Endoscopic clip for closure of persistent tracheoesophageal fistula in an infant.

INTRODUCTION Tracheoesophageal fistula (TEF) is an abnormal communication between the trachea and the esophagus that can lead to respiratory distress and/or feeding problems. The majority of infants with a TEF also have esophageal atresia, both of which are usually repaired concurrently. Unfortunately, recurrent fistulae occur in 3% to 12% of case series and can be difficult to repair. A recurrent TEF is best visualized on an esophagram, which may require a pullback technique whereby contrast is injected into a feeding tube as it is pulled back up the esophagus. Recurrent TEF can be repaired endoscopically, thoracoscopically, or using an open approach. Endoscopic repair involves de-epithelialization of the fistulous tract (using electrical or chemical cautery) with or without placement of adhesive glue. Successful rates of closure on the first attempt combining all techniques is 49%, with combination de-epithelialization and tissue adhesive achieving the highest closure rate at first attempt (68%) and overall (93%) with an average of two attempts required. Success rates are lower with TEFs that are wide (>2 mm), angled anteroinferiorly to posterosuperiorly, subjected to positive pressure ventilation, and located so distally that the patient cannot be intubated with a cuff below the repair to minimize the amount of positive pressure being delivered to the repair site itself. Anecdotal evidence suggests that for distal TEFs that can be glued with tissue adhesive but cannot be compressed by an endotracheal tube cuff, cautery alone may be more beneficial than added tissue adhesive, which may stent the wound edges apart. Occasionally, endoscopic approaches cannot close a recurrent TEF, and open or thoracoscopic approaches are required. Unfortunately, these can be associated with high levels of postoperative morbidity, mortality, and recurrence. The use of an endoscopic clip in the esophagus was first described in an adult for closure of a perforation incurred following dilatation for achalasia. A review of this procedure in 17 adults found that all perforations were successfully closed following endoscopic clipping. The use of endoscopic clips for closure of an esophageal perforation or TEF has not been described in children.