Background: Bronchopleural fistula (BPF) is a rare but severe complication of esophagectomy. Drainage tubes and intravenous antibiotics are often ineffective. Surgical treatment is not always possible due to the poor medical conditions of the patient. Endoscopic techniques can be a more suitable option. There are several reports of Amplatzer devices for closure of BPF associated with pulmonary resection, but this is the first case with a Cocoon septal occluder (CSO) in a patient with a lung abscess related to anastomotic leak after esophagectomy. 
Case report: 53-years-old man was admitted to hospital 17 days after esofaguectomy and intraoperative radiotherapy, with anastomotic leak and lung abscess. The patient had received neoadjuvant chemoradiotherapy, risk factors for these postoperative complications. Percutaneous TC-guide drainage was performed and an esophageal endoscopic stent was placed. Three days later, physical patient status got worse and new TC exam showed distal migration of the stent. Emergent cervical esophagostomy was performed. The patient went then under mechanical ventilation and with norepinephrine perfusion. A 4-5 mm fistula in the right main bronchus 2 cm distal to carina was identified by flexible bronchoscopy. Thoracic and General Surgery Departments dismissed surgical treatment of the BPF. Interventional Pneumologists proposed an endobronchial deployment of a CSO through a flexible bronchoscope in collaboration with Interventional Cardiologists. The procedure was uneventful, with immediate air leak resolution. In the 16th postsurgery day, the patient was transferred to conventional ward, receiving hospital release in the 29th postsurgery day.
Discussion: The CSO (Vascular Innovations Co Ltd. Nonthabury, Thailand)is a self-expandable,double-disk device designed for the occlusion of atrial septal defects.CSO is compressible inside a catheter and returns into its shape when deployed in the BPF to occlude the defect by a self-centering waist. The device can be easily recaptured and redeployed for optimal placement. Endobronchial deployment of septal occluder devices can be quickly performed under mild or even conscious sedation in contrast with surgical treatment. This makes this endoscopic technique very useful for patients without surgical options.
Learning point: endobronchial deployment of CSO is an effective, non invasive technique useful to close BPF for patients in poor medical condition without a surgical treatment option.


06 / ENDOBRONCHIAL CLOSURE OF BRONCHOPLEURAL FISTULA AFTER ESOPHAGECTOMY USING A COCOON SEPTAL OCCLUDER