Esophagotracheal fistula secondary to esophageal diverticulum is rare but challenging
to treat [1]. Some cases of esophagotracheal fistula successfully treated by endoscopic submucosal
dissection (ESD) have been reported [2]
[3]
[4], but to our knowledge we report the first case of esophagotracheal fistula secondary
to esophageal diverticulum successfully treated by ESD and clip closure.
We present the case of a 64-year-old man who contracted recurrent pulmonary infections
over 2 years. The upper digestive tract showed a niche formation in the right wall
of the esophagus at the T7 vertebral body level, but no obvious leakage of contrast
agent was found ([Fig. 1 a]). Computed tomography (CT) scan showed inflammation in the right lower lobe, with
partial atelectasis ([Fig. 2 a]). Gastroscopy revealed a diverticulum in the right lateral wall of the esophagus
and a 5-mm fistulous orifice inside the diverticulum ([Fig. 3 a]). After anti-infective treatment for 3 days, we performed ESD for the esophagotracheal
fistula and esophageal diverticulum ([Video 1]).
Fig. 1 Radiographic images. a A niche formation in the right wall of the esophagus at the T7 vertebral body level.
b Resolution of the esophageal diverticulum.
Fig. 2 Computed tomography scan. a Inflammation in the right lower lobe with partial atelectasis. b The pulmonary inflammation was significantly resolved.
Fig. 3 Endoscopic images showing the endoscopic submucosal dissection procedure. a A diverticulum in the right lateral wall of the esophagus and a fistulous orifice
inside the diverticulum. b Marking the surrounding mucosa of the esophageal diverticulum. c Dissecting the mucosal and submucosal layers inside the diverticulum. d Excision of the mucosal and submucosal layers with a snare trap. e Dissecting the mucosal patch surrounding the fistulous orifice. f Cutting off part of the muscularis propria inside the diverticulum. g Closure of the exposed area with Dual Action Tissue clips and SureClips (Micro-Tech
Endoscopy, USA Inc., Ann Arbor, Michigan, USA). h Gastroscopy showed that the esophagotracheal fistula was healed after 3 months.
Video 1 The endoscopic submucosal dissection procedure was performed to dissect the mucosal
and submucosal layers inside the diverticulum, followed by clip closure.
After marking the surrounding mucosa of the esophageal diverticulum and injecting
the submucosal layer, we dissected the mucosal and submucosal layers inside the diverticulum
([Fig. 3 b, c, d]). Then, a coagulation forceps was used to dissect the mucosal patch surrounding
the fistulous orifice to increase the chances of successful scarring ([Fig. 3 e]). Furthermore, we resected part of the muscularis propria inside the diverticulum
to prevent incomplete closure of the diverticulum ([Fig. 3 f]). Finally, two Dual Action Tissue clips (Micro-Tech Endoscopy, USA Inc., Ann Arbor,
Michigan, USA) and three SureClips (Micro-Tech Endoscopy, USA Inc.) were used to close
the exposed area ([Fig. 3 g], [Video 1]). The patient successfully restarted oral food intake and was discharged.
Repeat upper gastrointestinal radiography showed resolution of the esophageal diverticulum
([Fig. 1 b]), and CT scan showed resolution of the pulmonary inflammation ([Fig. 2 b]). Repeat gastroscopy confirmed the closure of the orifice during the subsequent
3 months ([Fig. 3 h]).
This case demonstrates that ESD and diverticulum closure by clips can be a valuable
procedure for treating chronic esophagotracheal fistula secondary to esophageal diverticulum.
Endoscopy_UCTN_Code_CCL_1AB_2AC_3AF
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