Endoscopic management of tracheoesophageal fistulas: a narrative review

Introduction

Background

Tracheoesophageal fistulas (TEFs) are abnormal connections between the esophagus and airway that result in gastric contents spilling into the airway. The clinical effect of this complication can severely impact quality of life with symptoms including, coughing, dysphagia, hemoptysis or hematemesis, recurrent aspiration and pneumonia, and hospitalization for respiratory failure. Conservative management often includes the recommendation to stop oral intake, leading to further decline in quality of life. This makes alternatives in management an important consideration (1).

In adults, TEFs are usually an acquired condition, and are classically divided into benign and malignant etiologies. Acquired benign fistulas account for approximately 50% of all acquired fistulas (2). Benign fistulas are still a morbid condition as they are complicated by recurrent aspiration and rarely close spontaneously; however, they carry a better prognosis with more definitive surgical options available compared to fistulas associated with malignancy. Etiologies for benign fistulas are often iatrogenic, the most common of which include post-intubation injury, post-radiation, and post-surgical (such as esophagectomy or laryngectomy). Post-intubation injury accounts for 75% of all acquired benign TEFs (3). Other causes include traumatic injuries, foreign bodies, invasive infections such as invasive candidiasis (4), and late presenting congenital fistulas. Successful closure of TEF is achieved with several surgical techniques in order to repair and restore normal breathing and swallowing. Surgical approaches generally include primary esophageal or tracheal closure or tracheal and esophageal resection and reconstruction. All approaches typically include interposing pedicled muscle or omental flaps (5).

Fistulas associated with malignancy carry a poor prognosis. They most commonly arise from esophageal cancer, comprising about 77% of cases. Tracheal and lung cancers make up much of the remainder (1). TEFs can occur in 5–15% of untreated esophageal cancer cases with further progression after treatment with radiation and/or chemotherapy. The development of fistulas is more uncommon in lung cancer, occurring less than 1% of the time. Left untreated, sepsis from aspiration is inevitable and often fatal. Overall prognosis of these patients is very poor with less than a year at the diagnosis of a TEF (6). Surgical approaches carry high complication rate (40%) and mortality (14%) (7). The recent focus has been therefore on less invasive treatment approaches. There is emerging evidence that treatment of TEF can improve survival (8), which makes an understanding of the available treatment options of even more importance beyond just a palliation of symptoms.

Rationale and knowledge gap

With the ever-evolving landscape of endoscopic therapies, more patients opt for less invasive treatment options for TEFs, especially if any prohibitive conditions for surgery are present. Esophageal self-expanding metallic (SEM) stents have been the mainstay and most reported of the non-surgical options. However, more novel approaches have been increasingly reported. As the response to therapy influences prognosis, a review of the available options and outcomes allows physicians to provide the best options for their patients. There are many developing therapies that use already commercially available products that endoscopists may be able to use in the appropriate clinical settings.

Objective

This article aims to summarize the endoscopic approaches to management of both benign and malignancy related TEFs as reported in the literature. We present this article in accordance with the Narrative Review reporting checklist (available at https://med.amegroups.com/article/view/10.21037/med-24-45/rc).

Methods

A literature review was conducted in the National Institute of Health’s PubMed database in July 2024. The search strategy is summarized in the Table 1. Only studies published in English with abstracts available were included. Over 2,700 articles were found. The first 800 abstracts returned for “tracheoesophageal fistula” were reviewed and used to guide more detailed searches including: (“tracheoesophageal fistula” AND stent), (“tracheoesophageal fistula” AND suture), (“tracheoesophageal fistula” AND occlude*), (“tracheoesophageal fistula” AND atrial), (“tracheoesophageal fistula” AND ventricular), (“tracheoesophageal fistula” AND glue), (“tracheoesophageal fistula” AND fibrin), (“tracheoesophageal fistula” AND histoacryl), (“tracheoesophageal fistula” AND cyanoacryl), (“tracheoesophageal fistula” AND alcohol), (“tracheoesophageal fistula” AND bioprosthe*), (“tracheoesophageal fistula” AND tissue), (“tracheoesophageal fistula” AND matrix), and (“tracheoesophageal fistula” AND platelet). References from returned articles were also reviewed for additional relevant publications. Total of 57 publications were considered relevant, and their full text was studied to collate information for this review. Thirty-four of those, in the format of scientific studies, case series, and case reports are summarized in Table 2.

Endoscopic management of TEFs

General considerations

Patients with either malignant or benign fistulas are often in their overall poor health due to malnutrition, ongoing infection, and their primary condition making surgical management and post-operative care challenging. A multidisciplinary discussion among aerodigestive specialists and involvement of palliative care team is desired during the management of these patients. A computed tomography (CT) of a neck or a chest is commonly used during initial evaluation of patients. The diagnosis of a fistula should be confirmed by barium esophagram, or direct endoscopic inspection by esophagogastroduodenoscopy (EGD) or bronchoscopy to determine the suitable management. Location and length of TEF with its distance from the carina and larynx, presence of esophageal obstruction and airway compromise are important attributes to be evaluated. If critical airway obstruction is present, a therapeutic bronchoscopy with recanalization and stent placement should be followed by esophageal stent placement. In those with poor nutrition status an alternative way of enteral and parenteral nutrition should be considered (Figure 1).

Figure 1 Proposed algorithm for management of tracheo-esophageal fistulas regardless of their etiology. CT, computed tomography; TEF, tracheoesophageal fistula.

Esophageal stenting

Esophageal stent placement has been used in both benign and malignancy related fistulas. Many TEFs located within the mid-to-distal trachea or bronchial airways can often be managed by esophageal stenting alone. Endoscopic treatment of malignant disease with SEM stents has become the mainstay in treating these patients (Figure 1). The stents are typically placed under fluoroscopic guidance often with the use of radiopaque makers to identify landmarks as well as the lesion. A guidewire is deployed under endoscopic guidance and fluoroscopy is used for stent positioning and deployment. The stent is ideally sized to extend one to two centimeters beyond the fistula (9). When the fistulas are located too high in the first third of the esophagus or contain gastric mucosa (post-esophagectomy) esophageal stenting may not be feasible. In one of the largest comparative studies by Chen et al., 86 patients with malignancy related TEFs were followed; 30 patients received esophageal metallic stent (five of which also received a tracheal stent) and 35 patients received gastrostomy or jejunostomy tubes. Overall survival was 145 days in patients receiving stents, compared to 77 days in those without stenting (8). In a retrospective review of 288 patients with malignancy related TEFs (194 patients having received stents compared to the 94 without), patients who received stents showed improvements in performance scores, pulmonary infections and fistula closure compared to those patients receiving conservative therapy (9). Esophageal stenting has also been compared to esophageal bypass surgery in a propensity matched analysis (10). This study showed a decrease in respiratory complications, length of stay, and time to antineoplastic therapies in the stenting group. Esophageal stents have also been placed after chemoradiotherapy with success in palliating symptoms; however, patients with T4 tumors involving vascular invasion receiving stenting had an increased risk of fatal hemorrhage (11). Complications of esophageal stent placement can include esophageal perforation, propagation of existing TEF, development of TEF, hemorrhage, tracheal compression, stent migration, worsening reflux, granulation tissue growth into stent and chest pain (11,15). Esophageal stents have also been assessed in TEFs of benign etiologies. Debordeau et al. performed a retrospective analysis of 22 patients who received endoscopic therapy. Fourteen patients had stent placement, seven had stent and over-the-scope clipping, and one had clipping only. Successful closure was seen in 45.5% of cases within 6 months. Ten patients had failure of fistula closure including six patients who died during follow-up (12). Studies looking at both benign and malignant causes of TEFs showed similar technical and clinical success rates (42). Proximal fistulas showed lower rates of both technical and clinical success (42,43). Despite its challenges, esophageal stenting remains an attractive minimally invasive therapeutic option as it decreases symptoms, complications, and likely improve overall survival in both benign and malignant etiologies.

Airway stents and dual stenting

Esophageal stenting alone is generally preferred over airway stenting alone, as the morphology of esophagus often allows for a better seal of the fistula and carries less risk of airway obstruction. Nonetheless, airway stenting is needed in cases of malignant airway obstruction, predicted airway compromise by esophageal stenting or in cases with inability to adequately seal the fistula from an esophageal approach. Figure 2A-2E and Figure 2F-2J represent two cases of malignant airway obstruction and TEF. Both patients were treated with dual stenting. See the figure legend for the details of the cases. Direct visualization during bronchoscopy helps with selection and sizing of a stent. SEM stents conform to airway shape better provide better seal of TEF. Silicone stents have studs on their surface allowing for better secretion clearance and preventing migration. On the other hand, those studs may stand in the way of a proper sealing. Both stent types come in tubular and Y shape, in different sizes, and with different types of deployment mechanisms. Deployment of silicone stents requires rigid bronchoscopy. SEM stent can be deployed over the guidewire or through the working channel of a flexible bronchoscope. There are no comparative studies of different types of airway stents for TEFs and therefore general stenting principles apply:

• Stent should ideally extent 2 cm proximal and distal to TEF or to extrinsic compression allowing for a good seal and providing sufficient airway stability.
• Minimal required amount of airway mucosa should be covered by a stent to allow proper mucosal clearance.
• Y shaped stents (SEM or silicone) should be reserved for lesions/obstructions involving or close to a main carina.
• Oversizing of a stent for more than 20% of airway lumen should be avoided to prevent propagation of a fistulous tract 5. The individual qualities of different stents should be considered.

Figure 2 Two case reports of dual stenting for TEF with a quality control evaluation. Case 1 top row—(A) CT of the chest with a malignant trachea-esophageal (blue arrow) and tracheo-mediastinal (red arrow) fistulas. (B) Endoscopic image with nasogastric tube in place and visible TEF (blue arrow). (C) Bronchoscopic image with visible TEF (blue arrow) and treacheo-mediastinal fistula (red arrow). (D) Fluoroscopy image post stents placement. (E) Quality control CT chest with visible fully covered metallic stent size 16 mm × 60 mm in the proximal trachea and fully covered 16 mm × 120 mm metallic stent in the proximal esophagus. Case 2 lower row—(F) CT chest with a malignant trachea-esophageal fistula located 1.5 cm from the carina (blue arrow) and narrowing of the distal trachea. (G) Bronchoscopic image and visible TEF (blue arrow). (H) Endoscopic image with visible silicone Y stent providing incomplete seal of the fistulous tract. (I) Quality control CT chest with silicone Y stent size 16–13–13 mm in the trachea and fully covered stent size 23 mm × 120 mm in the esophagus. (J) Quality control esophagram showing a contrast passing distally through the esophageal stent (green arrow). CT, computed tomography; TEF, tracheoesophageal fistula.

Similar to esophageal stents, airway stents can be deployed with the assistance of guidewire and fluoroscopy. Stent deployment under direct visualization via rigid bronchoscopy or through the working channel of a flexible bronchoscope allows for a better positioning as well as prevents complications related to inappropriate deployment (e.g., into fistulous tract). In a case-control study, 59 patients with TEF due to esophageal cancer were studied, including 31 patients who received tracheal SEM stent for malignancy related TEFs. Airway stenting [adjusted odds ratio (OR) =5.2], performance status (adjusted OR =6.1), and further treatment (adjusted OR =8.7) positively impacted the survival (13). A retrospective study that examined the utility of SEM stents for both central airway obstruction and TEFs secondary to malignancy showed that half of the 24 TEF patients had symptomatic improvement with a 3-month survival rate of 45.8% (14). Further innovative approaches continue to be seen. In one case report, a Y shaped SEM stent was threaded over a three-dimensional (3-D) printed model of the airway and was customized to the patient’s airway (44).

Combining esophageal and airway stents has traditionally been avoided because of the theoretical risk of developing new TEF or propagating the existing one. Three studies compared outcomes between tracheal stent alone vs. dual stenting and all showed better symptomatic response and better survival in groups with both stents (15-17). On the other hand, in a single center retrospective analysis of 216 patients with malignant esophageal obstruction managed by endoscopic stenting, 15 patients experienced fatal hematemesis. The mean time to massive bleeding was 16.9 after esophageal stent insertion. The presence of TEF (OR =9.1) and concomitant tracheal stent (OR, 7.9) were found to be two statistically significant risk factors associated with the hemorrhage (13). Khan et al. described the use of combined airway and esophageal stenting in a prospective study of 29 patients with esophageal cancer and airway involvement, including five patients with TEF present. Authors reported symptomatic improvement in all patients and did not report major hemorrhage or developing or propagating of TEFs in the 4-year study period (18). Another single center retrospective review of 35 patients receiving combined stenting for malignant tracheoesophageal disease including fistulas and stenosis demonstrated symptom improvement without the development of de novo fistulas at the stenting sites. Restenosis (7.7%) and stent migration (2.6%) were the most common complications of the airway stents. Airway compression with esophageal stent being placed prior to an airway stent (7%) and stent migrations (7%) were the most common complication of the esophageal stenting (19). In a novel case report, self-made twin magnetic stents were inserted via a tracheostomy. The magnets were used to fix both airway and esophageal stents to each other through the benign TEF opening to prevent migration. The patient was able to start oral nutrition, and the stents remained in place for 14 months as a bridge to surgical intervention (45).

Endoscopic suturing and clipping

Used initially for the treatment or prevention of post-procedural bleeding and defects, endoscopic suturing and clipping have also been used for the treatment of TEFs. These devices are either deployed over the scope or through the working channel of an endoscope. They have commonly been reported as part of a multi-modal approach to fistula management. Jin et al. reviewed 20 patients with fistulas of aerodigestive tract, including 12 with TEFs. Seven of those failed the previous therapy with an esophageal stent. All patients had a closure attempted via endoscopic suturing and received additional argon plasma coagulation. Half of the patients received additional clipping and two of them additional esophageal stent. The immediate endoscopic success for fistula closure was 100%, but sustained fistula closure at 3 months was seen in only 25% of patients. TEFs had shorter time to dehiscence than other fistula etiologies [hazard ratio (HR) =3.378] (20). Mahmoud et al. described over the scope suture placement in eight patients with benign TEFs; however, only two patients had successful fistula closure. Both patients with successful closure had also received subsequent SEM stents (21). In a larger retrospective review of endoscopic clipping over a half of 388 patients with TEFs had successful closure at one month (22). Two case series reported similar sustainability despite high technical success at the initial placement (23,24). It has been theorized that denudement or resection of the fistula’s mucosa may improve clinical success (46), as the necrotic and inflamed tissue at the site likely contributes to failure. Overall, minimal complications or adverse events have been reported with suturing and clipping techniques making it a safe approach. Complications may include pain, bleeding at the clipping/suturing site, luminal stenosis, and micro-perforation and are mild in nature (21,22). These techniques also do not have the same associations with development or worsening of fistulas, which may make them an attractive initial management approach. Endoscopic suturing for fixation has been shown to have an important utility in preventing esophageal stent migration. In a retrospective study of 125 patients who had fully covered SEM stent placed, stent migration was reduced from 33% to 16% after endoscopic suturing, including patients who had prior episodes of stent migration (47).

Occluding devices

Another more recent approach to TEF management includes the off-label use of occluding devices, namely cardiac septal defect occluders such as the Amplatzer^® device (Abbott Laboratories, Chicago, IL, USA). These devices have two self-expanding umbrellas connected by a smaller waist that traverses a fistula. The left atrial/ventricular umbrella is larger in diameter than the right one and should therefore cover the esophageal site to avoid unnecessary airway narrowing. A guidewire is deployed across the fistula, either from the trachea or the esophagus, and then used to deploy the sheath (Figure 3). The occluder can then be deployed under direct visualization and fluoroscopy. Rabenstein et al. first reported the use of ventricular septal defect using bronchoscopy and esophagoscopy (25). Since then, there have been other case reports of successful deployment of these devices (atrial or ventricular) with improvement in symptoms and successful healing of the fistulas (26). They have also been deployed successfully in chronically ventilated patients (27,28). 3-D CT with holographic assessment has been used to aid in appropriate sizing of the device (42). Dislodgement and migration of an occluder into the airway after epithelization of a fistula seems like the most common complication and patient can present with severe airway obstruction (25,48,49). Buitrago et al. reported a case of fatal hemoptysis one month after the occluder placement (50). The use of cardiac septal defect occluders should be used with caution and close follow-up of the patients is strongly warranted. It seems prudent to remove the septal occluder once there is epithelization of the umbrella and closure of the fistula is achieved to prevent potential complications. Other similar approaches have been described using nasal septal buttons (30) and also a novel dumb-bell shaped occluder (31).

Figure 3 A case of benign TEF caused by endotracheal tube cuff overinflation, managed with an ASD occluder size 23–10–18 mm. (A) CT of the chest with dilated trachea and visible TEF fistula (blue arrow). (B) Endoscopic view from the esophagus with visible TEF (blue arrow). (C) Bronchoscopic view (left) and endoscopic view (right) during placement of the ASD occluder. (D) Endoscopic view post ASD occlude placement. (E) T-tube stent placed on top of the ASD occluder device causing minimal airway lumen compromise (case report and images are courtesy of Dr. Eugene Shostak). ASD, atrial septal device; CT, computed tomography; TEF, tracheoesophageal fistula.

Tissue adhesives

Application of tissue adhesives to TEFs via endoscopic catheter has been reported with general success in pediatric patients (51). Fibrin sealant (e.g., Tisseel^®, Baxter, Deerfield, IL, USA) and cyanoacrylate glues (e.g., Histoacryl^®, B. Braun, Melsungen, Germany) have both been used. Fewer cases have been reported in adults, but both bronchoscopic and endoscopic approaches have been used. Depending on the characteristics of the fistula, a bronchoscopic approach has sometimes been preferred to prevent leakage of glue into the airway (32). These agents can also be used to treat very proximal lesions where stent placement may be difficult (33). A series of nine cases described endoscopic application of fibrin glue in combination with Vicryl mesh for larger upper gastrointestinal post-surgical leaks and fistulas. Two patients had TEF, one patient showed complete healing of the bronchoesophageal fistula after two applications, while the other had persistent TEF (34). Successful gluing has also been described in a mechanically ventilated patient who was high risk for surgical intervention (35). The broad availability and tolerability may make this a reasonable approach for small fistulas or in patients with contraindications to more invasive therapies.

Alcohol ablation

A combination of silver nitrate and dehydrated alcohol has been described to treat a group of seven patients with small (<5 millimeter) bronchopleural or TEFs, two of whom had TEFs secondary to radiation therapy. Silver nitrate was brushed over the site followed by an injection of dehydrated alcohol (approximately 0.25–0.5 mL per injection) around the fistula. Four patients required multiple ablations. One TEF had resolution while another had persistent fistula requiring an airway stent. All of the bronchopleural fistulas resolved (36). While widely available, more TEF specific efficacy data is needed before broader application of this technique.

Platelet rich plasma

Autologous platelet-rich plasma (PRP) has been used to promote wound healing in many medical conditions. The patient’s own blood is centrifuged to create the PRP and is injected submucosally around a fistulous tract. In a report of two cases of persistent TEFs after laryngectomy that failed both conservative and surgical approaches, PRP was injected in two to three sessions. Both patients had complete resolution of their fistulas on methylene blue dye tests within 3 weeks (37). An endoscopic approach has also been reported in a patient with TEF and esophageal stenosis after resection for cancer. This patient was first treated with PRP injection, a coated metal stent, acid suppression, and antibiotics. On one month follow-up, the fistula had improved, but the stent was removed due to a foreign body sensation. The patient received two subsequent injections and had a completely healed fistula with resolution of symptoms in 3 months (38). A bronchoscopic approach has been described in 3 patients with bronchopleural fistula after lobectomy. Each patient received between two and six PRP injections with one patient also requiring a membrane covered stent in the trachea. The fistulas resolved within 15 to 18 weeks on follow-up (39). Although promising case reports, further research is required before this treatment approach is used more frequently and its utility may be limited to small defects.

Bioprosthetics

The use of bioprosthetic materials such as acellular tissue matrix (e.g., Alloderm^®, AbbVie, Branchburg, NJ, USA) and aortic homograph for TEFs have largely been described in surgical contexts (52-54). Endoscopic applications have been less frequently described. In 2018, Mahajan et al. reported a 66-year-old female with history of histoplasmosis capsulatum infection with a calcified subcarinal node and an associated obstructing polyp of the right mainstem bronchus (40). One year after excision of her polyp, she returned with symptoms from a 2 cm defect along the medial wall of her right mainstem. She was initially treated with Dumon^TM silicone Y stent (Boston Medical Products, Shrewsbury, MA, USA) and a fully covered metallic esophageal stent. On 8-week follow-up, the fistula was improved but persistent. A bronchoscope was passed around the Y stent to placed four sheets of ACell^® (ACell Inc., Columbia, MD, USA) decellularized porcine urinary bladder matrix at the site using forceps. Ten days later, there was complete resolution of the TEF on surveillance bronchoscopy followed by removal of both stents one week later. She had continued resolution on follow-up at 10 months. An esophageal approach has also been described in a neonate with recurrent anastomotic stricture after esophageal atresia repair with strips of urinary bladder matrix sutured to the outside of an esophageal stent (41). Research on other substrates such as polymeric scaffolds made from natural and synthetic materials is underway (55). Their use may be appealing for larger defects and areas that are difficult to stent.

Quality control and follow-up

If persistent and clinically significant leak is suspected despite the initial treatment, repeat imaging with thin-slice CT or contrast esophagograms are preferred methods over an endoscopic evaluation. Small residual TEFs and inadequate seal can be difficult to visualize during endoscopic examination due to mucosal edema caused by presence of a foreign body or previous instrumentation. Stent revision is the next step when the persistent leak is confirmed. Alternative forms of feeding and comfort care measures only should be considered for chronic inoperable fistulas which failed the endoscopic management. Bronchoscopic airway stent revision to detect common stent related complications such as mucus plugging, tumor ingrowth, granulation tissue is usually recommended at 4–6 weeks after the insertion (56) while minding the overall clinical status of a patient.

Discussion

TEFs are a highly morbid condition with complex presentations that require variable approaches. Esophageal stenting with SEM stent is often able to be used alone as the initial endoscopic approach for both benign and malignancy associated fistulas. Smaller fistulas can be considered for more local therapies instead, such as sealant, platelet rich plasma or alcohol ablation. If central airway obstruction is present, airway or dual stenting might be the best first step. If fistula control is not achieved with esopahgeal stent and stent revision, additional airway stent, occluder device or palliation can be discussed based on the patient’s case and their needs.

The literature review of the endoscopic management of TEFs consists of small studies, case series often form single centers, case reports and experts’ opinions. This is likely further limited by a publication bias of only successful techniques especially amongst case reports. Large randomized studies comparing different methods are lacking. Our review was also limited to English articles. A thorough search was performed but additional reports in other databases may be present. The scope of our article was limited to an endoscopists’ perspective and does not include surgical techniques or such unique circumstances as post-laryngectomy fistulas. Although unable to confidently add a level of recommendation to the individual endoscopic techniques the narrative review provides a solid base for designing the future research in this area.

Conclusions

TEF possesses therapeutic challenges whether they are of malignant or benign origin. As this process is often accompanied by poor nutrition, recurrent infections and declining functional status, alternatives to surgery are an important consideration in management. A multidisciplinary approach weighing in surgical, endoscopic, and palliative options is often lacking but when present, is an important part of developing management plans for these complex patients. The early involvement of the appropriate aerodigestive and palliative specialists as the local resources allow helps with the complexity of these patients. Despite emerging new endoscopic techniques esophageal stenting alone remains the first-line treatment for endoscopic management of TEFs. Airway stenting is reserved for selected conditions of an inadequate fistula sealing or when a malignant or iatrogenic airway obstruction is present. Other non-standard approaches and off-label use of different devices should be used with caution and after thorough discussion with a patient and their family.

There is still much that is not understood about the management of TEFs with many opportunities for further research. More rigorous comparative studies would lead to better understanding of the techniques with the best outcomes and are an important step in future studies. New innovation in devices would help to improve closure of fistulas, ease of placement and decrease the complication rate. As the science of tissue scaffolding and other biological interventions improves, this approach also could offer a more enduring response with fewer complications. While uncommon, the life threatening and debilitating nature of TEFs make them an important focus of future study.

Acknowledgments

Authors would like to thank Eugene Shostak, MD, for providing a case report for the Figure 3.

Footnote

Reporting Checklist: The authors have completed the Narrative Review reporting checklist. Available at https://med.amegroups.com/article/view/10.21037/med-24-45/rc

Peer Review File: Available at https://med.amegroups.com/article/view/10.21037/med-24-45/prf

Funding: None.

Conflicts of Interest: All authors have completed the ICMJE uniform disclosure form (available at https://med.amegroups.com/article/view/10.21037/med-24-45/coif). Michal Senitko has served as scientific consultant for Intuitive Inc. and GE Healthcare Inc. Meredith Sloan reports support from University of Mississippi Medical Center for travel to APCCMPD meeting for faculty development. The other author has no conflicts of interest to declare.

Ethical Statement: The authors are accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. All clinical procedures described in this study were in accordance with the ethical standards of the institutional and/or national research committee(s) and with the Helsinki Declaration (as revised in 2013). Written informed consent for publication of this article and accompanying images was not obtained from the patients or the relatives after all reasonable attempts were made.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

1. Rodriguez AN, Diaz-Jimenez JP. Malignant respiratory-digestive fistulas. Curr Opin Pulm Med 2010;16:329-33. [Crossref] [PubMed]
2. Gudovsky LM, Koroleva NS, Biryukov YB, et al. Tracheoesophageal fistulas. Ann Thorac Surg 1993;55:868-75. [Crossref] [PubMed]
3. Qureshi YA, Muntzer Mughal M, Fragkos KC, et al. Acquired Adult Aerodigestive Fistula: Classification and Management. J Gastrointest Surg 2018;22:1785-94. [Crossref] [PubMed]
4. Mohamed AA, Lu XL, Mounmin FA. Diagnosis and Treatment of Esophageal Candidiasis: Current Updates. Can J Gastroenterol Hepatol 2019;2019:3585136. [Crossref] [PubMed]
5. Muniappan A, Wain JC, Wright CD, et al. Surgical treatment of nonmalignant tracheoesophageal fistula: a thirty-five year experience. Ann Thorac Surg 2013;95:1141-6. [Crossref] [PubMed]
6. Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 2008;34:1103-7. [Crossref] [PubMed]
7. Davydov M, Stilidi I, Bokhyan V, et al. Surgical treatment of esophageal carcinoma complicated by fistulas. Eur J Cardiothorac Surg 2001;20:405-8. [Crossref] [PubMed]
8. Chen YH, Li SH, Chiu YC, et al. Comparative study of esophageal stent and feeding gastrostomy/jejunostomy for tracheoesophageal fistula caused by esophageal squamous cell carcinoma. PLoS One 2012;7:e42766. [Crossref] [PubMed]
9. Wang QX, Duan ZH, Liu SQ, et al. Efficacy of stent placement in treatment of malignant tracheoesophageal fistula and relevant factors of fistula closure. Zhonghua Yi Xue Za Zhi 2023;103:111-6. [PubMed]
10. Yamamoto Y, Kitazawa M, Otsubu T, et al. Comparison of short-term outcomes between esopahgeal bypass surgery and self-expanding stent insertion in esophageal cancer: a propensity score matched analysis using a large-scale inpatient database. Surg Laparosc Endosc Percutan Tech 2023;33:395-401. [Crossref] [PubMed]
11. Sumiyoshi T, Gotoda T, Muro K, et al. Morbidity and mortality after self-expandable metallic stent placement in patients with progressive or recurrent esophageal cancer after chemoradiatherapy. Gastrointest Endosc 2003;57:882-5. [Crossref] [PubMed]
12. Debourdeau A, Gonzalez JM, Dutau H, et al. Endoscopic treatment of nonmalignant tracheoesophageal and bronchoesophageal fistula: results and prognostic factors for its success. Surg Endosc 2019;33:549-56. [Crossref] [PubMed]
13. Chung FT, Lin HC, Chou CL, et al. Airway ultraflex stenting in esophageal cancer with esophagorespiratory fistula. Am J Med Sci 2012;344:105-9. [Crossref] [PubMed]
14. Bai Y, Zhan K, Chi J, et al. Self-Expandable Metal Stent in the Management of Malignant Airway Disorders. Front Med (Lausanne) 2022;9:902488. [Crossref] [PubMed]
15. Freitag L, Tekolf E, Steveling H, et al. Management of malignant esophagotracheal fistulas with airway stenting and double stenting. Chest 1996;110:1155-60. [Crossref] [PubMed]
16. Herth FJ, Peter S, Baty F, et al. Combined airway and oesophageal stenting in malignant airway-oesophageal fistulas: a prospective study. Eur Respir J 2010;36:1370-4. [Crossref] [PubMed]
17. Ke M, Wu X, Zeng J. The treatment strategy for tracheoesophageal fistula. J Thorac Dis 2015;7:S389-97. [PubMed]
18. Khan A, Hashim Z, Neyaz Z, et al. Dual Airway and Esophageal Stenting in Advanced Esophageal Cancer With Lesions Near Carina. J Bronchology Interv Pulmonol 2020;27:286-93. [Crossref] [PubMed]
19. Bi Y, Ren J, Chen H, et al. Combined airway and esophageal stents implantation for malignant tracheobronchial and esophageal disease: A STROBEcompliant article. Medicine (Baltimore) 2019;98:e14169. [Crossref] [PubMed]
20. Jin D, Xu M, Huang K, et al. The efficacy and long-term outcomes of endoscopic full-thickness suturing for chronic gastrointestinal fistulas with an Overstitch device: is it a durable closure? Surg Endosc 2022;36:1347-54. [Crossref] [PubMed]
21. Mahmoud T, Wong Kee Song LM, Stavropoulos SN, et al. Initial multicenter experience using a novel endoscopic tack and suture system for challenging GI defect closure and stent fixation (with video). Gastrointest Endosc 2022;95:373-82. [Crossref] [PubMed]
22. Kobara H, Mori H, Nishiyama N, et al. Over-thescope clip system: A review of 1517 cases over 9 years. J Gastroenterol Hepatol 2019;34:22-30. [Crossref] [PubMed]
23. Haito-Chavez Y, Law JK, Kratt T, et al. International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video). Gastrointest Endosc 2014;80:610-22. [Crossref] [PubMed]
24. Law R, Wong Kee Song LM, Irani S, et al. Immediate technical and delayed clinical outcome of fistula closure using an over-the-scope clip device. Surg Endosc 2015;29:1781-6. [Crossref] [PubMed]
25. Rabenstein T, Boosfeld C, Henrich R, et al. First use of ventricular septal defect occlusion device for endoscopic closure of an esophagorespiratory fistula using bronchoscopy and esophagoscopy. Chest 2006;130:906-9. [Crossref] [PubMed]
26. Jiang P, Liu J, Yu D, et al. Closure of Nonmalignant Tracheoesophageal Fistula Using an Atrial Septal Defect Occluder: Case Report and Review of the Literature. Cardiovasc Intervent Radiol 2015;38:1635-9. [Crossref] [PubMed]
27. Cohen-Atsmoni S, Tamir A, Avni Y, et al. Endoscopic Occlusion of Tracheoesophageal Fistula in Ventilated Patients Using an Amplatzer Septal Occluder. Indian J Otolaryngol Head Neck Surg 2015;67:196-9. [Crossref] [PubMed]
28. Traina M, Amata M, De Monte L, et al. Chronic tracheoesophageal fistula successfully treated using Amplatzer septal occluder. Endoscopy 2018;50:1236-7. [Crossref] [PubMed]
29. Siboni S, D'Aiello AF, Chessa M, et al. Tailored endoscopic treatment of tracheo-oesophageal fistula using preoperative holographic assessment and a cardiac septal occluder. BMJ Case Rep 2022;15:e248981. [Crossref] [PubMed]
30. Bawaadam HS, Russell M, Gesthalter YB. Acquired Benign Tracheoesophageal Fistula: Novel Use of a Nasal Septal Occluder. J Bronchology Interv Pulmonol 2022;29:e38-43. [Crossref] [PubMed]
31. Zhu C, Li L, Wang Y, et al. Endoscopic closure of tracheoesophageal fistula with a novel dumbbell-shaped occluder. Endoscopy 2022;54:E334-5. [Crossref] [PubMed]
32. Sharma M, Somani P, Sunkara T, et al. Trans-Tracheal Cyanoacrylate Glue Injection for the Management of Malignant Tracheoesophageal Fistula. Am J Gastroenterol 2018;113:800. [Crossref] [PubMed]
33. Goh PM, Kum CK, Toh EH. Endoscopic patch closure of malignant esophagotracheal fistula using Histoacryl glue. Surg Endosc 1994;8:1434-5. [Crossref] [PubMed]
34. Truong S, Böhm G, Klinge U, et al. Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue. Surg Endosc 2004;18:1105-8. [Crossref] [PubMed]
35. Scappaticci E, Ardissone F, Baldi S, et al. Closure of an iatrogenic tracheo-esophageal fistula with bronchoscopic gluing in a mechanically ventilated adult patient. Ann Thorac Surg 2004;77:328-9. [Crossref] [PubMed]
36. Finley D, Krimsky W, Au J, et al. Bronchoscopic Treatment of Bronchopleural and Tracheoesophageal Fistulas Using Silver Nitrate and Dehydrated Alcohol. Chest 2011;140:833A. [Crossref]
37. Damien M, Leclercq C, Steffens Y, et al. Platelet-Rich Plasma, an Innovative and Noninvasive Technique for Closure of Tracheoesophageal Fistula After Laryngectomy, Report of 2 Cases. Ear Nose Throat J 2022; Epub ahead of print. [Crossref] [PubMed]
38. Han J, Yue L, Jia W, et al. Local injection of platelet-rich plasma offers a new therapeutic option for the treatment of esophagotracheal fistula: a case report. J Int Med Res 2024;52:3000605231220874. [Crossref] [PubMed]
39. Wu M, Lin H, Shi L, et al. Bronchoscopic Treatment of Tracheobronchial Fistula With Autologous Platelet-Rich Plasma. Ann Thorac Surg 2021;111:e129-31. [Crossref] [PubMed]
40. Mahajan AK, Newkirk M, Rosner C, et al. Successful endobronchial treatment of a non-healing tracheoesophageal fistula from a previous histoplasmosis capsulatum infection using decellularized porcine urinary bladder matrix†. J Surg Case Rep 2018;2018:rjy187. [Crossref] [PubMed]
41. Cairo SB, Tabak B, Harmon CM, et al. Novel use of porcine extracellular matrix in recurrent stricture following repair of tracheoesophageal fistula. Pediatr Surg Int 2017;33:1027-33. [Crossref] [PubMed]
42. Silon B, Siddiqui AA, Taylor LJ, et al. Endoscopic Management of Esophagorespiratory Fistulas: A Multicenter Retrospective Study of Techniques and Outcomes. Dig Dis Sci 2017;62:424-31. [Crossref] [PubMed]
43. Verschuur EM, Kuipers EJ, Siersema PD. Esophageal stents for malignant strictures close to the upper esophageal sphincter. Gastrointest Endosc 2007;66:1082-90. [Crossref] [PubMed]
44. Han Y, Yang S, Huang W, et al. A Hem-o-Lok-Induced Tracheoesophageal Fistula Cured by Temporary Airway Stenting Modified With Three-Dimensional Printing. Ann Thorac Surg 2018;106:e219-21. [Crossref] [PubMed]
45. Altorjay Á, Rüll M, Sárkány Á. Magnetic Twin Stent for Short-Term Palliation of Acquired Nonmalignant Tracheoesophageal Fistula. Ann Thorac Surg 2017;104:e211-3. [Crossref] [PubMed]
46. Pang M, Mousa O, Werlang M, et al. A hybrid endoscopic technique to close tracheoesophageal fistula. VideoGIE 2018;3:15-6. [Crossref] [PubMed]
47. Ngamruengphong S, Sharaiha RZ, Sethi A, et al. Endoscopic suturing for the prevention of stent migration in benign upper gastrointestinal conditions: a comparative multicenter study. Endoscopy 2016;48:802-8. [Crossref] [PubMed]
48. Miller PE, Arias S, Lee H, et al. Complications associated with the use of the amplatzer device for the management of tracheoesophageal fistula. Ann Am Thorac Soc 2014;11:1507-9. [Crossref] [PubMed]
49. Coppola F, Boccuzzi G, Rossi G, et al. Cardiac septal umbrella for closure of a tracheoesophageal fistula. Endoscopy 2010;42:E318-9. [Crossref] [PubMed]
50. Buitrago DH, Pinto D, Berkowitz SJ, et al. Fatal Hemoptysis After Closure of Gastrobronchial Fistula Using an Amplatzer Vascular Device. Ann Thorac Surg 2018;105:e71-3. [Crossref] [PubMed]
51. Richter GT, Ryckman F, Brown RL, et al. Endoscopic management of recurrent tracheoesophageal fistula. J Pediatr Surg 2008;43:238-45. [Crossref] [PubMed]
52. Udelsman BV, Eaton J, Muniappan A, et al. Repair of large airway defects with bioprosthetic materials. J Thorac Cardiovasc Surg 2016;152:1388-97. [Crossref] [PubMed]
53. Su JW, Mason DP, Murthy SC, et al. Closure of a large tracheoesophageal fistula using AlloDerm. J Thorac Cardiovasc Surg 2008;135:706-7. [Crossref] [PubMed]
54. Bhat W, Wiper J, Liddington M. Acellular dermal matrix for the treatment of a persistent tracheoesophegeal fistula. J Plast Reconstr Aesthet Surg 2015;68:e37-8. [Crossref] [PubMed]
55. Kuppan P, Sethuraman S, Krishnan UM. Tissue engineering interventions for esophageal disorders-- promises and challenges. Biotechnol Adv 2012;30:1481-92. [Crossref] [PubMed]
56. Lee HJ, Labaki W, Yu DH, et al. Airway stent complications: the role of follow-up bronchoscopy as a surveillance method. J Thorac Dis 2017;9:4651-9. [Crossref] [PubMed]