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Utley et al advocated cervical and transabdominal exclusion of the esophagus for the management of the giant tracheoesophageal fistula. Finally, Orringer and Sloan described the use of mediastinal tracheostomy to manage similarly difficult tracheal problems when ventilation is otherwise impossible. Division of the tracheoesophageal fistula, resection of the malatic trachea, and primary repair of trachea and esophagus would appear to be the most desirable management option. Grillo et al have cautioned that this approach should only be applied to the patient who can be immediately extubated after repair. Postoperative endotracheal intubation significantly increases the likelihood of repair disruption or recurrence of the tracheoesophageal pathology. These primary repair prerequisites could not be met in this patients case. Bartletts approach is a formidable procedure that involves combined cervical, thoracic and abdominal exposure. Cervical and thoracic control of the trachea and esophagus precedes division of the esophagus, exposure of the fistula, and longitudinal suture closure of the membranous trachea. A tailored patch of isolated esophageal wall is then used to bolster this posterior tracheal repair.