title: Surgical management of type III and IV laryngotracheoesophageal clefts: the three-layered approach.
abstract: OBJECTIVE
  The objective of this paper is to present our surgical experience with a cohort of four infants with laryngotracheoesophageal cleft (LTEC) in order to highlight our early failures and complications and to propose a comprehensive, three-layered approach in treating stages III and IV LTEC.
  
  
  METHODS
  An IRB approved, retrospective chart review was carried out of a cohort of four cases occurring within a 2-year period of time.
  
  
  RESULTS
  All patients had other significant anomalies, and the mortality rate was high: 75%. After our initial failures and difficulties with recurrent fistulas, tracheomalacia and tracheotomy dependence, we were able to achieve a successful outcome of a functional separation of the airway and the digestive tract without a tracheotomy in our last two patients. Unfortunately, both these patients died from factors not directly associated with the LTEC so long-term follow up was not possible. We now have one survivor, our second case, who is tracheotomy dependent.
  
  
  CONCLUSIONS
  Laryngotracheoesophageal clefts are rare congenital anomalies with high morbidity and mortality despite various forms of surgical repair. Fistulas, tracheostomy dependence, tracheomalacia, and chronic lung disease secondary to aspiration are frequent problems following LTEC repairs. We advocate an anterior approach to the cleft repair, a three-layered closure of the cleft to include an interpositional muscular flap, and a physiologic repair of the posterior larynx with a standard cartilage graft technique used in laryngotracheal reconstruction.
authors.affiliation: Division of Otolaryngology/Head and Neck Surgery, University of Southern California, Keck School of Medicine, Children's Hospital of Los Angeles, Los Angeles, CA 90027, United States. kgeller@chla.usc.edu
authors.forename: Kenneth
authors.initials: K
authors.lastname: Geller
authors.forename: Young
authors.initials: Y
authors.lastname: Kim
authors.forename: Jeffrey
authors.initials: J
authors.lastname: Koempel
authors.forename: Kathryn D
authors.initials: KD
authors.lastname: Anderson
mesh_terms: D002908:Chronic Disease; D004947:Esophagus / Q000002:abnormalities* / Q000601:surgery*; D005260:Female; D006801:Humans; D007223:Infant; D007830:Larynx / Q000002:abnormalities* / Q000601:surgery*; D008171:Lung Diseases / Q000209:etiology; D008297:Male; D013517:Otorhinolaryngologic Surgical Procedures / Q000379:methods*; D011183:Postoperative Complications; D053120:Respiratory Aspiration / Q000150:complications; D012189:Retrospective Studies; D012720:Severity of Illness Index; D014132:Trachea / Q000002:abnormalities* / Q000601:surgery*; D014138:Tracheoesophageal Fistula / Q000209:etiology; D014139:Tracheostomy