Endoscopic closure of a congenital tracheo-esophageal fistula using a through-the-scope suturing device in a young boy

Abstract

Figures

Schematic overview of different categories of tracheo-esophageal fistula Type A–E with respective distribution of occurrence of the subtypes (%), own picture based on McGowan et al. 2022 1 .

Argonplasma coagulation of tracheo-esophageal fistula Type E.

Successful endoscopic suturing of tracheo-esophageal fistula Type E with helices and locking plug in place.

Full text

Tracheoesophageal fistulas (TEF) are a congenital anomaly with an incidence of approximately 1 in 4,000 births. TEF are classified into types A–E, with type E being the most amenable to endoscopic closure ( Fig. 1 ) 1 . Advances in endoscopic techniques have expanded the therapeutic options for managing TEF. Here, we present a case of successful endoscopic closure of a TEF using a novel through-the-scope suturing device (TTS-SD, X-Tack, Boston Scientific) 2 . A 37-month-old boy presented with postprandial coughing and recurrent bronchopulmonary infections. Initial endoscopy revealed a small, non-functional porus without significant TEF. Six months later, the patient’s condition worsened with the diagnosis of a significant type E TEF, located 13 cm from the dental arch. An attempt of clip closure failed after 2 weeks. A fully covered self-expanding metal stent (fcSEMS, 10 × 80mm) was then placed but dislocated within days, another fcSEMS (20 × 80mm) was removed after 1 day due to thoracic pain. Given the narrow esophageal diameter, over-the-scope clips and overstitch devices were not feasible. The novel TTS-SD was employed instead. The fistula was debrided with argon plasma coagulation and brushing ( Fig. 2 ). Four helices were placed 4 mm from the fistula margin in a Z-shaped configuration and secured with a closure plug. Air insufflation confirmed successful closure ( Fig. 3 ). At 2 weeks, the helices were partially detached but the patient was asymptomatic. By six weeks, the helices had fully detached, with no symptoms. At 6 months, follow-up confirmed stable closure without recurrence ( Video 1 ). Endoscopic closure of Type E tracheoesophageal fistula presents a minimally invasive alternative to surgery 3 . The TTS-SD significantly expands the endoscopic therapeutic armamentarium, especially in narrow spaces or distorted anatomy. This case demonstrates the successful closure of a congenital H-fistula with endoscopic techniques, suggesting that endoscopy could be the method of choice for treating Type E fistulas.

Schematic overview of different categories of tracheo-esophageal fistula Type A–E with respective distribution of occurrence of the subtypes (%), own picture based on McGowan et al. 2022 1 .

Argonplasma coagulation of tracheo-esophageal fistula Type E.

Successful endoscopic suturing of tracheo-esophageal fistula Type E with helices and locking plug in place.

Endoscopic closure of a congenital tracheo-esophageal fistula using a through-the-scope suturing device in a young boy.Video 1

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