Use of a cardiac septal occluder for the closure of a benign bronchoesophageal fistula

A bronchoesophageal fistula (BEF) is a pathologic connection between the esophagus and a bronchus, requiring prompt medical attention. BEFs are most commonly encountered in the setting of malignancy. A benign BEF can result from infection, trauma, or a foreign body. Surgical repair is morbid; endoscopic management includes stent placement, fibrin glue, clips, and suturing, all with limited success.

A 79-year-old man presented with acute hypoxic respiratory failure secondary to pneumonia. He reported having a chronic cough exacerbated by eating. A modified barium swallow study and esophagram revealed movement of contrast material from the esophagus into the right lung on chest radiograph (Fig. 1A). The patient was given broad-spectrum antibiotic agents, and an EGD was performed. The findings were remarkable for a diverticulum in the mid-esophagus, having a fistula connecting the end of the diverticulum with the right mainstem bronchus. The BEF was not amenable to stenting or clip placement because of the diverticulum (Figs. 1B and C). Because the patient was a poor surgical candidate, we elected to use a cardiac septal occluder device to close the fistula. A 20-mm Gore Cardioform septal occluder (W. L. Gore & Associates, Flagstaff, Ariz), consisting of a nitinol frame covered with expanded polytetrafluoroethylene, was chosen for closure of the fistula. The deployed device expands into 2 apposing disks, effecting closure. When compared with other occluder devices, this device was chosen to mitigate concern for pressure necrosis. Successful deployment of the device was performed by use of a combination of endoscopic and fluoroscopic guidance (Video 1, available online at www.VideoGIE.org). The device was not completely expanded after deployment; however, the position appeared to be satisfactory (Fig. 1D). The patient was doing well at a 6-week follow-up visit; a repeated barium esophagram did not reveal any extravasation of contrast material into the lungs, and the device had completely expanded (Fig. 1E).

Figure 1.

A, Chest radiograph demonstrating contrast material in the right lung. B, Upper endoscopic view of the diverticulum in the mid-esophagus. C, Upper endoscopic view showing a fistula at the end of the diverticulum. D, Chest radiograph of an incompletely expanded septal occluder device after endoscopic placement (arrow). E, Barium esophagram demonstrating the septal occluder device in a mid-intrathoracic esophageal diverticulum (arrow). There is no extravasation of contrast material.

Disclosure

Dr Yeaton is a consultant for Cook Medical, Boston Scientific, and Gore Medical. All other authors disclosed no financial relationships relevant to this publication.

Supplementary data

Video 1

Endoscopic placement of a septal occluder for the closure of a bronchoesophageal fistula.