Treatment of bronchoesophageal fistula with a septal occluder device. And here are the disclosures. Bronchoesophageal fistula may be congenital or acquired. The common causes for acquired fistula include malignancy, trauma, surgery, and infections. Multiple studies have explored the endoscopic management of bronchoesophageal fistula, including the use of over-the-scope clip and stents. The septal occluder device has been described in case reports in the treatment of esophageal respiratory fistula and anecdotally for interocutaneous fistula. Here we present a case of a 42-year-old female with a history of AIDS. She has had multiple episodes of severe esophageal candidiasis, an HSV infection complicated by bronchoesophageal fistula since 2012. She has had recurrent aspiration pneumonia requiring frequent hospitalizations. She has been previously treated with multiple stents and over-the-scope clips with intermittent success. The patient presented to the hospital again with symptoms of aspiration pneumonia. An esophagram demonstrated persistent bronchoesophageal fistula with extravasation of contrast into the left lower lobe subsegmental bronchi. A multidisciplinary discussion was conducted with the interventional pulmonary team, and the decision was made to perform a joint procedure to close the fistula with the placement of a septal occluder device. The septal occluder device is a transcatheter device designed to close cardiac septal defects, either atrial or ventricular, with two dumbbell-shaped discs made of memory mesh that oppose both sides of the septal wall. The waist of the bridging segment between the two flange occupies the lumen of the fistula. The material on the device also promotes occlusion and tissue engrowth. The septal occluder device was assembled by loading the delivery system through an introductory catheter, attaching the decompressed device onto the delivery catheter, and then compressing the device into the catheter to be ready for deployment. The fistula is first visualized under bronchoscopy at the left lower subsegmental bronchus. EGD was then performed, which showed concern for candidiasis, and demonstrated a 6-millimeter fistula in the mid-esophagus. Contrast was given endoscopically, and the same extravasation can be seen going to the left lower lobe. The size of the opening of the fistula was reduced using an endoscopic suturing system with single-running sutures. A bronchoscope was advanced into the airway, and a guide wire was passed from the bronchus to the esophagus through the fistula under endoscopic guidance. The guide wire was grabbed with biopsy forceps from the esophageal side and pulled through the mouth, and bronchoscope was exchanged out over the wire. An introducer catheter was advanced over the guide wire from the bronchial side through the fistula into the esophageal side, and visualized in the esophagus. The wire was removed, and a loaded 14-millimeter septal occluder device was inserted through the catheter. The esophageal flange, which is a larger diameter flange, was deployed under direct visualization with the endoscope. Once confirmed that this flange was fully deployed, the catheter was pulled back to create a position of the flange to the wall, then the bronchial flange was deployed under fluoroscopic visualization. Upon initial deployment, contrast extravasation from the esophagus was still noted. The stent was then expanded and flattened from the esophageal and bronchial side using balloon dilation. No further extravasation from the esophagus was seen under fluoroscopy. The position of the device was also observed under bronchoscopy. The device was properly placed, so there's no occlusion of the left loris segmental bronchi. Esophogram was done two days after the procedure. No extravasation was found. The patient's diet was advanced, she tolerated it well, and was discharged from the hospital. One week later, another esophogram was done, which continued to show no extravasation. The patient reports no reoccurrence of symptoms and has been tolerating PO well. In conclusion, the treatment of bronchoesophageal fistula can be challenging. The ideal treatment modality depends on the location, size, etiology of the fistula, and the general condition of the patient. Endoscopic options with different closure device can have limited success, but the overall efficacy has been controversial. This case presents endoscopic treatment using a septal occluder device for refractory infection-related bronchoesophageal fistula with a promising outcome. The long-term efficacy and safety require further evaluation, however, this does offer a promising solution for this challenging problem.

bronchoesophageal fistula

septal occluder device

congenital

acquired fistulas

endoscopic management options