188188 © 2019 Journal of Digestive Endoscopy | Published by Wolters Kluwer - Medknow

Tracheoesophageal fistula (TOF) can be congenital or acquired. Acquired TOFcan be caused by iatrogenic or traumatic or due to malignancy with pulmonaryinfection or aspiration being the presenting symptom. Management of TOF isassociated with high mortality and morbidity and remains an interdisciplinarychallenge. Ingeneral,dependingon thesizeand locationof the trachealaspectofthefistula,surgicaltherapyinvolvesprimaryrepairofthefistulaand,ifnecessary,resection and reconstruction of the trachea. We present two cases of iatrogenicTOFfollowingsurgerysuccessfullyclosedusingover-the-scopeclips.This reportalsocomparesboththeOvescoandPadlockclipdevices.

Keywords: Endoscopic closure devices, over‑the‑scope clips, tracheoesophageal fistula

Tracheoesophageal Fistula: Bridging the Gap by Over‑the‑scope Clip ServicesAvinash Bhat Balekuduru, Siddharth Dhande, Lokesh Locheruvapalli Venkateshappa, Satyaprakash Bonthala Subbaraj

Address for correspondence: Dr. Avinash Bhat Balekuduru, Department of Gastroenterology, MS Ramaiah Memorial

Hospital, Bengaluru ‑ 560 054, Karnataka, India. E‑mail: avinashbalekuduru@gmail.com

closed – one by Padlock and another by Ovesco clips.Both the patients did well and were asymptomatic for1–6monthsaftertheplacementofclips.

Case ReportsCase presentation 1A 56-year-old male presented with a 7-year historyof cough on swallowing liquids and recent onsetpostprandial chest pain. He had recurrent lowerrespiratory tract infections requiring multiple coursesof oral antibiotics. He was diagnosed to have chronicbronchitisatanoutsidehospital.Hehadnovomitingorgastrointestinal (GI) bleeding. He had a history of theright posterolateral thoracotomy at the 5th intercostalspace for suspected lung tumor 7 years back, andthe operative details were not available. He had noaddictions.

At the time of her presentation, his completeblood count and differential were normal.

Introduction

Atracheoesophageal fistula (TOF) is an abnormalcommunicationbetweenthetracheaandtheesophagusdue to either a congenital or an acquired condition.Congenital TOF is due to an incomplete developmentof the tracheoesophageal septum occurring between the4thand8thweekoftheembryonicperiod.[1]AcquiredTOFissecondarytomalignancy,infections,ortraumaticwhichiseithermechanicaloriatrogenic.[2]Endotrachealtube(ETT)cuff-related traumacontributes to themajorityofTOFs inthenonmalignantgroup.TheincidenceoftrachealerosionasaresultofanETTinmechanicallyventilatedpatientsis0.3%–3%.[3] TOFs are thought to be due to erosion fromthe tube tip or cuff into the posteriorwall of the tracheatoresultinafistulouscommunicationwiththeesophagus.The other etiologies of iatrogenic complication includeendoscopicprocedures(e.g.,endobronchialbrachytherapy)orlobectomy.[4]

TOF may present with recurrent aspiration pneumoniaor recurrent hypoxemic events, which may prolongthe duration of mechanical ventilation. TOF may alsopresent with acute respiratory distress, evidence ofenteral feed in ETT aspirate during suctioning, positiveairleak,andgastricdistension.[5]

This case report describes two cases of TOF closureusing over–the-scope clips. BothTOFs are successfully

DepartmentofGastroenterology,MSRamaiahMemorialHospital,Bengaluru,Karnataka,India

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How to cite this article: Balekuduru AB, Dhande S, Venkateshappa LL, Subbaraj SB. Tracheoesophageal fistula: Bridging the gap by over-the-scope clip services. J Dig Endosc 2018;9:188-92.

Case Report

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DOI: 10.4103/jde.JDE_18_18

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Published online: 2019-09-24

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Esophagogastroduodenoscopy (EGD) was performedwhich revealed a pseudodiverticulum at 26 cm and afistulous opening at 30 cm from incisors [Figure 1].A barium esophagogram revealed a fistula between thelower esophagus and segmental bronchus of the rightlower lung field [Figure 2]. The option of endoscopicclosure and surgery was discussed with the patientand the relatives, and the following procedure wasperformed. Under conscious sedation, endoscopywas performed using forward-viewing single-channelgastroscope (GIF 180; Olympus Optical Co., Ltd.,Tokyo,Japan).PadlockClip(AponosMedical,Kingston,NH, United States) was successfully deployed for theclosure of esophageal edge of the fistula site. Repeatbarium swallow confirmed closure of TOF [Figure 3].Hewasasymptomaticat9-monthfollow-up.

Case presentation 2A 19-year-old male sustained road traffic accident andwas operated in a referral hospital for lacerated neckwound and fracture of the mandible. Postsurgery, he

had cough on swallowing liquids, was diagnosed tohave aspiration pneumonia, and was discharged onoral antibiotics. He underwent EGD and a fistulousopening was noted at 21 cm from incisors with upperesophageal sphincter at 17 cm. Barium esophagogramconfirmedthediagnosisofTOFintheupperesophagus.After discussing treatment options of surgery andendoscopic closure by clips, the following procedurewas performed. A trial suctioning was done usingan empty variceal band ligator cap, and later using9 mm × 11 mm Ovesco clip (Ovesco Endoscopy,Tubingen, Germany), the fistula was successfullyclosed, and he is asymptomatic at 1-month follow up[Figures4and5].

DiscussionTOF can be either congenital or acquired. CongenitalTOF can present in adults, but three criteria have tobe met: No surrounding inflammation or malignancy,absence of adherent lymph nodes, and presence ofnormalmucosa.[6]

The most common etiology of nonmalignant acquiredTOF is a complication of intubation with cuff-relatedtracheal injury. Thin barium can confirm and type theTOF.BraimbridgeandKeithclassifiedTOFas(i)TypeI,esophagealdiverticulumwithalargeostiumandafistulaat its tip; (ii) Type II, a short tract running directlyfrom the esophagus to the bronchus or the trachea; (iii)Type III, a fistulous tract connecting the esophagus toa cyst in the lobe, which, in turn, communicates with

Figure 1:TracheoesophagealfistulasecondarytolobectomyandPadlockclipclosure

Figure 2:BronchoesophagealfistulaTypeIII

Figure 3: Barium swallow image of successful clip closure oftracheoesophagealfistula

Figure 4:TracheoesophagealfistulaatpostcricoidregionandOvescoclipclosure

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Table 1: Tracheoesophageal Fistula ‑ Bridging the gap by over the scope clip servicesOTSC (Ovesco Endoscopy, Tubingen, Germany)[8] PADLOCK (Padlock Clip, Aponos Medical,

Kingston, NH, United States)[8]

Clipcharacteristics Nitinol(shapememory)Jawlikerowofteeth3teeth-a(rounded/atraumatic/babybear)forhemostasisandinthinwalledstructures-Esophagus:t(pointed/traumatic/mammabear)fortissuecaptureforreductionofclipslippage-forfistulaclosureorperforation;gc(longerpointed/papabear)forthickwalledstomach-gastrostomyclosure

Nitinol(shapememory)11mm,Hexagonal6innerprongsgatherandliftthetissueGapsbetweentheprongs-forbloodflowtopromotehealingTissuecontrollerslimitthedepthofpenetrationoftissue

Deliverysystem Similartovaricealligation LockIt(pushofthumb)Applicatorcap 3sizes:

11mm-9.5×11mm12mm-10.5×12mm14mm-11.5×14mmscopeLength:25mm(shorter)

2sizes:9.5×11mm(Clip)11.5×14mm(Proselect)Length:39mm(longer)

Triggercord Threadrunsretrogradethroughtheworkingchannelofscopeandfixedtothewheelatthebiopsyport[Figure6]

Bowdencablerunsparalleltoscopeandconnectedtothehandlewiththeassistant

Releaseofclip Suction-onceadequatetissueissuctioned-clipreleasedsimilartovaricealbanddeployment[Figure7]

Adequatesuction-clipreleasedbypressingahandle

Effectivetissuecontactzone 9mm 9mmAdvantages Twingrasper-Approximatesthegapingedgesofthelesion

Anchor-IftheedgesofthelesionareinduratedReloader-FordeployingasecondcliponalreadymountedOTSCsystemRemovesystem-forremovingOTSCclipsSmalldefects(10mm)-suctionwithclipclosure-bestLargedefects-UseotherdevicestoapproximatetheedgesAdvantagesaremore

Sixprongsincircumferentialfashionforfirmholdofthetissue.NograsperoranchordeviceLesscostly

Caution Induration/fibrosisofchronicfistulae-Bettertocauterisethemargins-mightimprovefistulaclosurerate

Angulatedpositionoftargetsite-DifficultSmallerviewassmallerdiameterofcap-chooseforsmallerdefectsEsophagealandlessercurvedefectsmightbedifficulttoapproximateClippinghardandfibroticlesionstoachievehemostasisisdifficultRebleedrateishighifclipdetachesin<24hBacterialcontaminationofclipmightprolonginfection

Comparativestudy Perfusionpressureresistance-300mmHgReliableandconsistent

Perfusionpressureresistance-9.2mmHgPoorincontrollinghemostasis

Contraindications EsophagealVarices EsophagealVaricesWhenhemostasisorclosurecannotbeverifiedonendoscopicfieldofviewArteries>2mmPolyps>1.5cmMucosal/submucosaldefect>3cm

Technicality Trialofsuctionoftheanticipatedclosuresitewiththevaricealbandingcylinderforapproximation

Indications AcutebleedingFullthicknesswallclosureCompression/approximationoftissueEndoscopicorsurgicalperforation/fistulaeclosure

Closureofulcers/Fistulas/perforation/postpolypectomysite<2cmMucosal/submucosaldefectsArteries<2mm

MRI Compatible Conditional-okif3Teslaandlowermagneticfield

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the cases, there was no immediate postproceduralcomplication. Both the clips were applied successfully.Padlock clip closure of TOF was attempted in twoother cases but failed in one case, therewas a strictureadjacent to TOF, and the approximation of the edgeswas not feasible, and in another, the defect was large3 cm with fibrotic edges. The main reason for successwascompleteapproximationofthebordersofthedefectinside thecapwithmaximumsuction inboth thecases.ThefirstcasewehadnooptionofOvescoclipasitwasnot available in India at that time. For the second case,Ovesco was chosen for technicality. The article waswritten with a table so that it becomes easy to selectbetween the twoclipswhichnoneof the earlier articleshadmentioned.ThecomparisonbetweenthetwoclipsisasgiveninTable1.

Size of the luminal defect and not the length of theleak or fistula outside the GI tract and time fromperforation play a role with smaller defects and acuteperforationsbeingeasiertoclosethanlargerandchronicones.[9] The classic acronym foreign bodies, radiation,infection/inflammation, epithelialization, neoplasm,distal obstruction, and steroids in the setting of fistulamanagement is imperative to long-term success.[9] Toour knowledge, there are only few case reports ofTOFsuccessfully sealedwith clips.Over-the-scope clip clipsare easy to apply, and they can be used for closure ofTOFs.

ConclusionsOver-the-scope clips might be considered for bridgingthe gap of TOF from the esophageal end. It can be analternativetosurgeryinselectedTOFcasessuchaspoorsurgical candidate, small defect <1 cm, benign etiologyofTOF,andinpatientconsentingforclip.

Declaration of patient consentThe authors certify that they have obtained allappropriate patient consent forms. In the form thepatient(s) has/have given his/her/their consent for his/her/their images and other clinical information to bereportedinthejournal.Thepatientsunderstandthattheirnamesand initialswillnotbepublishedanddueeffortswill be made to conceal their identity, but anonymitycannotbeguaranteed.

Financial support and sponsorshipNil.

Conflicts of interestTherearenoconflictsofinterest.

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Figure 7:SideviewofthetipofthescopewithmountedOvescoclip

Figure 5:Bariumswallowimageoftracheoesophagealfistulapre-andpost-clipclosure

Figure 6:TipofthescopewithmountedOvescoclip

thebronchus;and(iv)TypeIV,afistula that runs intoasequestratedsegmentorlobe.[7]

In Case 1, Type III Braimbridge and Keithbronchoesophagealfistulasecondarytoearlierlobectomywas noted. Padlock clipwas placed as theTOFwas at30 cm from incisors. In Case 2, the TOF was in thepostcricoid region and was secondary to intubation,and Ovesco clip was used for closure of TOF. In both

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