Endoscopic repair of tracheoesophageal fistula with septal occluder device. These are our disclosures. Septal defect occluders are percutaneous transcatheter devices for repairing cardiac atrial or ventricular septal defects. They were created in the 1990s but approved in the United States since 2001 for septal defect repair. They are composed of nitinol mesh with polyester material with self-expanding double-disc design. They can be recaptured and redeployed. Now to the case. This is a 60-year-old male with a history of esophageal adenocarcinoma, status post esophagectomy in 2019, and neoadjuvant chemoradiation, complicated by TE fistula. Other comorbidities include cirrhosis, severe kyphosis, insulin-dependent diabetes mellitus, and stroke. There are multiple attempted repairs at outside facilities including esophageal stent placement, clipping, and sutures, which have all failed. He is unable to tolerate any oral food or drinks and gets nutritionally fed through JTU. He is symptomatic with coughing, vomiting, and weight loss. Patient underwent an EGD and through this endoscopic view, there is the TE fistula, which was approximately 15 mm in diameter. During this session, he received argon plasma coagulation or APC ablation and suturing to repair the TE fistula. A tracheoscopy exam was performed, which revealed the closure of the fistula. Here is a fluoroscopic view of the follow-up swallowing study, showing the water-soluble contrast leaking through the TE fistula and into the bilateral bronchi, signifying that the repair was unsuccessful. One month later, patient underwent a repeat EGD with removal of previous sutures, repeat APC ablation, and suturing. Repeat swallowing study afterwards demonstrated persistent TE fistula. ENT evaluate the patient and discuss the challenges of surgically repairing the TE fistula, which includes location, body habitus, and severe kyphosis. Patient underwent his third EGD for attempted TE fistula repair. In this endoscopic view, we are looking from the esophageal side of the TE fistula via a side-viewing endoscope. A needle knife was used to abrade the edges of the TE fistula in a circumferential manner. Then the endoscope tip was swapped with the suturing tip and was loaded with a 2.0 polypropylene suture. The TE fistula was sutured with three sutures in an interrupted fashion with cinches on both ends with good tissue approximation. A follow-up swallowing study was done, and as shown in this fluoroscopic view, the third attempt at suturing the TE fistula failed and it is still persistent. After three failed TE fistula repairs via endoscopic suturing, decision was made to try a VSD septal occluder to close the fistula. Of note, ENT re-evaluate the patient and again note the challenges with surgical repair, but the patient wanted to explore other possible options. In this endoscopic view, we have visualization of the trachea on the left and the esophagus on the right. From the esophageal side, a 14mm VSD septal occluder was carefully deployed by initially entering the tracheal side and then retracting and releasing the device. A bronchoscopy was performed next and it showed the VSD septal occluder in good position. After the procedure, the patient clinically improved with decreased cough and started tolerating nectar thick dye. One month later, the patient started trialing clear liquids with poor PO tolerance. Another swallowing study was done, which showed that there was a small leak of the TE fistula. Patient underwent repeat EGD to replace the previous 14mm VSD occluder with an 18mm VSD occluder. Here is the previous septal occluder device. And here is the new septal occluder being deployed. And then a later clip showing the final placement and position. Patient presented for a 1 month follow-up after the VSD occluder device was replaced. His coughing significantly improved and he tolerated PO intake and gaining weight. This fluoroscopic image shows the contrast going down the esophagus without any leaks around the septal occluder. Here we have another case, a 53-year-old male with a history of laryngeal cancer, status post laryngectomy and chemoradiation, complicated by esophageal stricture with resulting TE fistula after a prolonged time of esophageal stenting. He initially tolerated some oral nutrition after his esophageal lumen was secured with frequent stenting. However, he progressively worsened and could not tolerate oral intake and developed more aspiration events, resulting in GJ2 placement. Patient was evaluated by ENT and underwent a right supraclavicular flap reconstruction. Postoperatively, patient had persistent TE fistula with continual reflux, aspiration events and poor oral tolerance. ENT recommended GI referral who attempted endoscopic TE fistula repair. In this endoscopic view, the opening of the TE fistula, initially 3 cm in diameter, remained even after 3 suture placements. However, the opening significantly decreased to 1.8 cm. Attempts to further close the area was unsuccessful. Due to failed previous attempts of repairing the TE fistula, the decision was made to try closing the fistula with an 18 mm VSD occluder device. In this next endoscopic view, after the appropriate position was identified, the VSD occluder was loaded and deployed through a sheath from the esophageal side. However, it was misdeployed and did not sit in the fistula. This next clip demonstrated the VSD occluder being reloaded onto the endoscope without difficulty. This time, the device was deployed from the tracheal side instead of the esophageal side. Note that later in the clip, we can appreciate the carina further down the trachea. And in this clip, the device is seen on the esophageal side. One month later, patient is tolerating soft foods and small sips of soup without any choking or coughing episodes. Follow-up swallowing study is currently scheduled. In conclusion, these two cases demonstrate utility of VSD occluder devices for repairing larger TE fistulas that failed mainstay treatment. Smaller TE fistulas less than 1 cm usually have higher success rate with standard suturing or clipping. When TE fistulas are greater than 1 cm, they are less likely to be fixed by endoscopic techniques, so other therapy options are explored. Identifying novel methods afford more options for patients who failed prior treatment and have debilitating quality of life symptoms.

tracheoesophageal fistula

TE fistula repair

VSD occluder device

esophageal adenocarcinoma

laryngeal cancer