Wednesday, May, 17th 2023
Today started off like any other. Overnight he had a few more then usual Emesis (throwing-up/reflux) then normal. Not much of a concern unless it becomes a pattern. Also, this is a common complication to his GI anatomy.
Family/Team Meeting
We had a great ‘care conference’ with the family, the Esophageal Team at Boston Children’s and Dr. Goldin from Seattle Children’s today. I cannot express the amount of love and support that Dr. Goldin and the team from Seattle Children’s that we feel. Overall the meeting went well and pushing for this type of collaboration is one of our major ‘pro-tips’ to other families with complex-medical kids.
Richard specific details:
- He has a few centimeters of esophagus to use
- There will be something to connect, but it may be a centimeter or so higher
- He does not have a long stricture
- The fistula itself is strictured-his TEF is right at the anastomosis site
Goals:
- Treat TEF and open the anastomosis between esophagus and stomach
- To use the same incision that he already has. Possibility that they may need to go in through the right side of the chest
- To prevent TEF recurrence-put tissue in between the area (aka posterior tracheopexy to avoid recurrence of TEF)
- Use nerve-monitoring to avoid vocal cord injury
- Extubate at the end of case if possible
Risks:
-Re-stricture and esophageal leak
Healing/Recovery:
-3 major factors to healing= amount of tension, blood supply, and tissue quality, these factors will determine amount of sedation/paralysis used in order to prevent swallowing during healing
-If for some reason Richard is unable to extubate- possible reasons= significant injury to the laryngeal nerves, pain control issue, significant secretion burden, subglottic swelling
Follow up:
-Depending on how much esophageal work is done-will have endoscopy 3 or 4 weeks after surgery
- May need several dilations following surgery-therefore, may need prolonged time in Boston
- Seattle vs Boston extent of follow up? To be determined with more information at his 3 to 4 week post op endoscopy
Miscellaneous:
-When do we remove central line?–> potential for removal with his 3 or 4 week post-surgery endoscopy if he is doing well and clinically appropriate
-Gastric pullup chat worst case scenario jejunal interposition surgery
-Indicators for jejunal interposition surgery being needed:
- recurrent pneumonias=Main indicator
- esophagitis resulting in cancerous tissue in the esophagus-unlikely in Richard due to amount of esophagus and it being higher up
- degree of vomiting
The rest of day was normal pre-op day. We stopped j-feeds at midnight and added a IV drop to get him ready for OR. The biggest surprise was a difference in how Seattle and Boston transition from the Surgical Acute Care floor to the ICU after a planned surgery and ICU admission.
The biggest difference is once he rolls out of the room for pre-op early in the morning we lose our Surgical Acute Care bed/room and then do not get an assigned ICU bed/room until he hits post-op. This means that papa will need to pack everything up and spend most of tomorrow effetely a homeless bum on the couch in the Surgical Waiting room while most of our stuff is in a storage room in another building…..