Background: A tracheoesophageal fistula (TEF) represents a condition characterized by abnormal communication between the gastrointestinal tract and the airways. Although the current gold-standard treatment is surgery, pre-existing clinical conditions may represent contraindications. We therefore propose a bronchoscopic approach through rigid bronchoscopy without tracheostomy for total repair in patients suffering from benign tracheoesophageal fistulas. Methods: Fistula suture through rigid bronchoscopy with either absorbable (Vycryl 3.0, Ethicon, Inc.) or non-absorbable (Prolene, Ethicon US, LLC. 2022.) sutures was performed using a long needle holder as an alternative resolutive procedure to surgery. From 2015 to 2022, we retrospectively reviewed 10 consecutive patients affected by TEFs in our Endoscopic Unit at San Camillo-Forlanini Hospital (Rome, Italy) who underwent this bronchoscopic procedure. The coprimary outcomes were the proportion of fistulas successfully treated with the innovative treatment proposed and the rate of procedure-related complications. Results: The complete healing of the fistula was achieved in nine of the ten patients after 1 year. Follow-up with flexible bronchoscopy was scheduled and carried out at 1, 3, and 12 months following rigid bronchoscopy. Overall, seventeen endoscopic repair procedures were performed. Five of these patients required more than one endoscopic treatment to reach complete fistula closure. Fistula closure was not achieved post-procedure in one patient. No complications during procedures or in the follow-up period were reported. Conclusions: Despite the small cohort, our preliminary study has demonstrated that the endoscopic approach through rigid bronchoscopy, without tracheostomy, represents a safe and satisfactory alternative for patients affected by TEFs who are not suitable for surgery.

Bronchopleural fistulas represent a relatively frequent complication of pulmonary resections.This pathology may be treated by different approach depending on morphology,site or dimension of the fistula.An endoscopic less invasive treatment may be desirable but sometimes difficult,depending on the dimensions of the leak.We present a new method proved to be efficient in larger and chronic fistulas.Through a rigid bronchoscope,a small cylinder of PVA(polyvinyl alcohol)sponge is inserted to the fistula and then charged with a very fluid,slow activated cyanoacrylate.The cylinder increases its volume while the cyanoacrylate gradually polymerizes and solidifies,with tight adherence to the walls of the fistula.The immediate result is the occlusion of it,but the sponge also induces inflammatory reaction which brings to a granuloma (Figure1).We treated 7 patients with post resection fistulas ranging from 4 to 8 mm.The site was the bronchial surgical suture in 6/7 patients and in one case the right wall of distal trachea,after N4R lymphectomy.A complete occlusion of the fistulas was achieved in 7/7 patients and a definitive result in 5/7.The procedure took 40±5minutes to be performed.No severe complications occurred after the interventional endoscopic procedures.This new technique may represent an effective treatment in patients with larger fistulas, but also on difficult sites like trachea.

Surgical repair of tracheo-esophageal fistula is a complex procedure that can be challenging in compromised patients.Surgical repair remains the gold standard,however,in compromised patients,may be difficult or dangerous.We present our experience with a totally endoscopic approach based on the suture of a fistula with resorbable stitches.The procedure was performed in a young patient with a congenital tracheo-esophageal fistula located in the middle third of the trachea 2cm long.The patient had rigid bronchoscopy.A rigid telescope (Storz)connected to a camera and a rigid aspirator were inserted through the tube.The fistula was exposed and sutured by means of resorbable stitches (Vycryl© 3.0),using a long needle holder.The knots were tied outside of the tracheoscope and were pushed down with a knot pusher.The surgical thread was cut with a contact Yag laser fiber (Figure 1).The procedure lasted 40 min, and the patient was discharged after 24 h.He was able to eat normally the same day.After 3 months, the patient was in excellent condition, free of cough and of pulmonary symptoms.A monthly endoscopic examination and CT scan confirmed the stability of the suture,and no recurrence of the fistula was observed.Our experience demonstrates that an endoscopic suture of the fistula is feasible and may be effective for palliation.Long-term follow-up will indicate whether this procedure may also be considered a definitive intervention.