HJAR May/Jun 2026

HEALTHCARE JOURNAL OF ARKANSAS I  MAY / JUN 2026 39 the surgical suite — surgeons opened Cape’s chest, identified the azygos vein overlying the fistula and then isolated the fistula be- tween the airway and the distal esophagus. Using two silk sutures, the surgeons tied off the fistula and then closed his chest. Surgery Three: Reconstruction At four pounds, Cape’s esophagus had grown enough to connect to his stomach, and his care team felt he could handle hav- ing extensive reconstructive surgery. Almost two months after his birth, surgeons con- nected the two ends of his esophagus with permanent ligation of the TEF, repaired his duodenal atresia, and rearranged the ori- entation of his intestines using the Ladd’s procedure. Anesthesiologists with additional training in pediatric care managed Cape’s airway. The successful surgery laid the ground- work for Cape to leave the NICU onApril 13, 2025, almost six months after he was born. Surgical Takeaways In a case like Cape’s it’s imperative to have a surgical team experienced in caring for children as small as he was and surgeons who are used to managing this particular disease process and performing opera- tions on children of Cape’s size. The tactics, including timing and approach, were dis- cussed as a team. Neonatologists, surgeons, and anesthesiologists communicated pre- op, intra-op, and post-op to determine the best steps forward. Cape’s case also highlights the impor- tance of matching the baby to the right re- sources. Achild that small, with those types of anomalies, needs to be in a Level IVNICU at a Level 1 Children’s Surgery Center to en- sure the best outcomes. The American Col- lege of Surgeons’ Level 1 designation is the highest possible for a children’s hospital and represents excellence in surgical quality. The designation reflects that a hospital has the right people, equipment, and processes in place to care for children at all developmen- tal stages and ages. Cape’s care represents the multidisci- plinary effort required with the sickest, smallest, and most vulnerable babies with complex congenital anomalies that require stays in the NICU before, during, and after reconstructive surgery. Cape has continued to receive follow- up care at Arkansas Children’s Northwest in Springdale, including having an ingui- nal hernia repair. He is an example of how experts throughout the health system can collaborate, allowing patients to stay within Arkansas and receive consistent care. n M. Sidney Dassinger III, MD, is a pediatric surgeon, chief of pediatric general surgery,andmedical direc- tor of surgical quality atArkansas Children’s Hospital. He is also a professor of pediatric surgery at the Uni- versity ofArkansas for Medical Sciences in Little Rock. Jeffrey Burford, MD, is a pediatric surgeon and the National Surgical Quality Improvement Program pediatric surgeon champion at Arkansas Children’s Hospital in Little Rock. He is also an associate pro- fessor of surgery at the University of Arkansas for Medical Sciences. Jeffrey Burford, MD Pediatric Surgeon Arkansas Children’s Hospital Surgery One: G-Tube Placement The day after Cape’s birth, a G-tube was placed, allowing Cape’s stomach, which had filled with air, to decompress. The surgical team puts in about 100 gas- trostomy tubes annually, but placing a gas- trostomy tube in a baby weighing less than 800 grams is rare. Given Cape’s tininess, en- suring that Cape’s stomach did not perforate during placement was challenging. The tube was placed in the NICU because he was too fragile to move to the operating room. Cape is among the smallest babies into which the team has placed a gastrostomy tube. Surgery Two: Ligating the TEF In addition to having an abnormal con- nection between his trachea and his esopha- gus, called a tracheoesophageal fistula (TEF), Cape also had a patent ductus arteriosus — a heart vessel that didn’t close after birth — and duodenal atresia — a blockage in part of the small intestine. Due to the combina- tion of a TEF and duodenal atresia, stomach acid refluxed into his lungs, damaging them significantly. While the team hoped to delay surgery until he reached two pounds, the growing damage moved up the target sur- gery date to eight days after his birth, when he had reached 1.85 pounds. The surgical team felt that he was too small to undergo repair of his esophagus at 1.85 pounds, so they decided to repair that later. They, could, however, address the fis- tula to protect his lungs. During the surgery — once again done in the NICU rather than “Cape’s care represents themultidisciplinary effort required with the sickest, smallest, andmost vulnerable babies with complex congenital anomalies that require stays in the NICU before, during, and after reconstructive surgery.”