Case closed. Endoscopic management of a refractory tracheoesophageal fistula. These are our disclosures. A 67 year old man with past medical history of esophageal adenocarcinoma diagnosed in 2007 underwent neoadjuvant chemotherapy and radiation, followed by transhiatal esophagectomy with cervical esophago anastomosis. This was complicated by a tracheoesophageal fistula. His story begins in December of 2007 when he underwent a transhiatal esophagectomy with cervical esophago gastric anastomosis. In June 2008, the patient presented with several weeks of coughing with oral intake. An esophagram was performed which revealed a tracheoesophageal fistula. Here you can see the patient swallowing barium with a small area of extra luminal contrast. The red arrows indicate that this contrast is filling the airway, consistent with a tracheoesophageal fistula. Computed tomography of the chest further demonstrates this connection between the trachea and the esophagus. Again this is indicated by the red arrow. Over the next three years, the patient underwent over 20 endoscopic and surgical procedures in order to close his fistula, including esophageal and tracheal stem placement, semicosal fiber and glue injections, vascular plug placement, and three thoracotomies, the last of which was in June 2011 with takedown of the fistula, tracheal resection, and the construction of a primary anastomosis. In 2018, he was admitted to the hospital with aspiration pneumonia. An esophogram showed recrudescence of the tracheoesophageal fistula. Computed tomography of the chest shows multifocal bronchial plugging and secretions in the left lower lobe consistent with an aspiration pneumonia. He was managed conservatively until this year when the patient was again admitted with aspiration pneumonia. At this point the decision was made to place a surgical jejunostomy for nutritional support while completely avoiding oral intake. Shortly thereafter, the patient was referred to the advanced endoscopy team for a second opinion. An upper endoscopy was performed. The tracheoesophageal fistula could be readily identified with air bubbles emanating from the trachea to the esophageal opening. Given the expectation for endoscopic intervention, bronchoscopy was performed simultaneously to ensure airway safety and avoidance of major blood vessels during endoscopic maneuvers. Saline was also flushed through the bronchoscope and into the fistula's tract. As you can see here, a rush of fluid and air bubbles can be seen extruding from the esophageal side of the orifice, confirming the fistula. This fistula was known to be in the proximal esophagus, 6.5 centimeters above the carina. On screen left, you can see the endoscope at the level of the fistula. On screen right, you can see the bronchoscopic view with the light from the endoscope visualized in the airway. This is demonstrated again as the endoscope is advanced through the esophagus. Given the chronicity of the fistula, fibrotic mucosa, and limited space for endoscopic maneuverability, the decision was made to utilize an endoscopic tach and suture system for closure. The red arrows here indicate the portion of the device that attaches to the scope shaft and contains three helical tachs, allowing easy reloading of the suture. The red arrows here show the handle feature, which allows rotation of the tachs into the mucosa, all of which are ultimately fastened along a single suture. Here you can see the tach and suture system loaded on an upper endoscope. The first tach, which is preloaded in the system, was advanced into the esophageal mucosa and deployed. On the upper right, you can see how the tach is released from the catheter. Once the tach spirals into the tissue, the catheter is removed and reloaded on the same suture. The catheter is then re-advanced down the upper endoscope in anticipation of placing the next tach. The tachs are intentionally placed circumferentially around the fistula. This pattern is better illustrated in this image. Once all the tachs are deployed, the suture is loaded into the cinching device. The cinching device is positioned. Slow, deliberate tension is applied with caution not to break the suture or allow the tachs to release from the esophageal mucosa. The suture is tightened and ultimately cinched. As you can see, partial closure of the tracheoesophageal fistula was successful. Preparation is then made for additional tach placement. Again, numerous tachs were placed in a circumferential pattern around the fistula. As you can see, placing the tachs in a perpendicular orientation to the mucosa allows full rotation of the tach into the esophageal wall. While maneuverability is always somewhat limited in the esophagus, this device loads through the channel of a standard gastroscope. As a result, positioning and placement of these tachs can be easily oriented toward the desired location on the esophageal wall. Minimal tension on the suture prior to cinching demonstrates complete coaptation of the tachs. Eventually, all of these tachs are similarly cinched. The tracheoesophageal fistula is entirely closed. An esophagram performed two weeks later showed resolution of the tracheoesophageal fistula. The previously seen extraluminal contrast was not identified on this study. The patient's diet was advanced without symptoms or concern for aspiration. The patient continues to do well several months following the procedure. In conclusion, tracheoesophageal fistula are a major source of morbidity and mortality and can often be refractory to treatment. Surgical and endoscopic treatments have been described with limited success given chronicity of the tracheoesophageal fistula, fibrotic mucosa, and or limited space for endoscopic maneuverability. Our case illustrates that an endoscopic tach and suture system may offer a new option for the management of a refractory tracheoesophageal fistula. Simultaneous bronchoscopy may be a useful adjunct for this type of closure.

refractory tracheoesophageal fistula

esophageal adenocarcinoma

surgical jejunostomy

endoscopic intervention

bronchoscopy