Endoscopic Repair of Tracheoesophageal Fistula Using an Amplatzer Septal Occluder Device: 2017 Presidential Poster Award

Abstract

Benign tracheoesophageal fistulas (TEF) are usually caused by direct trauma, caustic ingestion, radiation and infection. Symptoms are mainly respiratory infections due to recurrent aspirations, excessive secretions and cough. The Amplatzer device has been used extensively to treat septal defects with the goal of inducing an endothelial response and closure of the defect. We present our experience using a cardiac septal occluder for an endoscopic TEF repair. A 49-year-old female presented with failure to thrive, dysphagia, and 40lb weight loss in 6 months. She had endoscopic PEG-J placement and noted to have a large esophageal diverticulum. One day later she had severe abdominal pain. A barium swallow noted a ruptured distal esophageal diverticulum with multiple fistula tracts communicating with the right lower lobe bronchial tree. A metal esophageal stent was subsequently placed. Three weeks later the esophageal stent was removed but a 15mm circular defect was found at 35cm from incisors on the anterior lateral wall of esophagus. This defect was approximated with 2 over the scope (OTS) clips and a 23mm x 10cm EndoMax covered metal stent was deployed across the esophageal defect. Two months later during stent removal, a tiny residual defect was noted near the previous OTS clip. Over the course of 3 months, she was admitted for respratory failure due to recurrent pneumonia necessitating antibiotics caused by reformation of TEF despite multiple endoscopic interventions of either stent placement or OTS clips. Eventually, it was decided to perform endoscopic repair of TEF using a septal occluder device. The distal esophageal fistula was cannulated using a 7Fr Wilson-Cook Omni cannula over a glidewire. A 8 mm fistula tract between the right lower bronchus and esophageal diverticulum was noted. The guide wire was manipulated up the trachea, grasped and pulled out the ETT using a snare. A 7 mm septal occluder device was advanced inside 6 Fr introducer sheath to the distal esophagus. The distal (esophageal) disc and the proximal (bronchial) disc was released inside the fistula tract. A postprocedure esophageal occlusion fistulogram showed no extravasation of contrast medium into the trachea or mainstem bronchi. We demonstrate the technical feasibility and efficacy of the cardiac septal occluder to close a TEF. This novel technique is an alternative to surgical repair, although the long term efficacy and potential for epithelialization or migration are unknown.Figure: Tracheoesophageal Fistula.Figure: Guidewire through Tracheoesophageal Fistula.Figure: Occlusion of Tracheoesophageal Fistula using Septal Occluder Device.