CPT® Code 43314

1. Indications

The esophagoplasty procedure is indicated for patients with congenital defects of the esophagus, particularly when these defects are associated with a tracheoesophageal fistula. The following conditions may warrant this surgical intervention:

• Congenital Esophageal Defect A structural abnormality in the esophagus present at birth that may require surgical correction.
• Tracheoesophageal Fistula An abnormal connection between the trachea and esophagus that necessitates repair to prevent complications such as aspiration and feeding difficulties.

2. Procedure

The esophagoplasty procedure involves several critical steps to ensure effective repair of the esophagus and any associated tracheoesophageal fistula. The following outlines the procedural steps:

• Step 1: Incision and Access The procedure begins with a right posterolateral thoracotomy, where the surgeon makes an incision in the skin and extends it through the soft tissues. The scapula is retracted to allow access to the thoracic cavity without disrupting the pleura.
• Step 2: Exposure of the Esophagus The surgeon performs a retropleural dissection, retracts the lung, and exposes the esophagus. The mediastinal pleura may be opened as necessary to fully visualize the defect that requires repair.
• Step 3: Inspection and Debridement The esophagus is dissected free from surrounding tissues to allow for thorough inspection and repair of the defect. The muscular wall of the esophagus at the defect site is inspected and debrided as needed to ensure healthy tissue is available for repair.
• Step 4: Mucosal Repair The mucosal defect is exposed, and the mucosal tissue is trimmed back until healthy tissue is encountered. The mucosal tissue is then inverted and sutured to close the defect.
• Step 5: Muscular Layer Repair A second layer of sutures is placed in the muscular wall of the esophagus to reinforce the repair. This may include the use of microvascular anastomosis of an intercostal muscle flap to provide additional support.
• Step 6: Tracheoesophageal Fistula Repair In cases involving a tracheoesophageal fistula, the fistula is divided, and the trachea is repaired with sutures. The esophagus is then repaired in two layers, with the suture line reinforced using a flap of mediastinal pleura, intercostal muscle, and rib periosteum as needed.
• Step 7: Placement of Feeding Tube and Closure A nasogastric feeding tube is placed prior to the closure of the chest. A chest tube is inserted into the retropleural space to facilitate drainage, and the thoracic incision is then closed.

3. Post-Procedure

After the esophagoplasty procedure, patients typically require careful monitoring and post-operative care. Expected recovery may involve a hospital stay to ensure proper healing and management of any complications. The placement of a nasogastric feeding tube allows for nutritional support while the esophagus heals. Patients may also have a chest tube in place to drain any fluid accumulation in the thoracic cavity. Follow-up appointments are essential to assess the healing process and ensure that the esophagus and trachea are functioning correctly. Additional considerations may include pain management and gradual reintroduction of oral feeding as tolerated.