A Corcoran et al. J Pediatr Gastroenterol Nutr. 2026;82:828–839. Endoscopic tracheoesophageal fistula closure—Electrocautery combined with esophageal clip application in pediatric patients

This retrospective study with 15 patients shows the feasibility of endoscopic closure of tracheoesophageal fistulas (TEFs) in pediatric patients by a highly-specialized multidisciplinary team.

Background: Surgical repair of esophageal atresia (EA) is usually completed in infancy, yet TEF can still be identified later in life. These late-presenting fistulas fall into three general categories .⁵ First, true recurrences arise when the original site of TEF ligation breaks down, resulting in reformation of the fistula at the prior repair site. These occur in approximately 5%–10% of patients. Second, missed congenital fistulas were present at birth but went undetected during the initial evaluation or operation…Third, acquired fistulas can develop de novo in children without a history of EA, typically resulting from chronic inflammation and tissue breakdown due to an inciting injury, prolonged infection, or a retained foreign body. In children with repaired EA, similar fistulas may develop along a new tract months or years after surgery, often arising from the same underlying mechanisms.

Open repair of TEF can be a technically challenging operation, and depending on the location, it requires re-do thoracotomy or neck dissection. Given the morbidity and mortality associated with these open surgical approaches, there has been a growing trend toward endoscopic repair of recurrent, acquired and missed congenital TEF.^4–9 

Key findings:

• in 14 patients, 14 of 15 fistulas were closed successfully
• Ten TEF were closed with electrocautery and esophageal clip placement while five were closed with cautery alone

Discussion Points:

• Repeated procedures are often necessary to both achieve and ensure closure for endoscopically treated TEFs.

My take (borrowed from authors): Endoscopic closure using “electrocautery with or without esophageal clip application is a safe, minimally invasive, and effective treatment for all types of TEFs…While especially valuable for patients who are poor surgical candidates due to comorbidities, this approach may also be considered as a first-line option prior to surgical intervention in select cases.”

Related blog posts:

• Selective Acid Suppression for Esophageal Atresia Patients
• Evidence-Based Algorithm for Surveillance in Esophageal Atresia Patients JL Yasuda et al. J Am Coll Surg 2024; 238: 831-843. The algorithms above suggest that at minimum, EA patients should have endoscopy every 5 years (likely starting between 12-18 months). More frequent endoscopy (every 2-3 years) may be worthwhile in those with risk factors (e.g. long gap EA, hiatal hernia, and prior esophagitis) and follow-up endoscopy is needed sooner if change in therapy (stricture dilation, esophagitis treatment or treatment de-escalation)
• Do PPIs Increase the Risk of Eosinophilic Esophagitis in Patients with Esophageal Atresia?
• How Effective are Stents for Anastomotic Esophageal Strictures in Patients with Esophageal Atresia
• More Often Than Not Esophagitis in Children with Esophageal Atresia is NOT due to Reflux
• How Bad is Reflux in Children with Esophageal Atresia?
• How Long Should Be PPIs Be Used in Patients with Esophageal Atresia?
• Endoscopic Surveillance after Esophageal Atresia: Low Yield in Pediatrics This study with 209 patients (Koivusalo et al. JPGN 2016; 62: 562-66) reported that “routine endoscopic surveillance had limited benefit and seems unnecessary” before 15 years of age.