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Staple division was performed above and below the fistula avoiding disruption of the inflammatory wall of the fistula (Fig 2). This maneuver created a new back wall of trachea and restored a closed ventilatory circuit with minimal dead space. Tube pharyngostomy drainage was accomplished by transoral localization of the superior pharyngeal recess lateral to the larynx with the aid of a large right-angled surgical clamp. A cervical cut down was then made at a point above the superior cornu of the thyroid cartilage over the site of transoral pressure applied by the instrument. A 20 Fr mushroom catheter was then pulled through the incised opening into the pharynx. Stamm gastrostomy was then performed. This very ill patient tolerated the procedure well. Adequate ventilation was achieved for several months until the patients death from progressive pulmonary parenchymal failure. Discussion Blunt and penetrating trauma, mediastinal granulomatous disease and instrumentation of the trachea and esophagus are known etiologic factors leading to benign tracheoesophageal fistulization. The most common etiology, however, results from pressure necrosis of the closely opposed walls of the cervical esophagus and trachea by chronic endotracheal tube trauma. Figure 2. GIA stapler being applied above the proximal extent of the inflammatory process avoiding entry into the fistulous communication.