Laryngotracheoesophageal cleft (type IV): Management and repair of lesions beyond the carina

Strategies for managing Type IV laryngotracheoesophageal clefts at Great Ormond Street Hospital for Children

“…CPB is significantly more invasive than ECMO as it generally requires cannulation of the aorta as well as the right atrium with relatively large catheters which can obscure the surgical field [20,21]. Although ligation of the common carotid artery following ECMO has been well documented in infants and small children [15], in our case we reconstructed the artery on decannulation as described by Angel et al [22].…”

“…Using this approach the ETT can be secured anteriorly with a ureteric catheter sling as described by Ryan [15] to help keep it out of the way. However, for single-stage repair using the anterior cervico-thoracic approach any ETT prevents adequate surgical exposure of the cleft.…”

Surgical management of type III and IV laryngotracheoesophageal clefts: The three-layered approach

“…The first case was approached laterally as described by Donohoe and co-workers [14]. Due to problems with exposure, inability to address the laryngeal repair, and risk to the recurrent laryngeal nerves, and fistula formation, we were led to abandon the lateral approach in favor of the anterior approach, as illustrated by the last three cases.…”

Anterior approach bilateral musculomucosal flaps repair for laryngotracheoesophageal clefts

“…Endoscopic repair of minor defects such as type 1 or 2 clefts have been described using suspension microlaryngoscopy and laryngeal instruments. 2,3 LTEC can be exposed from a posterior, lateral, or anterior route, 4,5 and an open anterior approach offers good visualization for long clefts such as type 3 or 4 and helps avoid injury to the vagus and recurrent nerves. 4,6-8 However, patients may need mechanical ventilation and stenting for 2 to 3 weeks under deep sedation because of laryngotracheal instability.…”

“…4,6-8 However, patients may need mechanical ventilation and stenting for 2 to 3 weeks under deep sedation because of laryngotracheal instability. Cleft repair procedures may be considered under 2 general classifications: recanalization of the esophagus and the trachea after separation 4,5,7,9 and closure of the cleft by creating a partition. 8,10 The first important point is not only making 2 tracts but also creating an adequate lumen for the trachea.…”