S4320 Chronic Tracheoesophageal Fistula to Native Esophagus After Colonic Interposition

Introduction: A tracheoesophageal fistula (TEF) is an aberrant connection between the trachea and esophagus that can result in aspiration events and recurrent pneumonias. TEF can be congenital in nature (i.e., esophageal atresia) or acquired as a complication of surgery or trauma. It is treated with surgical resection of the fistula and airway repair. Esophageal repair is preferred while esophagectomy with diversion is sometimes necessary. Reconstruction techniques include colonic interposition whereby a portion of the colon is anastomosed to the proximal esophagus and stomach. We present a case where the native esophagus was ligated and left in-situ and a right sided colonic interposition was done. The native esophagus led to formation of a TEF. Case Description/Methods: A 45-year-old woman had a traumatic injury at age 6 resulting in tracheal and esophageal rupture. She underwent right colonic interposition to her proximal esophagus. Her native esophagus was ligated proximally just distal to the esophago-colic anastomosis and distally at the gastro-esophageal junction. Since her colonic interposition, she had chronic bronchitis and bacterial pneumonia. A computed tomography chest showed a large fistula of the blind distal esophagus to the carina with confirmation via bronchoscopy. After multidisciplinary discussion, endoscopic intervention was attempted with argon plasma coagulation ablation of the blind native esophagus mucosa with suture closure of the TEF opening and bronchial stents placed to close the 2 esophago-tracheal fistulas. However, repeat computed tomography chest showed that the TEF remained open. The risks and benefits of surgical repair was discussed with patient, who decided not to pursue surgery. She is currently being managed with pulmonary hygiene measures and long-term antibiotic therapy with no recent hospitalizations. Discussion: Though unconventional, endoscopic intervention with suture closure of the TEF was pursued due to the high-risk nature of surgery intervention, which would require a right thoracotomy with complete esophagectomy of the native esophagus and complex tracheal repair with mesh under ECMO support. Other endoscopic options for TEF closure include the use of sealants, clip closure or stent placement. This case underscores the rare occurrence of TEF development from a retained blind native esophagus located adjacent to the trachea and demonstrates potential endoscopic approaches that may be considered prior to high-risk surgical repair in challenging clinical scenarios.