A case of esophagorespiratory fistula successfully managed with a new technique for esophagoscopic closure

Fistulas between the esophagus and the tracheobronchial tree are rarely seen in adults. Malignancy is the most common cause of these fistulas, and these generally have a poor prognosis. Benign causes of such fistulas are iatrogenic (i. e. intubation, sclerotherapy, and surgery), infections, inflammatory conditions, and corrosive ingestion. Bronchoesophageal fistulas of benign origin are rare but have a favorable outcome with appropriate treatment [1] [2] [3]. We report here the case of a patient with an esophagorespiratory fistula (ERF) who was managed successfully with a new technique for esophagoscopic closure.

A 68-year-old man was diagnosed with non-small-cell lung cancer 6 months previously. Right distal lobectomy was performed at initial diagnosis. Esophageal fistula developed after paraesophageal lymph node excision, which was undiagnosed during the procedure. The patient was admitted to a chest diseases clinic with a complaint of cough after 20 days. Thoracoscopy was performed and revealed a suspicious fistula. Computed tomography of the chest revealed a fluid collection with destruction of the middle lobe. The patient underwent a right middle lobectomy plus esophageal myoplasty (closure of the fistula was achieved with a serratus and intercostal muscle flap) but eventually the fistula opening appeared unchanged. The patient was referred to our clinic for further evaluation and treatment of ERF.

Initial evaluation with esophagoscopy demonstrated an ERF with an esophageal opening of 3 cm in diameter and 2 cm in length, which was located 15 cm from the tooth at the proximal part of the esophagus. We decided to use a new technique for endoscopic closure of the fistula, after obtaining written informed consent from the patient. Despite the placement of four endoclips (HX-600-135; Olympus, Tokyo, Japan), beginning with the closest side of the fistula, a desirable mucosal apposition was not obtained. Consequently an endoloop (MAJ-254; Olympus) ligation was performed using a two-channel endoscope (EG-3840 T; Pentax, Tokyo, Japan). After the loop had been correctly placed, it was released over the fistula margins. The endoloop was then attached to these areas with a metallic clamping device that was sent from the other working channel of the scope. The endoloop was then tightened around the fistula margins. Closed fistula margins with endoloop placement over the endoclips were seen at the follow-up esophagoscopy 1 week later ([Fig. 1]). After the drain had been removed and oral feeding had begun, the patient was discharged from the hospital.

Fig. 1 a Esophagorespiratory fistula with an esophageal opening of 3 cm in diameter and 2 cm in length. b Endoloop was then attached to these areas with metallic clips. c Endoloop was then tightened around the fistula margins. d Closed fistula margins.

The most frequent causes of a fistula between the esophagus and tracheobronchial tree in adults are carcinoma of the bronchus, esophageal carcinomas, thyroid and mediastinal neoplasms [1] [2]. Closure of the ERF is much more important than treatment of the underlying malignancy. Among the various palliative treatments, placement of a covered expandable metallic stent is emerging as a superior alternative to the use of unexpandable esophageal prostheses and other conservative treatment methods such as percutaneous gastrostomy and surgical esophageal bypass [4]. A benign cause in an adult is uncommon and may be either congenital or acquired. In recent years increasing reports of newly diagnosed acquired benign ERF cases have been published. This appears to be due to the increase in fistulas caused by surgical procedures, blunt chest trauma, and prolonged ventilatory assistance. Direct surgical repair with resection of the fistula carries an excellent prognosis. The fistula is isolated, divided, and closed, with interposition of a pleural or muscle flap. Endoscopic obliteration has been recommended for patients who decline to undergo or are unfit for thoracotomy [1] [5].

To our best knowledge, this is the first report of a patient with a benign acquired fistula between the airways and digestive tract being successfully treated via an endoscopic approach with the use of an endoloop and endoclips. Our endoscopic technique may be considered a viable alternative to surgery in patients with benign and malignant ERF who are unfit for surgery or who prefer a nonsurgical approach.

Competing interests: None

References

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