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Laparotomy, gastrostomy and gastric drainage procedure follow. This extensive operation is not likely to be tolerated by many of these severely ill patients. Secondly, few institutions are presently equipped with the iron lung he used to ventilate without positive pressure trauma to the precarious tracheal repair. Mediastinal tracheostomy is also a formidable procedure involving resection of manubrium and the medial third of the clavicles and first and second ribs to allow exposure and control of the lower trachea. This procedure may still be required on rare occasion to achieve airway control and adequate ventilation in difficult cases of tracheoesophageal fistula. Utley et al appreciated that suture line tension resulting in stenosis of the tracheal and esophageal repair was a serious technical problem leading to reconstructive failure with giant tracheoesophageal fistulae. His approach of esophageal diversion controlled the fistula without the need for thoracotomy. Unfortunately, a large blind esophageal pouch was created which was a source of pulmonary sepsis and increased dead space ventilation. Distal control of the fistula was also delayed until laparotomy and division of the gastroesophageal junction could be achieved.