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The approach of esophageal exclusion illustrated in this report allows total transcervical control of the fistula. An upper sternal split can be easily accomplished through this approach to facilitate control of the distal esophagus when necessary. This illustration depicts the completed cervical esophageal exclusion which creates a compact new posterior wall of trachea for the ventilator-dependent patient (Fig 3). Access to the gastrointestinal tract can then be accomplished with total fistula control achieved before laparotomy. The potential complication of further abdominal distention and aspiration of gastrointestinal contents through the lower end of tracheoesophageal fistula is averted. Stamm gastrostomy was performed for initial gastrointestinal decompression and subsequent access for enteral alimentation. Although we routinely perform a jejunostomy when prolonged gastric decompression is necessary, we have not found it necessary with this technique when the esophagus is proximally excluded. Certainly, the primary focus of the medical team attending these critically ill patients should be prevention of this devastating complication. Close scrutiny of the endotracheal tube cuff pressure is obviously important. High compliance, low pressure cuffed tubes should ideally be used. Figure 3. Completed prcxedure of cervical esophageal exclusion to acutely manage the giant tracheoesophageal fistula occurring in the ventilator-dependent patient.