Closure Of Tracheoesophageal Fistula Research Articles

Modified method for tracheoesophageal fistula closure in intractable cases

ObjectiveTracheoesophageal puncture (TEP) is one of the most established methods for voice reacquisition following total laryngectomy. The most difficult complication following TEP is the management of saliva leakage or secretion into the trachea due to TE fistula enlargement. In this study, we devised a new strategy to close TE fistulas and confirmed its safety and effectiveness. MethodsSkin incision: If the tracheal mucosa around the voice prosthesis appears intact and normal, an arcuate incision, from 10 to 2 o'clock, is made on the skin 5 mm superior to the edge of the stoma. However, if the surrounding tracheal mucosa is fragile because of leaking, the incision is made on the superior edge of the stoma, with later reconstruction of the posterior tracheal wall. Separation of the trachea and esophagus: If the esophagotracheal spatium appears normal and is easy to dissect, the connective pipes can be found easily. After cutting the pipe, a ligature alone is sufficient for the tracheal side; however, the esophageal wall is closed with Gambee sutures. If the esophagotracheal spatium is compromised and the posterior tracheal wall is fragile (due to saliva leakage), we remove the posterior wall and reconstruct the area using the superior skin flap. We performed our novel method on four patients with intractable conditions; postradiotherapy for laryngeal cancer, total pharyngo-laryngo-esophagectomy (TPLE) with jejunum reconstruction, TPLE with gastric lifting reconstruction, and in a patient who underwent cervicothoracic incisional drainage for descending necrotizing mediastinitis. ResultsNone of the cases showed postoperative leakage from the fistula, and oral intake was resumed without difficulty. ConclusionThis study showed that this strategy based on TE fistula conditions is effective even in difficult-to-treat cases.

Airway and anesthesia management in tracheoesophageal fistula closure implantation: a single-centre retrospective study

ObjectiveTo review and analyze the airway and anesthesia management methods for patients who underwent endoscopic closure of tracheoesophageal fistula (TEF) and to summarize the experience of intraoperative airway management.MethodWe searched the anesthesia information system of the First Affiliated Hospital of Nanjing Medical University for anesthesia cases of TEF from July 2020 to July 2023 and obtained a total of 34 anesthesia records for endoscopic TEF occlusion. The intraoperative airway management methods and vital signs were recorded, and the patients’ disease course and follow-up records were analyzed and summarized.ResultsThe airway management strategies used for TEF occlusion patients included nasal catheter oxygen (NCO, n = 5), high-flow nasal cannula oxygen therapy (HFNC, n = 4) and tracheal intubation (TI, n = 25). The patients who underwent tracheal intubation with an inner diameter of 5.5 mm had stable hemodynamics and oxygenation status during surgery, while intravenous anesthesia without intubation could not effectively inhibit the stress response caused by occluder implantation, which could easily cause hemodynamic fluctuations, hypoxemia, and carbon dioxide accumulation. Compared with those in the TI group, the NCO group and the HFNC group had significantly longer surgical times, and the satisfaction score of the endoscopists was significantly lower. In addition, two patients in the NCO group experienced postoperative hypoxemia.ConclusionDuring the anesthesia process for TEF occlusions, a tracheal catheter with an inner diameter of 5.5 mm can provide a safe and effective airway management method.

Optimal Surgical Method and Timing for Low-birth-weight Esophageal Atresia Babies: Multi-institutional Observational Study

Aim of the studyPrevious research has shown that low birth weight is one of the risk factors for esophageal atresia. However, there remains a paucity of evidence on the timing and the treatment method. MethodData were collected using a multi-institutional observational study in 11 hospitals that performed surgeries on esophageal atresia babies whose birth weights were ≤1500 g from 2001 to 2020. ResultsOf the 46 patients analyzed, median birth weight was 1233 (IQR 1042–1412) g. Within 46 cases, 19 (41%) underwent definitive esophageal anastomosis at the median of age in 8 (IQR 2–101) days. Thirteen out of 19 experienced either closure of tracheoesophageal fistula, gastrostomy, or esophageal banding at the first operation, followed by esophageal anastomosis. Seven infants, including four cases of <1000 g, underwent anastomosis after one month of age to wait for weight gain (variously 2–3000 g). Twenty-one out of 27 infants (78%) who did not receive anastomosis died within one year of age, including 21 (78 %) with major cardiac anomalies and 24 (89%) with severe chromosomal anomalies (trisomy 18). Six survivors in this group, all with trisomy 18, lived with palliative surgical treatments. ConclusionIn our study, the definitive esophageal anastomosis was effective either at the first operation or as a later treatment after gaining weight. Although having severe anomalies, some infants receive palliative surgical treatments, and the next surgery was considered depending on their condition. Evidence LevelII.

First-time use of a porcine small intestine submucosal plug device to close an acquired tracheo-esophageal fistula

BackgroundAcquired tracheo-esophageal fistula (TEF) is a rare, life-threatening pathology, responsible for severe comorbidities. Its management is a real therapeutic challenge and remains controversial.Case presentationWe report the first case of endoscopic treatment of TEF by using a porcine small intestine submucosal (SIS) plug device in a young quadriplegic patient after failed surgical closure by cervicotomy. After 1 year of follow-up, oral feeding of the patient was resumed and no clinical signs of fistula recurrence were evident.ConclusionTo our knowledge, we obtained for the first time, a satisfactory result for TEF closure with the use of a porcine SIS plug.

Treatment of tracheoesophageal fistula and consequences of severe spinal injury

Modern approaches to intensive care and anesthesiology make it possible to save patients with various severe traumas. Prolonged mechanical ventilation allows stabilizing the patient's status, but can result severe complications including tracheoesophageal fistula. Our patient received severe combined injury after road accident, i.e. compression-comminuted fractures of DIV, DV, DVI vertebrae with spinal cord compression, ThIII compression fracture, compression-comminuted fracture of bodies and arches ThIV, V, VI with ThVI dislocation, lower paraplegia and pelvic organ dysfunction, left-sided laryngeal paresis, brain concussion and contusion of both lungs. Mechanical ventilation has been performed for 1.5 months. The patient suffered inflammatory complications: bilateral pneumonia complicated by right-sided pleural empyema, sepsis, tracheostomy suppuration followed by cervical soft tissue abscess. Pleural drainage and debridement, as well as drainage of abscess were performed. At the same time, we diagnosed external esophageal fistula at the CVII level. Tracheoesophageal fistula closure via cervical access was carried out at the first stage. Postoperative period was uneventful. After 20 days, we performed spondylosynthesis ThI-ThVII, and decompression laminectomy ThIV-ThVI. Spine stabilization by metal elements has a beneficial effect even without spinal cord recovery regarding better conditions for neurological and social rehabilitation. Thus, treatment was performed in a highly specialized multi-field hospital by thoracic surgeons and vertebrologists. We realized the treatment plan and obtained favorable results with minimal risk of postoperative complications.

Outcome of Newborns with Tracheoesophageal Fistula: An Experience from a Rapidly Developing Country: Room for Improvement.

This is a retrospective review of the medical electronic charts of patients with TEF that were followed at Sidra Medicine in the state of Qatar. The review included the patients who were operated upon in the period of 2011-2021 but continued to follow at our institution in the period of 2018-2021. Demographic data, associated anomalies, preoperative, operative, and postoperative courses, and growth parameters were collected. A total of 35 patients with TEF (24 males and 11 females) were collected. 49% were full term. We identified seven patients (20%) with isolated TEF, TEF with VACTERL association in 29% of our patients, other chromosomal anomalies in 17%, or associated with other anomalies (not related to VACTERL) in 34% of the patients. The majority of the patients (94%) were of type C-TEF (TEF with esophageal atresia-EA/TEF). All patients were operated except for one patient who died at 2 days of life due to cardiac complications. Median age at which surgery was performed was 2 days (range 1-270 days). Median follow-up was 32 months (range 7-115 months). Immediate postoperative complications were encountered in eleven patients (33%) and included anastomosis leak in 12%, air leak in 6%, sepsis in 6%, chylothorax in 3%, vocal cord palsy and fistula recurrence (combined) in 3%, and failure of TEF closure in 3% of the patients. Long-term respiratory complications were encountered in 43% of our patients. Long-term gastrointestinal complications included gastroesophageal reflux (GERD) in 63%, dysphagia in 31%, and anastomotic stricture in 34% of the patients. Growth was affected in around a quarter of the patients at 6 months after surgery and 22% at 12-month assessment postoperatively. While only five patients died at our institution, only one was directly related to failure of TEF closure and postoperative complications. This descriptive study reports the clinical outcome of TEF from a rapidly developing country. The distribution of the patients' characteristics and postoperative complications was almost comparable to those from developed countries. This study would aid in addressing the prognostic factors and establishment of evidence-based management pathways of newborns with TEF to improve the clinical outcome in our center and other pediatric tertiary centers in developing countries.

S368 Chronic Tracheoesophageal Fistula Successfully Treated Using an Amplatzer Closure Device Under Endoscopic Visualization

Introduction: In tertiary care centers, where advanced endoscopic expertise is available, the placement of an Amplatzer septal occluder is practical and safe. This allows for potential fistula closure, especially in patients with severe comorbidities or in critical condition or those with chronic or recurrent tracheoesophageal fistulas (TEF). Case Description/Methods: A 72-year-old man with a history of gastroesophageal reflux disease (GERD) and well-differentiated esophageal adenocarcinoma who presented for dysphagia and cough. Social history was negative for smoking, smokeless tobacco, alcohol ingestion and illicit drug use. Home medications include famotidine. He had no known significant family history. The patient had undergone numerous esophagogastroduodenoscopies (EGD) since 2017 for recurrent strictures requiring TTS balloon dilations, intralesional triamcinolone acetonide injections and esophageal stenting complicated by formation of a tracheoesophageal fistula (TEF) at the anastomotic site. The TEF was initially treated with stenting 3 months prior to presentation. The patient underwent EGD and bronchoscopy with visualization of a 5 mm fistula. He was then evaluated by the surgery team for consideration of surgical repair, however the patient declined surgical intervention. Given the clinical condition of the patient with recurrent aspiration events, failed endoscopic management and refusal of surgical intervention, it was decided to remove the esophageal stent and attempt placement of an Amplatzer septal occluder. An 18 mm Amplatzer device (AD) was successfully placed with satisfactory closure of the TEF. Repeat endoscopy 5 months later, showed that the device had remained in the correct position and the patient remained asymptomatic following advancement of his diet. Discussion: Acquired TEF is a rare complication, the incidence in the US has yet to be reported. Amplatzer occluder devices, originally designed for transcatheter closure of cardiac defects, have shown promise in the treatment of TEFs. It is suggested that the placement of the AD induces granulation tissue formation around the device allowing for complete closure of the fistula without compromising airway patency. Upon review of current literature only one other case report was found where an AD was used for the management of refractory TEF. In the setting of large or difficult to manage TEFs and patients who are not surgical candidates, Amplatzer septal occluder devices can be used to successfully treat complicated TEFs. Watch the video at https://tinyurl.com/ACGAbstractS368Figure 1.: Amplatzer device deployed with successful tracheoesophageal fistula closure.

Platelet-Rich Plasma, an Innovative and Noninvasive Technique for Closure of Tracheoesophageal Fistula After Laryngectomy, Report of 2 Cases.

An innovative and noninvasive technique for closure of persistent tracheoesophageal fistula after total laryngectomy is described. In our preliminary study, two patients were included. No clinical and radiological signs of locoregional recurrence prior to treatment were diagnosed. We performed local injections of autologous platelet-rich plasma (PRP) according to our protocol. Complete closure of the fistula was observed in both patients who were able to take normal feeding. No side effects associated with the procedure were observed. These preliminary results are encouraging to consider PRP injection before more invasive surgical techniques in the treatment of persistent tracheoesophageal fistulas after total laryngectomy.

Analysis of surgical treatment strategy and outcome factors in persistent tracheoesophageal fistula: a critical analysis of own cases and review of the literature.

Surgical closure of persistent tracheoesophageal fistulas (TEFs) is complex. Most patients present with multiple risk factors, which may negatively impact the outcome and influence the treatment strategies. This retrospective study included 22 patients presenting with persistent TEFs. Preoperative RT, comorbidities, tissue conditions of the TEFs and neck skin, and surgical techniques were evaluated regarding a possible impact on success rates and outcome. 21 patients were operated, 95.45% with final success. However, in 52.39% repeated surgery was needed. Final closure of TEFs was achieved in 91.47% only after more invasive surgery was performed. The surgical technique applied had the most significant impact on success rates and outcome compared to all other risk factors analyzed. Our own data and that of the literature point out that the surgical strategy should be adapted to the patients' individual risk factors. According to the literature, surgical closure of persistent TEFss is demanding. Our data suggest that, considering that the majority of patients with persistent TEFs exhibit multiple risk factors, early performance of more invasive surgery seems associated with a better outcome.

Triple stent placement for tracheoesophageal fistula closure

Triple stent placement for tracheoesophageal fistula closure

Repair of congenital H-type tracheoesophageal fistula by electrocautery

Congenital H-type tracheoesophageal fistula is a rare type of congenital tracheoesophageal malformation. In this malformation, the esophagus remains unobstructed, complicating and delaying the diagnosis. We present our experience with three infants with congenital H-type tracheoesophageal fistula who were initially treated by a minimally invasive approach via endoscopy with electrocautery. Two of the three patients ultimately required a surgical procedure after failure to close the fistula via electrocautery despite multiple attempts over several months. One of the three patients was successfully treated via electrocautery after the second procedure. In our center, three infants with congenital H-type tracheoesophageal fistula were initially treated endoscopically with electrocautery. Two out of the three ultimately required a surgical procedure. If considering endoscopy with electrocautery, providers and families should recognize that the procedure may need to be performed several times before the fistula is successfully closed. Additionally, failed attempts may put patients at risk for complications such as respiratory decompensation, pneumonia and poor growth and may prolong hospitalization. • Congenital h-type tracheoesophageal fistula closure with endoscopic electrocautery. • 2 of 3 patients ultimately required surgical repair. • 1 of 3 patients was successfully treated with electrocautery via endoscopy. • Patients requiring surgical repair had complications after endoscopy.

Endoscopic closure of tracheoesophageal fistula with a novel dumbbell-shaped occluder.

Tracheoesophageal fistula (TEF) is a challenging condition that is difficult to treat. Several reports have described successful TEF treatment with an Amplatzer occluder (AGA Medical Corporation, Plymouth, Minnesota, USA) [1] [2]. However, Daniel et al. reported the case of a benign gastrobronchial fistula patient who underwent treatment with the Amplatzer device and died of fatal hemoptysis [3]. Inspired by this case, we developed a new dumbbell-shaped occluder device [4]. Compared with the Amplatzer occluder, this device has no protrusions, which reduces the risk of bleeding; even if the patient coughs, it will not increase airway damage.

Surgical treatment of esophageal atresia with lower tracheoesophageal fistula in an extremely preterm infant (510 g, 25 + 5 weeks): a case report

BackgroundThe surgical management of esophageal atresia in extreme-low-birth-weight infants (< 1000 g) is challenging. We report on an extreme-low-birth-weight infant who was extremely preterm (510 g, 25 + 5 weeks) and of prenatally unknown Gross type C esophageal atresia.Case presentationAfter resuscitation and intubation, the tracheoesophageal fistula was closed on the first day of life in the neonatal intensive care unit via an extrapleural approach using a titanium clip. On the sixth day of life, the Caucasian child was extubated. To minimize the operative trauma in the initial neonatal period, we prolonged gastrostomy placement until the 22nd day of life (weight 725 g). At the age of 3 months (weight 2510 g), thoracoscopic esophageal anastomosis was performed. The postoperative course was unremarkable. During the further clinical course, eight esophageal dilations were necessary. Currently, the patient swallows without difficulties at the age of 4 years and thrives well [15 kg (Percentile 28); 100 cm (Percentile 24)].ConclusionsOur case shows that minimized postnatal surgical trauma with primary tracheoesophageal fistula closure at the bedside, delayed gastrostomy, and minimally invasive esophageal repair after substantial weight gain (> 2.5 kg) is a good strategy for esophageal atresia/tracheoesophageal fistula in extreme-low-birth-weight infants.

Thulium LASER for endoscopic closure of tracheoesophageal fistula in esophageal atresia's spectrum: An appropriate tool?

PurposeTo report our experience with endoscopic Thulium LASER for treatment of recurrent TEF after EA surgery, and for H-Type fistulas. MethodsA retrospective chart review of consecutive patients undergoing standardized endoscopic closure as first line therapy of recurrent tracheoesophageal fistula (RTEF) and H-type fistula using Thulium LASER, from 2013 to 2019, in a pediatric tertiary care center. Control endoscopic procedure was systematically performed. If persistence of the TEF was noted an external approach was performed. Patient demographics, medical history, symptoms, TEF type, treatment modalities, complications and outcomes were collected. ResultsEleven patients with tracheoesophageal fistula were included: six RTEF after primary repair of esophageal atresia and five H-type fistulas. The average age at endoscopic treatment was 19 months (SD 23 months, range 13 days–63 months). Closure of the fistula after single endoscopic procedure with Thulium LASER was obtained in 3 RTEF (50%) and 1 H-type fistula (20%). Six patients with failure of endoscopic treatment were cured after a single external procedure without any complications. One child, treated for H-type fistula, presented a severe complication of Thulium LASER treatment. Median follow-up after last repair was 24 months (range: 14–72 months). All fistulas were successfully treated. ConclusionsIn H-Type fistula, success rate of Thulium LASER is only 20% and thus should not be used. In contrast, in RTEF, success rate of 50% is achieved, avoiding as many open procedures, and Thulium LASER could be considered as first line treatment. In any case, open surgery is safe and efficient and can be considered as a first-line treatment for H-type fistulas, and as a salvage treatment for endoscopic treatment failures. Levels of EvidenceLevel IV.

Low gestational age is associated with less anastomotic complications after open primary repair of esophageal atresia with tracheoesophageal fistula

BackgroundThe aim of this study was to evaluate anastomotic complications after primary one-staged esophageal atresia (EA) repair relating to the patients` gestational age (GA).MethodsRetrospective data analyses of patients who underwent closure of tracheoesophageal fistula (TEF) and primary esophageal anastomosis from 01/2007 to 12/2018 in two pediatric surgical centers. Exclusion of EA other than Gross type C, long-gap EA, minimal invasive or staged approach. Postoperative complications during the first year of life were assessed. Associated malformations, the incidence of infant respiratory distress syndrome (IRDS) and intraventricular bleeding were analyzed.ResultsInclusion of 75 patients who underwent primary EA repair. Low GA was associated with significantly lower incidence of anastomotic complications (p = 0.019, r = 0.596, 95% CI 0.10–0.85). Incidence of anastomotic leakage (0% vs. 5.5%; p = 0.0416), recurrent TEF (0% vs. 5.5%; p = 0.0416) und anastomotic stricture (0% vs. 14.5%; p = 0.0019) was significantly lower in patients < 34 gestational weeks. Incidence of IRDS (55% vs. 0%; p < 0.0001) and intraventricular bleeding (25% vs. 3.6%; p = 0.0299) was significantly higher in patients < 34 gestational weeks.ConclusionsDespite prematurity-related morbidity, low GA did not adversely affect surgical outcome after primary EA repair. Low GA was even associated with a better anastomotic outcome indicating feasibility and safety of primary esophageal reconstruction.

Repair of Adult Benign Tracheoesophageal Fistulae With Absorbable Patches: Single-Center Experience

This group previously reported on the repair of a wide tracheoesophageal fistula with a bioabsorbable patch. The current study describes a consecutive series of patients operated on using the same technique. Data of patients undergoing surgical closure of tracheoesophageal fistula at a single center from 2011 to 2018 were extracted and analyzed. An absorbable patch was used in 8 of 23 patients (34.8%) operated on for tracheoesophageal fistula during the study period. Causes of the fistulae included postintubation injury (n= 6), mediastinal radiotherapy (n= 1), and a complication of lung resection (n= 1). The median fistula size was 27.5 mm (range, 15 to 45 mm). In 3 patients, the surgical approach was through cervicotomy and in 5 it was through right thoracotomy. Prosthetic materials consisted of Gore Bio-A (W.L. Gore & Associates, Inc, Newark, DE) tissue reinforcement in 6 patients and polyglactin 910 knitted mesh in 2 patients. In every case, the prosthesis was covered with a pedicled muscle flap. The esophageal defect was treated by primary closure in 7 patients and by esophageal exclusion in 1. Fistula recurrence and postoperative death occurred in 1 patient (12.5%), whereas 7 patients experienced postoperative complications (87.5%). Five patients resumed oral intake, and 3 breathed without a tracheal appliance. Compared with the other patients, in those who underwent repair of their fistula using a prosthesis, the median size of the airway defect was larger, morbidity was greater, and the rate of resumption of oral intake was lower. Repair of tracheoesophageal fistulae with synthetic prostheses is feasible and may be effective in complex cases. Further research is needed to identify the ideal prosthetic material.

DOZ047.118: Surgical treatment of children with button battery injury

Abstract Introduction The foreign body of the esophagus—button battery causes severe changes of the esophagus. Ingestion of large-sized button batteries (≥20 mm) in children younger than 4 years is associated with increased morbidity and mortality. The most serious complication is the perforation of the esophagus or tracheoesophageal fistula (TEF), which may require a long-term multistage surgical treatment. Other issues that can be caused by button battery injury are esophageal stenosis and laryngeal paralysis. There are 40 children with esophageal injuries who were treated in Filatov Children Hospital between 2011 and 2019. Among them, several children did not need surgical treatment at all (40%), but five patients (12.5%) needed colon transposition. Button battery injury also causes reversible or irreversible damage of the recurrent laryngeal nerve, which required complex reconstructive operations on the larynx and trachea. Patients and Methods We retrospectively analyzed 40 patients with different types of injury after button battery removal. The average age of the patients was 1 year and 8 months. A total of 16 patients (40%) have had no esophageal or laryngeal pathology after button battery removal. Six patients (15%) developed esophageal stenosis. Two patients (5%) had esophageal perforations. Sixteen patients (40%) developed TEF. Bivocal chord paralysis was identified in 10 patients (25%). Results Esophageal dilations were performed in five patients (12.5%). Eight patients (20%) underwent laparoscopic fundoplication and gastrostomy. Spontaneous TEF closure formed in four patients (10%). Ten patients (25%) underwent different types of reconstructive surgeries in different periods after battery removal. Among eight patients (20%) who underwent early reconstructive surgeries three (7.5%) developed different complications, which require esophageal replacements. Tracheostomy was performed in 11 children (27.5%), five (12.5%) of whom required reconstructive surgery on the larynx. There was no mortality in our observation. Conclusion In this study, we conclude that TEF after button battery removal can close spontaneously and should not be operated in the acute period. Fundoplication and gastrostomy and tracheostomy can be procedures of choice in these patients. Also recurrent nerve injuries can be unstable. They can cause severe injuries of esophagus, trachea, and larynx, which can require esophageal replacement and vocal chord lateralization procedures with long-term and multiple-stage treatment.

The Use of Endoclips in Thoracoscopic Correction of Esophageal Atresia: Advantages or Complications?

Background: Thoracoscopic correction of esophageal atresia (EA) with tracheoesophageal fistula (TEF) has been increasingly widespread, but is still one of the most advanced pediatric surgical skills. This procedure has a challenging learning curve, and usually initially requires a longer operative time than the open approach; furthermore to perform this intervention, the surgeon must be very experienced in endocorporeal knotting. In our opinion, standardization of the technique and the application of "tricks" (including the use of titanium endoclips for TEF closure) to make surgical steps easier, faster, and safe would be useful to the surgeon and to the patient above all. Materials and Methods: We present our experience in thoracoscopic treatment of EA/TEF over the past 12 years; during this period, we have treated 32 neonates. We reviewed all patient clinical records evaluating demographics, surgical technique, postoperative period, and long-term follow-up. Results: Thirty-one patients were affected by type C EA (five presented with a long-gap defect); one by type E EA. Mean gestational age was 36 + 5 weeks (29-41). Mean weight at surgery was 2340 g (990-3715 g). Through a transpleural thoracoscopic approach, after Azygos vein division, TEF was closed by sutures (silk/polydioxanone [PDS]) in 4 patients while in the remaining 28 two 5 mm titanium endoclips were applied. Esophageal anastomosis was then performed with 8-12 interrupted 5/0 absorbable sutures. We had two intraoperative complications in endoclips application (migration and misplacement), which were immediately resolved. After a contrast study on sixth to seventh postoperative day (average eighth), in the absence of leakage, oral feeding was started and chest tube removed. Four to six weeks after surgery, patients underwent endoscopic evaluation. At a follow-up of 9 years, we had no postoperative complications due to endoclips: neither TEF recurrence, nor problems due to clips dislocation. Conclusions: Although the benefits of thoracoscopic correction of EA/TEF are still discussed, we agree with this part of recent literature that considers thoracoscopic approach as a feasible, safe, and advantageous alternative to the traditional open approach. We also want to emphasize that in our experience, TEF closure by titanium endoclips is fast, reducing operative time, and effective, with no reported long-term complications in our case series. Overall success rate after clips application is, in our series, 100%. The only limit we have found, above all for low-weight patients, is the diameter of the clip applier which needs a 5 mm access even if the surgeon uses 3 mm operative instruments.

Pharyngocutaneous and tracheoesophageal fistula closure using supraclavicular artery island flap.

Pharyngocutaneous fistula is a common complication of laryngopharyngeal surgery, being associated with increased morbidity and mortality. Classical regional and free flaps, frequently used in the treatment of this complication, have several limitations, including bulking, donor site morbidity and long operative time. The supraclavicular artery island flap (SCAIF) is a fasciocutaneous flap and presents as an alternative option with good results and without the previously stated limitations. We describe our experience with SCAIF in pharyngocutaneous and tracheoesophageal fistula closure. Between April and December 2017, four patients with pharyngocutaneous and two patients with tracheoesophageal fistula underwent fistula closure with SCAIF. Clinical records were retrospectively reviewed. Pharyngocutaneous fistulae were associated with anterior esophageal wall defects ranging from 4 to 13.5cm2. Tracheoesophageal fistulae defects were smaller (approximately 2cm2). Fistula closure was achieved in all patients, oral diet was started on the 14th day post-operative and there were no signs of recurrence during follow-up. The donor area was complicated with the formation of hematoma in two patients. The SCAIF has unique features that makes it an ideal option for pharyngocutaneous and tracheoesophageal fistula closure, namely, reliable perfusion, quick and simple dissection, pliability and minor donor site morbidity. Local complications do not significantly affect long term morbidity of the donor area and can be avoided with simple measures.

Atrial septal defect occluder devices for closure of tracheoesophageal fistulas: are they safe?

Atrial septal defect occluder devices for closure of tracheoesophageal fistulas: are they safe?