Post written by Biswa Ranjan Patra, MD, DM, from Seth GS Medical College and KEM Hospital, Mumbai, India.

Refractory tracheoesophageal fistulas (TEFs) are difficult to treat, even with various surgical or endoscopic modalities.

This case involves a 5-year-old child with a congenital TEF that recurred after 2 surgical corrections and endoscopic attempts at closure. We describe a novel technique using modified polydioxanone suture mesh with 3 sessions of fibrin glue application. Polydioxanone sutures 3-0 in size were used to knit the tubular mesh after inserting multiple knots. The suture mesh was then placed in the fistula and fixed with clips after ablating the edges with argon plasma coagulation.

Subsequently, a double-lumen catheter was used to deliver processed components of fibrin sealant into the fistula tract to form the final fibrin clot (Fig. 2). Two sessions of repeat ablation and fibrin glue application were performed at 2 weekly intervals, achieving complete closure of the TEF over a total treatment duration of 8 weeks. To our knowledge, this is the first instance of use of bioabsorbable surgical suture mesh to assist fistula closure successfully.

With this method, we adopted principles of directed tissue healing by using a matrix made of absorbable suture mesh to induce granulation tissue. Such methods using native tissue growth for closure by secondary intention are long lasting compared with that of mechanical ones. They are effective, especially in chronic fistulas with compromised vascularity, such as in the setting of surgical repairs or anastomotic site fibrotic fistulas or those in the background of chronic inflammation.

Although the search for an ideal method will continue, the important message remains that once a fistula is recurrent or refractory, it is less likely to respond to forceful mechanical closures. In such scenarios, switching to tissue growth inducers with absorbable sutures, plugs, or occluders should be attempted.

Further research may be directed toward developing bioabsorbable closure devices that can stay longer, occlude, induce tissue growth, and eventually become absorbed, leading to closure of such chronic fistulas.

Modified polydioxanone (PDS) suture mesh with fibrin glue application. A, Endoscopic view showing esophageal fistula opening. B, Ablation of the visible mucosa around the fistula using argon plasma coagulation. C, Placement of modified suture mesh inside the fistula tract using biopsy forceps. D, Endoscopic clips used to affix the mesh to the fistula margin. E, Double-lumen catheter used to deliver components of the fibrin sealant. F, Final fibrin clot formed inside the fistula tract.

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