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for treatment of a chronic post-surgical tracheoesophageal fistula Acquired tracheoesophageal fistula is a rare condition, often linked tomalignancy, trauma, or iatrogenic cuff-related injury. Poor nutrition, infection, radiotherapy, and steroid use are predisposing factors. Surgical management is difficult, timeconsuming, and associated with significant morbidity and mortality [1]. Conservative endoscopic therapeutic options, such as self-expandablemetal stents, clips, and sealants have been investigated with satisfactory results. In recent years, over-the-scope clip (OTSC) systems have shown good technical and clinical success as a result of their more vigorous closure than regular through-the-scope clips and because of their wider mouths and ability to grip larger amounts of tissue [2]. Recently a novel tissue-closure device (Padlock Clip; Aponos Medical, Kingston NewHampshire, USA) has been developed and tested in porcine models, providing secure closure of full-thickness wall defects [3]. It consists of a hexagonal nitinol ring with six inner needles and is preassembled on an applicator cap. It is thumb-press deployed by the Lock-It delivery system, which is located parallel to the endoscope, so does not require the working channel or other instruments (●" Fig.1). Simple suction is enough to obtain tissue adhesion to the instrument tip. When deployed, the ring instantly springs back to its original form. In 2007, a 60-year-old man underwent laryngectomy for laryngeal cancer followed by chemoradiotherapy. In March 2014, he was admitted to our hospital because of recurrent bronchitis and cough. Computed tomography (CT) scanning, Gastrografin esophagography, and endoscopy showed a tracheoesophageal fistula (●" Fig.2). Several unsuccessful treatments were attempted, including surgery, salivary bypass stenting, and endoscopic clipping. In September 2014, we decided to try placing a Padlock Clip. Using endoscopic and fluoroscopic control, we successfully deployed the clip at the esophageal edge of the fistula (●" Video 1; ●" Fig.3). The patient did well after treatment and no immediate or delayed complications occurred. After 5 months of follow-up, he is feeding normally and no recurrence of symptoms has been reported. To our knowledge, this is the first clinical experience of closure of a tracheoesophageal fistula using a Padlock Clip. Fig.2 The tracheoesophageal fistula seen on: a radiological view (fistula indicated by green arrow); b endoscopic view; c bronchoscopic view. Fig.1 Photographs showing: a the new Padlock Clip; and b its extrascope Lock-It delivery system. Cases and Techniques Library (CTL) E437

New endoscopic over-the-scope clip system for treatment of a chronic post-surgical tracheoesophageal fistula