Successful endoscopic closure of multiple tracheoesophageal fistulas following implantation of two atrial septal defect occluders.

Chronic tracheoesophageal fistulas [TEFs] represent one of the greatest challenges for endoscopists [1]. A 63-year-old man diagnosed with adenocarcinoma of the esophagogastric junction was treated with neoadjuvant chemoradiotherapy and esophagectomy. He developed two TEFs, which required the implantation of two self-expandable stents and a feeding jejunostomy. The prostheses were withdrawn 3months later, and a tracheal prosthesis was put in place. Given the persistence of the fistulas, the patient was referred to our center. Endoscopy and bronchoscopy revealed two fistulous orifices, 8mm in diameter and 1cm apart (●" Fig.1). The fistulas were closed using two atrial septal defect occluders (ASDO, Amplatzertypeprosthesis; AGAMedical Corporation, Golden Valley, Minnesota, USA), which are normally used for closure of interauricular septal defects [2]. A pediatric endoscope was inserted into the trachea and the two fistulous orifices were identified. Through one of these, access was gained to the lumen of the esophagus and the gastric plastyby insertinga0.035-inchguidewire. Once the pediatric endoscope had been withdrawn from the trachea, and under endoscopic vision from the esophagus, an ASDO with an 8-mm neck and two flaps was placed from the trachea, over the guidewire, and into the esophagus to seal off the fistulous tract between the lumen of the trachea and esophagus (●" Fig.2 and ●" Fig.3). Three weeks later, the procedure was repeated using a second ASDO with a 4-mm neck and 13-mm diameter flaps, which occluded the esophageal and tracheal lumen of the other fistula (●" Fig.4,●" Fig.5, ●" Video1). Thepatient resumedoral feeding. Endoscopic reviews at 3 and 4 months confirmed healing of the fistulas. Since the description by Rabenstein of the use of ASDOs in the treatment of TEFs, several authors have confirmed the safety and efficacy of this procedure inTEFs [3–5].