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The predisposing factors to endotracheal tube-induced tracheoesophageal fistula described by Cooper and Grillo were all present in this case. This patient required prolonged positive pressure ventilation and an indwelling nasogastric tube was concomitantly required to provide enteral alimen- tation. Furthermore, the endotracheal tube cuff required progressively higher pressures to maintain a ventilatory seal as a result of deteriorating pulmonary function. The chronic nature of this fistulous process is characterized by the lack of subcutaneous emphysema and the finding of worsening pulmonary secretions, intermittent abdominal gaseous distention and deterioration in pulmonary function over the weeks preceding this admission. Several approaches have been employed to manage the giant tracheoesophageal fistula. Thomas and Grillo et al advocated an approach of fistula division and primary repair of trachea and esophagus supported with interposed viable muscle. Bartlett described acute management of an extensive tracheoesophageal fistula by esophageal division and primary closure of the posterior tracheal defect. He followed this with bolstering of the repair with the free posterior wall of the previously involved esophagus.