Pediatric surgery expert witness discusses artery puncture during tracheoesophageal fistula repair surgery

A pediatric surgery expert witness discusses a puncture to a patient’s pulmonary artery during surgery. This case involves a pediatric patient born to a diabetic mother. The patient had a past medical history significant for intrauterine growth restriction, prematurity and VATER association. VATER association is a non-random collection of coinciding congenital defects which include vertebral, anal, tracheoesophageal and renal pathology. The patient underwent surgery to repair a tracheoesophageal fistula and sustained a major complication during the procedure. An endoclose needle was inadvertently pushed through the esophagus at the inferior aspect and punctured the pulmonary artery on the way out. The patient desaturated quickly and the decision was made to perform an emergency thoracotomy to control the bleeding. The patient was eventually stabilized and returned to the pediatric ICU. In the post-operative period a CT scan of the patient’s head was performed which revealed a right frontal acute subdural hemorrhage. The patient was left with severe brain damage as a result of extensive brain hypoxia encountered during the code.

Question(s) For Expert Witness

Can you comment on adequate surgical technique when approaching the pulmonary artery?

Expert Witness Response E-005319

Based on the history of the presenting complaint, it appears that the treating surgeons were using a relatively new approach to repair the esophagus. This new techniques helps to avoid having to create a formal surgical anastomosis, but rather relies on passing a suture across the esophageal gap, as facilitated by an endoclose needle, and then subsequently dilating the newly-formed connection over several sessions. This technique was published in the literature, I believe, in 2010. This is certainly not the standard method of esophageal atresia repair, and most surgeons in the country do not perform the procedure in this fashion. The complication described is unfortunate, and perhaps should be considered as a pitfall to this technique moving forward. However, since it is such a new surgical approach for a disease classically treated in a different manner, I am sure that complications such as this are not widely known about in the pediatric surgery community. Regarding adequate surgical technique when approaching the pulmonary artery, that is a more difficult question to answer. A large bore needle injury to the right pulmonary artery (I assume that it was the right side that would be injured when using this technique) should be able to be controlled via right thoracotomy, with proximal control gained by opening the pericardium anterior to the hilum of the right lung. Injuries more proximally or to the main pulmonary artery might be difficult to access in this way and might require a median sternotomy and/or cardiopulmonary bypass.