Fistula can develop rarely between the esophageal lumen and other
mediastinal structures. The majority of cases are caused by malignancy. Benign
causes include infections, other inflammatory conditions, postsurgical trauma,
and prolonged periods of endotracheal intubation or tracheostomy tube
placement. In most cases of fistula, surgery is required. There are, however,
a
number of reports in the literature of endoscopic methods of attempting fistula
closure: the application of fibrin glue, use of covered esophageal stents, and
clipping have been described, for closure of esophagotracheal,
bronchoesophageal, and esophagopleural fistulas [1]
[2]
[3]
[4].
We report the case of a patient who developed an
esophagomediastinalbronchial fistula ([Fig. 1])
after a pulmonary resection (sleeve lobectomy).
Fig. 1 Esophagography with a
water-soluble contrast agent shows an esophagomediastinal fistula.
An external mediastinal drain was inserted, and
esophagogastroduodenoscopy (EGD) promptly identified a large fistula opening of
25 mm in diameter in the middle part of the esophagus ([Fig. 2]).
Fig. 2 Opening of the
fistula.
Another EGD was done 2 days later, with attempted closure of the
fistula by clipping. However placement of the clips using the traditional
method was very difficult, because the edges of the fistula were fibrotic and
because of the large diameter of the opening. For these reasons, five clips
(Resolution; Microvasive, Boston Scientific, Natick, Massachusetts, USA) were
positioned at the edges of the opening ([Fig. 3])
and an endoloop (Olympus, Tokyo, Japan) was looped and tightened round the
heads of the clips in order to close the opening ([Fig. 4]).
Fig. 3 Clips positioned at the
edges of the fistula opening.
Fig. 4 Endoloop attached to the
heads of the clips.
Another EGD performed 1 month later revealed complete healing of the
fistula with formation of scar tissue ([Fig. 5]).
Fig. 5 Endoscopic view showing
complete healing of the fistula.
To the best of our knowledge, this is the first report of an
endoscopic approach that combined clips and endoloop to treat a fistula.
Because of the limited width of an open clip, it is difficult or impossible to
close a large mucosal defect, so we believe that in such situations the
technique described could be a useful procedure when traditional clip
application fails.
Endoscopy_UCTN_Code_TTT_1AO_2AI
