Tracheoscopy first: to rule out proximal fistula, to define the gap even in type C and D, and to exclude wide laringo-tracheo-esophageal cleft.
Measure the gap precisely, both with and without tension before deciding the timing of surgical procedure.
Always avoid primary cervical esophagostomy (waste of time and esophageal length).
Choose the best intercostal space for thoracotomy (looking at “gapogram” and the vertebral body where the gap falls), use a muscle-splitting technique, use a retropleural approach when possible, preferable through e subperiosteal approach.
Don’t try to perform the anastomosis immediately; perform a gastrostomy and close proximal fistula (type B). Define initial gap and re-measure it every 15 days.
Gap <3 vertebral bodies:
Ready to do the anastomosis, alert senior staff always.
At anastomosis, use a Hegar dilator (4–5 mm) trough the gastrostomy into the lower esophageal stump to help intra-operative identification of the lower pouch.
Always attempt primary anastomosis.
If a left esophagostomy has already been done, move it to the right neck (when right thoracotomy and esophageal re-anastomosis is considered possible and planned).
Handle tissues very gently: Use stay sutures on both esophageal ends; don’t clamp esophagus with forceps.
Mobilize both upper and lower esophageal segments extensively.
Verify the gap is bridged before opening either lower or upper esophageal pouch.
If the gap can be bridged, do the anastomosis.
If the gap is still “unbridgeable,” consider:
Intra-operative traction on each end for 10 min
Upper pouch sliding
Further dissection of upper pouch through a cervical approach
Upper esophageal flap (as small as possible)
Esophageal lengthening with external traction and redo thoracotomy 6 days later
Drain the chest (even if extrapleural approach); avoid costal synostosis.
Maintain the patient sedated and paralyzed for at least 6 days.
Don’t move, rotate, or hyperextend the neck during patient’s transportation and for at least 6 days.
Check the chest drain daily to exclude drainage of saliva: white with foam instead of serous or seroanguinous.
Contrast study on post operative day 6–7, to rule out leak, before starting feeding.