V5 - A Case of Endoscopic Repair of Tracheoesophageal Fistula With Septal Occluder Device

Introduction: Septal occluder device (SOD) are percutaneous transcatheter devices that are primarily used for repairing cardiac septal defects (VSD). They are composed of nitinol mesh with polyester material with self-expanding double-disc design that can be recaptured and redeployed. Because tracheoesophageal fistulas (TEF) are structurally similar to septal defects, SODs have the potential to be repurposed for TEF repair.

Case Description/Methods: A 60-year-old man presented with a history of esophageal adenocarcinoma status post esophagectomy in 2019 and neoadjuvant chemoradiation complicated by TEF. Multiple TEF repairs were done previously at other institutions, including esophageal stenting, clipping, suturing, which have all failed. He had no oral intake with persistent coughing and weight loss. An EGD was done in 2022, which showed a 15 mm in diameter TEF, which he received argon plasma coagulation (APC) and three sutures in an interrupted fashion with cinches on both ends. Follow-up swallowing study showed water-soluble contrast leaking through the TEF. One month later, patient underwent repeat APC and suturing, but repeat swallowing study showed persistent TEF. Otolaryngology (ENT) team evaluated the patient and discussed the challenges of surgically repairing the TEF. Patient underwent a third TEF repair, which was also unsuccessful. ENT re-evaluated the patient and noted the same challenges with surgical repair so the decision was made to try a VSD SOD to repair the TEF. From the esophageal side of the TEF, a 14 mm VSD SOD was deployed through the fistula opening and then retracting the device into place. A bronchoscopy was performed, which showed the SOD in good position. Patient had no complications and tolerated nectar thick diet before discharging home. One month later, patient presented for a follow-up swallowing study, which showed a small leak of the TEF. Patient underwent a repeat EGD to replace the 14 mm VSD SOD with a 18 mm VSD SOD. Repeat swallowing study, one month later, showed no contrast leak into the trachea. Patient endorsed significant symptomatic relief with oral tolerance and weight gain.

Discussion: This case demonstrates the utility of SOD for repairing large TEF that fail mainstay treatment. Smaller TEF (less than 1 cm) usually have higher success rates with standard suturing and clipping. When TEF are greater than 1 cm, it is less likely to be fixed by endoscopic techniques so other therapy options are explored.