Closure of residual fistula after esophageal atresia repair in a 5-year-old using endoscopic submucosal dissection of surrounding mucosa

Esotracheal fistulas after esophageal atresia repair recur in 5 to 10 % of cases [1] [2] and lead to recurrent pneumonia or mediastinitis. Several surgical techniques are effective in closing an esotracheal fistula by thoracotomy or cervicotomy [3], but endoscopic success has never been published for this indication.

We present the case of a 5-year-old patient with a previous history of type III esophageal atresia neonatal surgery, chronic respiratory congestion, and poor weight gain. She experienced a fistula recurrence with a large tracheoesophageal defect ([Fig. 1]).

Fig. 1 First endoscopic submucosal dissection to remove mucosa surrounding the fistula. a Appearance of the residual tracheoesophageal fistula (red arrow showing the fistula). b, c Deep dissection of the entire fistulous tract using a clip-and-line system. d Clips placed in the submucosa to close the orifice.

We performed an endoscopic fistula closure after prior endoscopic submucosal dissection (ESD) of the surrounding mucosa as previously reported for a button battery-induced esotracheal fistula [4] or idiopathic chronic fistula [5]. The patient underwent tracheal intubation with balloon placement just under the fistula. ESD was assisted by clip-and-line traction to dissect deeper into the fistula tract ([Video 1]). Once the mucosa was resected, we closed the area using four clips anchored in the submucosa. A radiological check objectified the tightness of the closure.

Video 1 Successful endoscopic closure of a residual fistula after esophageal atresia repair in a 5-year-old using endoscopic submucosal dissection of the surrounding mucosa.

The postoperative consequences were favorable, marked by a disappearance of the patient's respiratory symptoms during the following 3 months. A radiological check with opacification carried out 3 months before the gesture shows a tiny residual fistula and pseudo-diverticular scarring ([Fig. 2]). The patient underwent a second procedure, during which ESD of the surrounding mucosa was done with deep cutting of the diverticular wall. Then, a new closure of the resected area was done. The closure of the residual fistula was confirmed by radiological control after 1 month.

Fig. 2 Aspect of esophageal transit before and after the second procedure. a Radiological opacification after first endoscopic closure: small residual fistula and pseudo-diverticular scarring (red arrow showing the fistula). b Radiological opacification after second endoscopic gesture: no residual fistula.

Currently, the management of recurrent esotracheal fistulas after atresia surgery is not well defined. Endoscopic closure after ESD of the surrounding mucosa could allow a definitive resolution of the esotracheal fistulas and avoid a second risky surgery.

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• References

• 1 Kovesi T, Rubin S. Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest 2004; 126: 915-925
• 2 Bruch SW, Hirschl RB, Coran AG. The diagnosis and management of recurrent tracheoesophageal fistulas. J Pediatr Surg 2010; 45: 337-340
• 3 Daniel SJ, Smith MM. Tracheoesophageal fistula: open versus endoscopic repair. Curr Opin Otolaryngol Head Neck Surg 2016; 24: 510-515
• 4 Gruner M, Heissat S, Pitiot V. et al. Successful endoscopic closure of a refractory button-battery tracheoesophageal fistula in a 3-year child using endoscopic submucosal dissection of the surrounding mucosa. Endoscopy 2017; 49: E212-E214
• 5 Bertrand G, Jacques J, Rivory J. et al. Deep endoscopic submucosal dissection of a refractory tracheoesophageal fistula using clip-and-line traction: a successful closure. Endoscopy 2017; 49: 1278-1280