DEEP ENDOSCOPIC SUBMUCOSAL DISSECTION OF A REFRACTORY ESOTRACHEAL FISTULA USING CLIP AND LINE TRACTION: A SUCCESSFUL CLOSURE

Chronic esotracheal fistula is a rare disease causing a therapeutic challenge. Unlike for most digestive fistulas, drainage with pigtail stent is not possible.

We present here the case of a 47-year-old man referred for a chronic 4 mm (23 cm from DA) esotracheal fistula from unknown cause. His past history revealed several pulmonary infections since his childhood.

Several endoscopic treatments were attempted with clip closure and then hot biopsy forceps abrasion of the surrounding mucosa but without obtaining complete closure.

Then, we proposed an endoscopic submucosal dissection (ESD) of the surrounding mucosa resecting a 1 cm mucosal patch centered on the fistula as previously described. Patient underwent tracheal intubation with balloon placement just under the fistula. To allow deep dissection of the fistula tract we added a clip and line traction to put the fistula out of the wall. The fistula tract was then sectioned at the deepest possible point.

Finally, we closed the resected area with 4 clips anchored into the submucosa. We realized a radiologic control with opacification that showed no sign of fistula in the tracheal tract

Evolution was rapidly favourable without pain and aspiration coughing disappeared. A 2 months radiologic control with opacification showed no residual fistula. Last clinical follow up after 4 months confirmed complete resolution of the cough and aspiration events.

Nowadays, the management of esotracheal fistula is not well codified, and endoscopic place is not known. Endoscopic abrasion with argon plasma and stents are not very effective with only 53% of healings. ESD could be a good option to improve scaring and to allow definitive resolution of those fistulas.