Endoscopic management of esophagorespiratory fistulas

Esophagorespiratory fistulas (ERFs) are pathologic communications between the esophagus and respiratory tract. They are devastating conditions of malignant or benign (often iatrogenic) etiologies. Patients with ERF have significantly increased mortality and decreased quality of life. Multiple management options exist for the treatment of ERFs including surgical, endoscopic, and oncologic approaches. Surgical management, with fistula closure and removal of diseased esophageal or pulmonary tissue, is the time-honored treatment of ERF. However, these surgeries are major undertakings and many patients with ERF are poor surgical candidates. As such oncologic and endoscopic therapies are often employed. Many endoscopic therapies exist for the management of ERF and include: esophageal stenting, airway stenting, combined esophageal, and airway stenting, over-the-scope clip placement, cardiac septal occlusion devices, and other novel therapies (argon plasma coagulation, fibrin glue, endoscopic suturing, and polyglycolic acid sheets). These treatments can be employed alone or in combination. Each endoscopic management strategy has its own clinical success rate and adverse events. Although advances in endoscopic techniques have broadened the tools available to treat ERFs; little if any data are available comparing the various endoscopic management strategies. Despite this an experienced clinician may select the appropriate intervention to maximize the risks/benefits of the procedure based on the size, location, and etiology of the fistula.