Deep endoscopic submucosal dissection of a refractory tracheoesophageal fistula using clip-and-line traction: a successful closure.

Chronic tracheoesophageal fistula is a rare disease presenting a therapeutic challenge. Unlike the case with most digestive fistulas, drainage with a pigtail stent [1] is not possible. We present here the case of a 47-yearold man referred for a chronic 2-mm tracheoesophageal fistula (23 cm from mouth) of unknown cause. His past history revealed several pulmonary infections since childhood. Several endoscopic treatments were attempted with clip closure and then hot biopsy forceps abrasion of the surrounding mucosa, but complete closure was not obtained. We therefore proposed endoscopic submucosal dissection (ESD) of the surrounding mucosa, namely a 1-cm mucosal patch (▶Fig. 1 and ▶Fig. 2, ▶Video1) centered on the fistula, as previously described [2]. The patient underwent tracheal intubation with balloon placement just under the fistula. To allow deep dissection of the fistula tract we added a clip-and-line traction (▶Fig. 3) [3] to pull the fistula Trachea a b c Fistula