CPT® Code 43313

1. Indications

The esophagoplasty procedure, coded under CPT® Code 43313, is indicated for patients with congenital defects of the esophagus. These defects may lead to significant complications, including difficulties in swallowing and potential nutritional deficiencies. The procedure is specifically performed when there is a need for plastic repair or reconstruction of the esophagus without the presence of a tracheoesophageal fistula.

• Congenital Esophageal Defects These are structural abnormalities present at birth that affect the esophagus, necessitating surgical intervention to restore normal function.

2. Procedure

The esophagoplasty procedure involves several critical steps to ensure effective repair of the esophagus. Initially, a right posterolateral thoracotomy is performed, where the surgeon makes an incision in the skin and extends it through the soft tissues to access the thoracic cavity. The scapula is retracted to allow entry into the thorax while preserving the pleura. Following this, retropleural dissection is conducted, during which the lung is retracted to expose the esophagus adequately. The mediastinal pleura may be opened as needed to provide full visibility of the esophageal defect. Once the defect is identified, the esophagus is dissected free from surrounding tissues to facilitate inspection and repair. The muscular wall of the esophagus at the defect site is carefully examined and debrided if necessary to ensure a clean area for repair. The mucosal defect is then exposed, and the mucosal tissue is trimmed back until healthy tissue is encountered. This is crucial for ensuring a successful repair. The mucosal tissue is inverted and sutured to close the defect. Following this, a second layer of sutures is placed in the muscular wall of the esophagus to reinforce the repair. To further enhance the strength of the repair, microvascular anastomosis of an intercostal muscle flap may be utilized. Prior to closing the thoracic cavity, a nasogastric feeding tube is placed to facilitate postoperative nutrition, and a chest tube is inserted into the retropleural space to manage any potential fluid accumulation. Finally, the thoracic incision is closed, completing the esophagoplasty procedure.

• Step 1: Incision and Access A right posterolateral thoracotomy is performed, involving an incision through the skin and soft tissues to access the thoracic cavity.
• Step 2: Retropleural Dissection The lung is retracted to expose the esophagus, and the mediastinal pleura may be opened as necessary to visualize the defect.
• Step 3: Dissection of the Esophagus The esophagus is dissected free from surrounding tissues to allow for inspection and repair of the defect.
• Step 4: Inspection and Debridement The muscular wall of the esophagus at the defect site is inspected and debrided as needed to ensure a clean repair area.
• Step 5: Mucosal Repair The mucosal defect is exposed, trimmed back to healthy tissue, inverted, and sutured to close the defect.
• Step 6: Muscular Wall Repair A second layer of sutures is placed in the muscular wall of the esophagus to reinforce the repair.
• Step 7: Flap Reinforcement The repair may be reinforced using microvascular anastomosis of an intercostal muscle flap.
• Step 8: Placement of Tubes A nasogastric feeding tube is placed prior to closure, and a chest tube is inserted into the retropleural space.
• Step 9: Closure The thoracic incision is closed to complete the procedure.

3. Post-Procedure

After the esophagoplasty procedure, patients are typically monitored for any complications related to the surgery. The placement of a nasogastric feeding tube allows for nutritional support during the initial recovery phase, as the esophagus may require time to heal before normal feeding can resume. The chest tube placed in the retropleural space is used to drain any excess fluid or air that may accumulate, ensuring proper lung expansion and reducing the risk of complications such as pneumothorax. Patients may experience discomfort and will be managed with appropriate pain relief measures. Follow-up care is essential to monitor the healing process and to ensure that the esophagus is functioning properly post-repair. Any signs of infection or complications should be addressed promptly to facilitate a smooth recovery.