Multimodal endoscopic treatment of primary esophago-pleural fistula

A 48-year-old man was admitted to our hospital following the onset of cough, fever, and shortness of breath. Clinical history included psychotic syndrome and recurrent erosive esophagitis.

In the emergency room, a chest radiograph showed right pleural effusion. However, despite full conservative management, his condition worsened rapidly. A computed tomography scan revealed communication between the distal esophageal lumen and the right pleural space ([Fig. 1]). Subsequent upper endoscopy showed extensive ulceration of the esophageal wall, with a small orifice at its distal part ([Fig. 2]).

Fig. 1 Computed tomography scan image of massive right pleural corpuscolated effusion. A small esophago-pleural fistula could be identified (arrow).

Fig. 2 Endoscopic view of large ulceration of the esophageal wall, with an orifice, about 8 mm in size, in its distal part.

An over-the-scope clip (OTSC, 12 mm, traumatic type; Ovesco Inc., Tübingen, Germany) was deployed over the orifice ([Video 1]). To ensure complete occlusion of the defect, a colonic partially covered metal stent (Niti-S, 22 mm × 10 cm; Taewoong Medical, Inc., Gyeonggi-do, South Korea) was positioned, protecting the orifice against gastroesophageal reflux ([Fig. 3]).

Computed tomography scan and endoscopic view identified an esophago-pleural fistula. Combined treatment with an over-the-scope clip (Ovesco Inc., Tübingen, Germany) and stent placement was performed. Two months later, an upper tract radiograph and an upper endoscopy revealed complete healing of the fistula.

Fig. 3 A radiographic image confirmed that both the over-the-scope clip and the partially covered (colonic) self-expandable metal stent were in place.

The patient improved during the subsequent 30 days, and 2 months later, the metal stent was removed using a “stent-in stent” technique. Subsequent upper endoscopy showed complete healing of the esophageal wall even though the OTSC was no longer in place.

Primary benign esophago-pleural fistula is a rare but challenging condition, burdened by a high mortality and often requiring surgical treatment [1]. Self-expandable metal stents are well known therapeutic techniques used in the management of leaks and fistulas involving the esophageal wall or anastomosis [2]. Furthermore, the OTSC represents a new endoscopic approach for the closure of upper gastrointestinal leaks and fistulas [3]. However, as in the case described above, a tailored and multimodal approach (stent and OTSC) could be safer and more effective than a single modality, avoiding the need for surgery [4] [5].

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• References

• 1 Cherveniakov A, Tzekov C, Grigorov GE et al. Acquired benign esophago-airway fistulas. Eur J Cardiothorac Surg 1996; 10: 713-716
• 2 Van Boeckel PGA, Sijbring A, Vleggaar FP et al. Systematic review: temporary stent placement for benign rupture or anastomotic leak of the oesophagus. Aliment Pharmacol Ther 2011; 33: 1292-1301
• 3 Haito-Chavez Y, Law JK, Kratt T et al. International multicenter experience with an over-the-scope clipping device for endoscopic management of GI defects (with video). Gastrointest Endosc 2014; 80: 610-622
• 4 González-Haba M, Ferguson MK, Gelrud A. Spontaneous esophageal perforation (Boerhaave syndrome) successfully treated with an over-the-scope clip and fully covered metal stent. Gastrointest Endosc 2016; 83: 650
• 5 Goenka MK, Goenka U. Endotherapy of leaks and fistula. World J Gastrointest Endosc 2015; 7: 702-713