J. L. Che Morales and G. K. Vargas Mendoza: J Extra Corpor Technol 2026, 58, 90--94 91
Figure 1.( A): Tracheoesophageal fistula. Esophagus at the bottom.( B): From top to bottom, distal and proximal ends of the trachea( blue arrows). Esophagus with primary closure( yellow arrow).( C): T-Montgomery piece attached to an orotracheal tube for ventilation.
Support Society( ELSO). To provide extracorporeal support during the tracheoesophageal fistula repair, the team implemented veno-venous extracorporeal membrane oxygenation( VV-ECMO) using a femoro-femoral cannulation approach. A multistage left femoral cannula( 23 Fr) was utilized for drainage, while a smaller single-lumen cannula( 19 Fr) was selected for return. These cannulas were then connected to a Medtronic 560 bioconsole, which managed the ECMO circuit. For gas exchange, an adult Quadrox-i polymethylpentene membrane oxygenator was utilized within the circuit, ensuring efficient oxygenation and carbon dioxide removal throughout the surgical procedure. Cannulation was performed under ultrasound guidance utilizing the Seldinger technique. The drainage cannula was inserted via the right femoral vein, positioning its tip precisely at the junction between the superior vena cava and the right atrium to ensure optimal blood extraction. The return cannula was inserted through the left femoral vein, carefully positioning the distal tip at least 10 cm above the proximal drainage ports, thus optimizing ECMO flow dynamics and minimizing recirculation risk. A single dose of 5000 IU of heparin was administered before surgery and then heparin infusion was initiated at 50 IU / kg / hr, guided by ELSO anticoagulation recommendations, and subsequently titrated according to serial ACT measurements to maintain effective anticoagulation while mitigating bleeding risks [ 5 ]. Once adequate oxygenation and acid-base balance were confirmed following the initiation of ECMO, the surgical team proceeded with the removal of the endotracheal tube( ETT). This step allowed the entire procedure to be conducted in a state of apnea, thereby eliminating airway movement and facilitating access to the surgical field. The surgery was performed over a 10-hour period, during which the patient remained apneic, with VV-ECMO providing full respiratory support throughout the operation( Table 1). During the procedure, ECMO flows were carefully titrated to maintain arterial oxygen saturation consistently above 95 % and to keep PaCO₂ within normal physiologic limits, thereby ensuring adequate gas exchange and support throughout the period of total apnea. Patient arterial blood gases were obtained at
least hourly, with additional samples taken whenever circuit adjustments were made. In addition, intermittent circuit blood gas analyses were performed to verify oxygenator performance and confirm effective extracorporeal gas exchange. Intraoperatively, ECMO management emphasized precise control of oxygenation and ventilation parameters to guarantee cerebral protection in this neurologically compromised patient. This approach differs from bedside ECMO management, which typically prioritizes longer-term hemodynamic stability and anticoagulation balance rather than acute fine-tuning of gas exchange. Circuit parameters were documented every 15 min, with alarm systems in place to detect and immediately signal real-time changes. For safety, cross-matched blood products were prepared and available throughout the operation; in the event of hemorrhagic complications, transfusions would have been delivered via central or peripheral venous access rather than directly into the ECMO circuit. A primed backup ECMO circuit was also maintained on standby to ensure uninterrupted support in the event of emergency circuit failure. The ECMO console was continuously managed by three dedicated team members: an ELSO-certified perfusionist, a cardiothoracic surgeon, and a critical care physician experienced in extracorporeal support.
The surgeon carried out a cervicotomy up to the tracheal plane, identifying a 50 mm long TEF and creating a frontal opening through a previous tracheostomy of the 2nd to 5th tracheal rings. The surgeon separated the trachea from the esophagus and performed primary closure in two planes, using a nasogastric tube as a splint. The surgical team interposed bundles of sternocleidomastoid muscle over the esophageal closure and a fibrin sealant. Then, since the back wall of the trachea was absent, a bovine pericardial patch was used to close the defect. A Montgomery tube was then put in as a splint, with one end 7 mm from the vocal cords and the other 15 mm from the main carina. To ensure adequate ventilation, the team cannulated the distal branch of the T tube with a 4.5 Fr tube through the horizontal extremity( Figure 1). Ultimately, the team successfully removed the ECMO device and transferred the