Vivek Kumbhari, MD, FRACP from Johns Hopkins Medical Institutions in Baltimore, Maryland, USA presents this video case titled “Closure of a chronic tracheoesophageal fistula by use of a cardiac septal occluder” from the VideoGIE section.

In this video, we demonstrate the use of a cardiac septal occluder (Amplatzer; St Jude Medical, Plymouth, Minnesita, USA) to close a tracheoesophageal fistula (TEF). This device is a self-expandable double umbrella shaped polyester covered nitinol wire mesh. A 72-year-old female presents for management of a chronic, iatrogenic TEF as a result of tracheal stenting to manage a tracheal stricture as a consequence to prolonged intubation. A combined bronchoscopic, esophagoscopic and fluoroscopic approach were used. The fistula was located 2cm below the upper esophageal sphincter and measured 10mm in size. The cardiac septal occluder was deployed across the fistula with a procedure time of 10 minutes. The patient was discharged home the same day and a contrast swallow at 6 weeks revealed no active fistula. The patient recommenced diet and remains well without episodes of aspiration pneumonia.

Figure 1. Deployment of the cardiac septal occluder under esophagoscopic and bronchoscopic visualization. A, The 2 umbrellas can be seen inferior to the endoscopes. B, Esophageal view of the umbrella occluding the fistula.

In adults, an acquired tracheoesophageal fistula is most commonly the result of cuff-induced tissue necrosis form prolonged mechanical ventilation. These patients are often poor surgical candidates, and hence a minimally invasive technique for closure may offer significant benefits. We demonstrate the technical feasibility and efficacy of the cardiac septal occluder to close a chronic proximal TEF. This novel technique may be an alternative to surgical repair although the longer-term efficacy is unknown.

Endoscopists must be open to using devices that are not specially designed for use in the gastrointestinal tract. It is essential that a multidisciplinary team approach be used in these circumstances and one should readily collaborate with their surgical colleagues.

There are reports of successful use of this device in closing tracheoesophgaeal, gastrojejunal, gastroesophageal, gastrocolonic fistula as well as gastric leaks. Of note, as opposed to the intravascular space, epithelialization does not appear to occur in the gastrointestinal tract. Migration of the device has been reported with potentially serious consequences and therefore it should be used only as a salvage therapy.

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