A 23-year-old man with polytrauma was admitted to the intensive care unit for level
3 postoperative support. His medical history included VATER syndrome [1] with corrective surgery for the tracheoesophageal fistula (TEF). Ventilatory support
according to ARDSNet criteria in the acute phase was complicated by a persistent air
leak and significant gastric distension, raising the possibility of a residual TEF.
An initial gastroscopy failed to show a fistulous opening. A Ryle’s tube for gastric
air drainage and nasojejunal tube for enteral feeding were left in situ. Flexible
bronchoscopy through the endotracheal tube showed a flap with access to the esophagus
from the bronchial tree just above the carina, confirming the clinical suspicion of
a TEF.
At repeat endoscopy, the site of the communication was not immediately apparent but
a mucosal flap was noted in the upper esophagus ([Fig. 1 a]). We performed a rendezvous bronchoscopy and identified a 1-cm fistulous opening
in the esophagus at 26 cm from incisors ([Fig. 1 b]). This was successfully closed using an over-the-scope clip (OTSC; Ovesco, Tübingen,
Germany) ([Fig. 1 c]). The feeding nasojejunal tube was replaced endoscopically ([Fig. 1 d]). Successful closure of the fistula was confirmed by the complete absence of air
drainage from the Ryle’s tube, improvement in the ventilatory mechanics, and by a
Gastrografin swallow. The patient was subsequently weaned off the ventilator and extubated.
Fig. 1 Endoscopic views showing: a the suspected mucosal flap at the site of the tracheoesophageal fistula (TEF); b the rendezvous bronchoscope visible using the endoscope, previously loaded with an
over-the-scope clip (OTSC) and positioned in the esophagus; c the OTSC placed at the esophageal opening of the TEF; d a feeding nasojejunal tube that was placed endoscopically at the end of the procedure.
OTSCs are widely used for closure of perforations and fistulas [2]
[3]. Nonsurgical closure of a TEF by rendezvous bronchoscopy and gastroscopy performed
simultaneously has not been reported previously. The fistulous opening of a TEF can
usually be identified during gastroscopy; however, in cases where the fistula is small
and covered by a mucosal flap, as described here, a combined procedure can facilitate
identification of the opening and direction of the fistula to aid accurate clip placement.
This technique has the potential for use in closure of similar defects where a definitive
surgical procedure would carry a high risk. In our case, the immediate requirement
to enable adequate ventilation in a patient with an acute head injury was successfully
achieved.
Endoscopy_UCTN_Code_TTT_1AO_2AI
