Sealing the Breach: A Surgical Solution for Tracheoesophageal Fistula With a Simple Two-Layer Closure.

Tracheoesophageal puncture (TEP) followed by voice prosthesis placement stands as the primary method for voice rehabilitation after laryngectomy, heralded for its effectiveness. While generally well-tolerated, the procedure does pose potential long-term complications. These include prosthesis valve leakage, scarring, and prosthesis displacement, all of which can impede phonation capabilities. Of these, prosthesis leakage emerges as the most critical concern, precipitated by the progressive widening of the fistula. This complication can precipitate aspiration pneumonitis, stemming from the loss of physical separation between the esophagus and trachea. This case series details three instances where persistent tracheoesophageal fistula arose following TEP, necessitating surgical intervention. Herein, we present the clinical manifestations, surgical approach employing a simple two-layer closure, and ensuing outcomes.

Airway stent intervention in a high-volume center: safe procedures and educational perspectives.

Background: Airway intervention, including stenting, can rapidly improve a patient's respiratory condition, but the procedure requires highly specialized techniques and expertise. Therefore, educating young endoscopists and passing on the techniques are major issues. However, the best way to educate new doctors on these techniques remains unclear. This study analyzed our educational system for airway intervention and its outcomes. Methods: Patients who underwent airway intervention regarding airway stents under general anesthesia in our department between January 2010 and September 2023 were included. The outcomes of interventions related to airway stents in our hospital were evaluated retrospectively, including from an educational perspective. Results: A total of 96 patients (76 undergoing stenting for airway stenosis, 8 stenting for airway-esophageal fistula, and 12 stent removal) were analyzed. The median experience level of the main physician was 5 (range, 1-17) years, and that of the supervising physician was 18 (range, 5-23) years. The median number of physicians who participated in the interventions was four. A rigid bronchoscope was used in 86.5% of cases. The procedure success rate was 95.8%. Intraoperative complications occurred in 8.3% and postoperative complications in 10.5% of cases, and there was 1 procedure-related death (1.3%). In the analysis of factors related to the development of complications, the years of experience of the main physician had no influence. Conclusions: These findings indicate that our method of airway intervention is safe. Young endoscopists were able to master the technique by gaining experience under the supervision of experts.

Pediatric vascular ring outcomes for surgically repaired vs. unoperated children: a single-center experience.

Background: Vascular rings represent 1% of congenital cardiovascular abnormalities. Phenotypic expression varies from asymptomatic to severe forms related to either oesophageal or tracheal compression. While refinement in prenatal screening led to an increase in fetal diagnosis, optimal management in asymptomatic neonates and infants is currently a matter of debate. We report our center experience of vascular ring management over three decades. Methods: In this single-center retrospective study, data were extracted from patient medical records. To obtain information on symptoms/medication at follow-up, clinical records from pediatric clinics were reviewed. For patients followed in other institutions, a web-based questionnaire was sent to referring pediatricians. Results: Out of 82 patients, 69 were symptomatic (84%). Common symptoms included recurrent respiratory tract infections (43%), stridor (32%), gastro-esophageal reflux (33%), and dysphagia (26%). Diagnosis relied on cardiac ultrasound, barium swallow studies, and chest computerized tomography scan. Surgical repair (thoracotomy 91%) was performed in 79 patients (96%). Median age at repair was 13 [interquartile range (IQR), 4.4-48] months. There was no mortality. Minor complications occurred in 14 patients (18%). Median hospital length of stay was 7 (IQR, 6-9) days. In total, 24% of patients remained symptomatic (median follow-up 54 months). Half of those were asthma-related, with nearly 90% freedom from ring-related symptoms. Conclusions: Most patients were symptomatic at the time of diagnosis. Vascular rings such as pulmonary slings or tracheal compression syndromes require prompt management. Despite surgery, 24% of patients were not symptom-free at follow-up. Finally, surgery in asymptomatic patients resulted in low morbidity supporting the current recommendation of early surgical repair. Level of Evidence: III.

Modified method for tracheoesophageal fistula closure in intractable cases.

OBJECTIVE: Tracheoesophageal puncture (TEP) is one of the most established methods for voice reacquisition following total laryngectomy. The most difficult complication following TEP is the management of saliva leakage or secretion into the trachea due to TE fistula enlargement. In this study, we devised a new strategy to close TE fistulas and confirmed its safety and effectiveness. METHODS: Skin incision: If the tracheal mucosa around the voice prosthesis appears intact and normal, an arcuate incision, from 10 to 2 o'clock, is made on the skin 5 mm superior to the edge of the stoma. However, if the surrounding tracheal mucosa is fragile because of leaking, the incision is made on the superior edge of the stoma, with later reconstruction of the posterior tracheal wall. Separation of the trachea and esophagus: If the esophagotracheal spatium appears normal and is easy to dissect, the connective pipes can be found easily. After cutting the pipe, a ligature alone is sufficient for the tracheal side; however, the esophageal wall is closed with Gambee sutures. If the esophagotracheal spatium is compromised and the posterior tracheal wall is fragile (due to saliva leakage), we remove the posterior wall and reconstruct the area using the superior skin flap. We performed our novel method on four patients with intractable conditions; postradiotherapy for laryngeal cancer, total pharyngo-laryngo-esophagectomy (TPLE) with jejunum reconstruction, TPLE with gastric lifting reconstruction, and in a patient who underwent cervicothoracic incisional drainage for descending necrotizing mediastinitis. RESULTS: None of the cases showed postoperative leakage from the fistula, and oral intake was resumed without difficulty. CONCLUSION: This study showed that this strategy based on TE fistula conditions is effective even in difficult-to-treat cases.

Impact of definitive surgery for esophageal atresia on long-term outcomes in patients with trisomy 18.

This study investigates the long-term outcomes of palliative and definitive surgeries for esophageal atresia (EA) in patients with trisomy 18 syndrome. A retrospective study included 25 cases undergoing EA surgery at our center between 2008 and 2022. The Palliative group (n = 16) comprised 13 cases with esophageal banding and 3 with tracheoesophageal fistula (TEF) division. The Definitive group (n = 9) included 5 cases with primary repair and 4 with staged repair following TEF division. The patient characteristics exhibited no significant differences between the groups. In the Definitive group, 56% (5/9) were successfully weaned off mechanical ventilation, compared with none in the Palliative group (p = 0.002). Survival-to-discharge rates were 31% (5/16) in the Palliative group and 67% (6/9) in the Definitive group. Home ventilator management was required for all 5 cases that required ventilation in the Palliative group, whereas only 17% (1/6) in the Definitive group needed it. The Palliative group also required continuous oral suction for persistent saliva removal, with two cases undergoing laryngotracheal separation. Overall, definitive surgery for EA in patients with trisomy 18 syndrome may provide enhanced respiratory stability, thereby improving the survival-to-discharge rate and overall quality of life for patients and their families.

Clinical Signs as a Guide for Esophagram After Esophageal Atresia/Tracheoesophageal Fistula Repair.

INTRODUCTION: Esophageal atresia/tracheoesophageal fistula (EA/TEF) is a congenital malformation that occurs in about 1 in 2500-4000 live births. After surgical repair, despite the lack of evidence supporting the routine use of postoperative esophagram, most surgeons report obtaining an esophagram prior to enteral feeding. We hypothesized that abnormal indicators in vital signs, drain characteristics, and chest radiograph (CXR) could be used to screen for anastomotic leak, thus reducing the need for a routine esophagram. METHODS: A single institution, retrospective chart review of all patients born with EA with or without TEF between 2009 and 2022 was performed. Vital signs, postoperative CXR, chest drain characteristics, and esophagram results were analyzed for patients who underwent repair. RESULTS: Forty-five patients who underwent EA/TEF repair were included in the study, and 40 patients had routine esophagram. Out of the twenty-two patients who had at least one abnormal indicator, 14 (64%) had an anastomotic leak. Seventeen patients (43%) had the absence of abnormalities of all three indicators, and none of these patients had an anastomotic leak (100% negative predictive value). Moreover, changes in drain characteristics and vital signs together presented high sensitivity (87.5%), specificity (90%), and negative predictive value (94%). CONCLUSIONS: In the absence of abnormalities in vital signs, CXR, and drain characteristics in patients undergoing EA/TEF repair, routine esophagram can be safely avoided prior to enteral feeding. Abnormalities in drain characteristics and vital signs together were highly sensitive and specific for anastomotic leak, thus potentially eliminating the need for routine CXR and thereby minimizing radiation exposure and cost.

Internal mammary artery perforator flap for repair of an upper thoracic tracheo-oesophageal fistula.

Tracheoesophageal fistulas (TOF) following esophagectomy for esophageal cancer are rare but potentially fatal. There is no consensus on treatment between stenting and surgical repair, although the latter is associated with better distant survival. In surgical repair, the interposition of a flap improves healing by providing well-vascularized tissue and reinforcing the repair zone. The flaps described are usually muscular and decaying. We present the case of a malnourished fifty-year-old man who underwent intrathoracic surgical repair of symptomatic recurrent TOF using a skin flap based on the perforators of the internal thoracic artery (IMAP). The perforator flap was completely de-epidermized and tunneled under the sternum by a proximal and limited resection of the 3rd costal cartilage and placed at the posterior aspect of the trachea, with the excess tissue rolled up on either side. At 9 months, the patient showed no recurrence and improved general condition. The de-epidermized IMAP tunneled under the sternum intrathoracically is a reliable alternative to the conventional muscle flaps described in TOF management and an attractive additional tool in the plastic surgeon's surgical arsenal.

Thoracoscopic primary repair is useful for esophageal atresia with tracheoesophageal fistula in neonates with low body weight.

PURPOSE: The surgical indication of thoracoscopic primary repair for esophageal atresia with tracheoesophageal fistula is under debate. The current study aimed to investigate the outcome of thoracoscopic primary repair for esophageal atresia with tracheoesophageal fistula in patients weighing < 2000 g and those who underwent emergency surgery at the age of 0 day. METHODS: The surgical outcomes were compared between patients weighing < 2000 g and those weighing > 2000 g at surgery and between patients who underwent surgery at the age of 0 day and those who underwent surgery at age ≥ 1 day. RESULTS: In total, 43 patients underwent thoracoscopic primary repair for esophageal atresia with tracheoesophageal fistula. The surgical outcomes according to body weight were similar. Patients who underwent surgery at the age of 0 day were more likely to develop anastomotic leakage than those who underwent surgery at the age of ≥ 1 day (2 vs. 0 case, p = 0.02). Anastomotic leakage was treated with conservative therapy. CONCLUSION: Thoracoscopic primary repair is safe and useful for esophageal atresia with tracheoesophageal fistula even in newborns weighing < 2000 g. However, emergency surgery at the age of 0 day should be cautiously performed due to the risk of anastomotic leakage.

Prenatal ultrasonic diagnosis of esophageal atresia and tracheoesophageal fistula combined with interrupted inferior vena cava: a rare case report.

PURPOSE: This is an extremely rare case of complicated fetal esophageal atresia (EA) with tracheoesophageal fistula (TEF) and interrupted inferior vena cava (IVC) diagnosed by prenatal ultrsonography and successfully treated with surgical repair. METHODS: A 35-year-old pregnant woman was referred to our center for prenatal ultrasound, and the fetus was found to have a series of abnormalities, such as an interrupted IVC associated with a dilated azygos vein, an upper neck pouch sign of the thorax, and polyhydramnios. With suspicion of EA with TEF and interrupted IVC, the infant was born at 39 weeks of gestation, and successfully underwent the surgical operation. RESULTS: The baby was doing well after 21 months of follow-up. CONCLUSION: It is beneficial for the prenatal ultrasonic diagnosis of EA with TEF in optimizing labor care, postpartum treatment, and prompting neonatal management.

A Cautionary Tale: Undetected H-type Tracheoesophageal Fistula in an Adolescent Male.

An H-type tracheoesophageal fistula is a rare congenital anomaly consisting of an abnormal passageway between the esophagus and the trachea without the presence of esophageal atresia. This condition is usually detected early in infancy; however, some patients may receive a delayed diagnosis. Symptoms experienced by people affected with an H-type tracheoesophageal fistula vary greatly and may consist of bouts of coughing when swallowing liquids and recurring lower respiratory infections. The most commonly used initial diagnostic tests can produce falsely negative results. The treatment of choice for the majority of H-type tracheoesophageal fistulas is an open surgical procedure; however, the thoracoscopic approach has proven effective in cases where the fistula is located below the thoracic outlet. In this case report, we describe a patient whose diagnosis of H-type tracheoesophageal fistula was delayed by 13 years and who was successfully treated using thoracoscopic surgery.

Statewide Hospital Admissions for Adult Survivors of Infant Surgical Diseases Over a 10-Year Period.

INTRODUCTION: The number of patients with congenital disease living to adulthood continues to grow. Often undergoing surgical correction in infancy, they continue to require lifelong care. Their numbers are largely unknown. We sought to evaluate hospital admissions of adult patients with esophageal atresia with tracheoesophageal fistula (EA/TEF), congenital diaphragmatic hernia (CDH), and Hirschsprung disease (HD). METHODS: The Florida Agency for Healthcare Administration inpatient database was merged with the Distressed Communities Index and Centers for Medicare and Medicaid Services Hospital and Physician Compare datasets. The dataset was queried for adult patients (≥18 y, born after 1970) with EA/TEF, CDH, and HD in their problem list from 2010 to 2020. Patient demographics, hospitalization characteristics, and discharge information were obtained. RESULTS: In total, 1140 admissions were identified (266 EA/TEF, 135 CDH, 739 HD). Patients were mostly female (53%), had a mean age of 31.6 y, and often admitted to an adult internist in a general hospital under emergency. Principal diagnoses and procedures (when performed) varied with diagnosis and age at admission. EA patients were admitted with dysphagia and foregut symptoms and often underwent upper endoscopy with dilation. CDH patients were often admitted for diaphragmatic hernias and underwent adult diaphragm repair. Hirschsprung patients were often admitted for intestinal obstructive issues and frequently underwent colonoscopy but trended toward operative intervention with increasing age. CONCLUSIONS: Adults with congenital disease continue to require hospital admission and invasive procedures. As age increases, diagnoses and performed procedures for each diagnoses evolve. These data could guide the formulation of multispecialty disease-specific follow-up programs for these patients.

Acquired tracheoesophageal fistula repaired with one-stage surgery without tracheal resection using lateral cervical approach, a case report.

INTRODUCTION: Acquired non-malignant tracheoesophageal fistula (TEF) is a rare pathological connection between the trachea and esophagus caused primarily by iatrogenic injuries. Cuff-related injury causes pressure necrosis of the tracheoesophageal walls, often due to the overinflation of tubes. PRESENTATION OF CASE: A 29-year-old male who was mechanically ventilated for 3 months developed TEF after weaning from ventilation. The patient had severe sepsis, right lower lobe pneumonia, and parapneumonic effusion requiring multidisciplinary approach management. Preoperative measures were applied, including control of sepsis, nutritional support, stomach decompression, lung physiotherapy, placement of the cuff distal to the fistula, and weaning from ventilation. We performed a one-stage TEF repair with an interposition strap muscle flap using the lateral approach. DISCUSSION: The surgical approach greatly depends on the fistula location, size, and concomitant tracheal stenosis. Large TEFs or tracheal stenosis are repaired with segmental tracheal resection and anastomosis. Small TEFs and a normal trachea are repaired with direct closure of tracheal and esophageal defects, which can be performed through lateral or anterior cervicotomy. CONCLUSION: This case emphasizes the importance of a multidisciplinary approach, preoperative management, and meticulous surgical technique in the management of acquired TEF.

A case of corrosive tracheoesophageal fistula: A complication of button battery ingestion.

Key Clinical Message: Button battery ingestion has been a common condition encountered by otorhinolaryngologists. Impaction in the esophagus can lead to serious and fatal complications such as tracheoesophageal fistula. Management involves a multidisciplinary team and varies from supportive therapy to surgical intervention. Abstract: Ingestion of button batteries has been seen with increasing frequency over the past decade. In several small numbers of reported cases, their impaction in the esophagus has led to severe, sometimes fatal, complications. The management of these cases has varied from expectant, supportive therapy to early surgical intervention. We report a case of button battery ingestion that was diagnosed late and resulted in a complication of tracheoesophageal fistula with migration to the thorax which was managed by open surgery.

Validation of a PHIS Esophageal Atresia and Tracheoesophageal Fistula Cohort in ICD-10.

OBJECTIVE: Validation of a contemporary International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) congenital esophageal atresia/tracheoesophageal atresia (EA/TEF) cohort in the Pediatric Health Information System (PHIS) database. STUDY DESIGN: Database study, validation. SETTING: Tertiary care center. METHODS: Search methods used to validate an ICD-9-CM EA/TEF cohort in PHIS were modified for ICD-10-CM. A retrospectively and prospectively maintained clinical database at a single high-volume EA/TEF center was used for comparison. Patients treated between October 1, 2015 and July 31, 2022 were included. Searches progressively narrowed the cohort by ICD-10-CM diagnosis codes, expansion to include incorrectly coded as 'iatrogenic, age less than 30 days, and use of at least 1 ICD-10-CM procedure code. Results of PHIS data and institution data were compared for accuracy. RESULTS: The most refined search of PHIS and the EA/TEF clinical database yielded 93 and 84 patients, respectively. The sensitivity was 99% and positive predictive value was 94%. A PHIS search using these methods and encompassing 49 children's hospitals yielded an EA/TEF cohort of 2479 patients. CONCLUSION: We present a validated search method in the PHIS database to identify a high-fidelity cohort of EA/TEF patients for multi-institutional study. We have demonstrated that a carefully maintained clinical database may be used to validate cohorts in PHIS. This cohort allows for improved practice variability and outcomes study of EA/TEF patients. Similar methods may be employed to generate other rare disease cohorts in PHIS. LEVEL OF EVIDENCE: Level 4.

Optimization of tracheoesophageal fistula model established with T-shaped magnet system based on magnetic compression technique.

BACKGROUND: The magnetic compression technique has been used to establish an animal model of tracheoesophageal fistula (TEF), but the commonly shaped magnets present limitations of poor homogeneity of TEF and poor model control. We designed a T-shaped magnet system to overcome these problems and verified its effectiveness via animal experiments. AIM: To investigate the effectiveness of a T-shaped magnet system for establishing a TEF model in beagle dogs. METHODS: Twelve beagles were randomly assigned to groups in which magnets of the T-shaped scheme (study group, n = 6) or normal magnets (control group, n = 6) were implanted into the trachea and esophagus separately under gastroscopy. Operation time, operation success rate, and accidental injury were recorded. After operation, the presence and timing of cough and the time of magnet shedding were observed. Dogs in the control group were euthanized after X-ray and gastroscopy to confirm establishment of TEFs after coughing, and gross specimens of TEFs were obtained. Dogs in the study group were euthanized after X-ray and gastroscopy 2 wk after surgery, and gross specimens were obtained. Fistula size was measured in all animals, and then harvested fistula specimens were examined by hematoxylin and eosin (HE) and Masson trichrome staining. RESULTS: The operation success rate was 100% for both groups. Operation time did not differ between the study group (5.25 min ± 1.29 min) and the control group (4.75 min ± 1.70 min; P = 0.331). No bleeding, perforation, or unplanned magnet attraction occurred in any animal during the operation. In the early postoperative period, all dogs ate freely and were generally in good condition. Dogs in the control group had severe cough after drinking water at 6-9 d after surgery. X-ray indicated that the magnets had entered the stomach, and gastroscopy showed TEF formation. Gross specimens of TEFs from the control group showed the formation of fistulas with a diameter of 4.94 mm ± 1.29 mm (range, 3.52-6.56 mm). HE and Masson trichrome staining showed scar tissue formation and hierarchical structural disorder at the fistulas. Dogs in the study group did not exhibit obvious coughing after surgery. X-ray examination 2 wk after surgery indicated fixed magnet positioning, and gastroscopy showed no change in magnet positioning. The magnets were removed using a snare under endoscopy, and TEF was observed. Gross specimens showed well-formed fistulas with a diameter of 6.11 mm ± 0.16 mm (range, 5.92-6.36 mm), which exceeded that in the control group (P < 0.001). Scar formation was observed on the internal surface of fistulas by HE and Masson trichrome staining, and the structure was more regular than that in the control group. CONCLUSION: Use of the modified T-shaped magnet scheme is safe and feasible for establishing TEF and can achieve a more stable and uniform fistula size compared with ordinary magnets. Most importantly, this model offers better controllability, which improves the flexibility of follow-up studies.

Temporal and Spectral Models as Correlates to Auditory-Perceptual Judgments of Overall Severity and Listener Comfort in Tracheoesophageal Voice.

INTRODUCTION: This study pursued two objectives: (1) to determine the potential association between listener (n = 51) judgments of 20 male tracheoesophageal speaker samples for two auditory-perceptual dimensions of voice, overall severity (OS) and listener comfort (LC); and (2) to assess the temporal and spectral acoustic correlates for these auditory-perceptual dimensions. METHODOLOGY: Three separate correlation analyses were performed to evaluate the association between OS and LC. First, scores of OS and LC from all listeners were pooled together, and then the correlation between OS and LC was computed. Second, scores of OS and LC were averaged over all listeners to derive a single estimate of OS and LC for each TE speaker sample; the correlation between the average OS and LC was then computed. Third, listener-to-listener variability in the association between OS and LC was evaluated by computing the correlation between OS and LC scores from each listener across all TE samples. Finally, two stepwise multiple regression models were created to relate the average LC score to spectral and temporal variation in the acoustic signal. RESULTS: While the pooled OS and LC scores had a moderate positive correlation (r = 0.66, p < 0.00001), the averaged OS and LC exhibited a near perfect positive correlation (r = 0.99, p < 0.00001). The significant differences between the pooled and averaged scores were explained by significant listener-to-listener variability in the association between OS and LC. OS and LC scores from 5 listeners had non-significant correlations, 10 had moderate correlations (r < 0.7), 35 listeners had high correlations (0.7 < r < 0.9), and 1 listener had a very high correlation (r < 0.9 < 1). Finally, the acoustic models created based on the spectral and temporal variations in the signal were able to account for 87.7% and 61.8% of variation in the average LC score. CONCLUSIONS: The strong correlations between OS and LC suggest that LC may, in fact, provide a more comprehensive auditory-perceptual surrogate for the voice quality of TE speakers. Although OS and LC are distinct conceptual dimensions, LC appears to have the advantage of assessing the social impact and potential communication disability that may exist in interactions between TE speakers and listeners.

Establishment of acquired tracheoesophageal fistula using a modified magnetic compression technique in rabbits and its postmodeling evaluation.

BACKGROUND: Previous studies have validated the efficacy of both magnetic compression and surgical techniques in creating rabbit tracheoesophageal fistula (TEF) models. Magnetic compression achieves a 100% success rate but requires more time, while surgery, though less frequently successful, offers rapid model establishment and technical maturity in larger animal models. AIM: To determine the optimal approach for rabbit disease modeling and refine the process. METHODS: TEF models were created in 12 rabbits using both the modified magnetic compression technique and surgery. Comparisons of the time to model establishment, success rate, food and water intake, weight changes, activity levels, bronchoscopy findings, white blood cell counts, and biopsies were performed. In response to the failures encountered during modified magnetic compression modeling, we increased the sample size to 15 rabbit models and assessed the repeatability and stability of the models, comparing them with the original magnetic compression technique. RESULTS: The modified magnetic compression technique achieved a 66.7% success rate, whereas the success rate of the surgery technique was 33.3%. Surviving surgical rabbits might not meet subsequent experimental requirements due to TEF-related inflammation. In the modified magnetic compression group, one rabbit died, possibly due to magnet corrosion, and another died from tracheal magnet obstruction. Similar events occurred during the second round of modified magnetic compression modeling, with one rabbit possibly succumbing to aggravated lung infection. The operation time of the first round of modified magnetic compression was 3.2 ± 0.6 min, which was significantly reduced to 2.1 ± 0.4 min in the second round, compared to both the first round and that of the original technique. CONCLUSION: The modified magnetic compression technique exhibits lower stress responses, a simple procedure, a high success rate, and lower modeling costs, making it a more appropriate choice for constructing TEF models in rabbits.

Primary repair of esophageal atresia Gross type C via thoracoscopic magnetic compression anastomosis: Is it the best option?

Magnetic compression anastomosis is a promising treatment option for patients with complex esophageal atresia; but, at the present time, should not be the first therapeutic option in those cases where the surgeon can perform a primary anastomosis of the two ends of the esophagus with acceptable tension.

Endoscopic repair of tracheoesophageal fistulas: A contemporary multi-institutional case series and literature review.

OBJECTIVES: Recurrent and primary tracheoesophageal fistulas (TEFs) are a challenging surgical pathology to treat, as standard open surgical approaches are associated with high morbidity and mortality. As such, endoscopic modalities have gained interest as an alluring alternative, yet variable success rates have been reported in the literature. The aim of this study was to provide a contemporary update of the literature and describe our institutional experience with the bronchoscopic obliteration of recurrent and primary TEFs. METHODS: Retrospective chart review of all pediatric patients having undergone endoscopic TEF repair at two pediatric academic centers in Montreal, Canada and Lille, France between January 1, 2008 to December 31, 2020. RESULTS: 28 patients with TEFs (20 recurrent, 8 primary) underwent a total of 48 endoscopic procedures. TEF repair was performed under endoscopic guidance using various combinations of techniques, including fistula de-epithelialization (endoscopic brush, thulium laser, trichloroacetic acid-soaked pledgets or electrocautery), tissue adhesives, submucosal augmentation, esophageal clip and stenting. Successful closure was achieved in 16 patients (57 %), while 12 (43 %) required eventual open or thoracoscopic repair. The mean number of endoscopic procedures was 1.7. There were no major treatment-related complications such as pneumothorax, mediastinitis or death (mean follow-up 50.8 months). CONCLUSIONS: Endoscopic repair of recurrent or primary TEFs is a valuable component of our therapeutic armamentarium and may contribute to decreased surgical morbidity in this complex patient population. Families should be counselled that endoscopic results may be more modest than with open or thoracoscopic approaches, and multiple procedures may be required.

X-ray-guided self-expandable metal stent (SEMS) implantation in oesophageal malignancy as an alternative treatment.

<b><br>Indroduction:</b> Significant dysphagia, aspiration pneumonia, and impossible oral nutrition in patients with unresectable or recurrent gastroesophageal malignancy or bronchial cancer invading the oesophagus with a tracheoesophageal fistula lead to cachexia. Dehiscence of the esophago-jejunal or gastroesophageal anastomosis may cause severe oesophageal haemorrhage. We believe that X-ray-guided oesophageal stent implantation (SEMS) is an alternative palliative method for microjejunostomy or full parenteral nutrition.</br> <b><br>Aim:</b> The aim of this paper was to assess the safety and efficacy of a novel X-ray-guided oesophageal stent implantation technique.</br> <b><br>Materials and methods:</b> This retrospective analysis included 54 patients (35 men and 19 women) treated for malignant dysphagia, gastroesophageal/gastrointestinal anastomotic fistula or bronchoesophageal fistula in two Surgical Units between 2010 and 2019, using a modified intravascular approach to oesophageal stent implantation.</br> <b><br>Results:</b> The presented modified intravascular method of oesophageal stent implantation was successfully performed in all described patients requiring oral nutrition restoration immediately following oesophageal stent implantation. Two patients with oesophageal anastomotic dehiscence died on postoperative days 7 and 9 due to circulatory and respiratory failure. One patient was reimplanted due to a recurrent fistula. Two patients with ruptured thoracic aneurysm and thoracic stent graft implantation due to oesophageal haemorrhage, who were implanted with an oesophageal stent, died on postoperative days 4 and 14.</br> <b><br>Conclusions:</b> The modified intravascular X-ray-guided SEMS technique may be a palliative treatment for patients with unresectable oesophageal malignancies.</br>.