team for the best outcomes with Dr. Alessandro D'Alarcon. 45 00:05:00,000 --> 00:05:07,000 And this approach proves valuable for complex cases, improving symptoms, and ensuring comprehensive care. 46 00:05:07,000 --> 00:05:09,000 Thank you for watching this video. 47 00:05:09,000 --> 00:05:13,000 Don't forget to subscribe to the Stay Current MD YouTube channel. 48 00:05:13,000 --> 00:05:19,000 Follow our social media channels and download the Stay Current MD app for tons of content in pediatric surgery. 49 00:05:19,000 --> 00:05:40,000 GlobalCastMD, along with Cincinnati Children's Hospital, sharing knowledge to improve child health around the globe.