ENDOSCOPIC CLOSURE OF COMPLEX OESOPHAGO-PLEURO-CUTANEOUS FISTULA

Aim:

Oesophago-pleural fistula is a difficult complication to treat in post gastrectomy patients, often requiring surgical interventions. However, recent advances mean that endoscopic techniques can provide a safe and effective alternative. Here, we describe a case of successful endoscopic closure of a oesophago-jejunal-pleurocutaneous fistula using multimodality endoscopic closure.

Methods:

A 64 year-old lady, who previously had a total gastrectomy for a neuroendocrine tumour presented with malnutrition and postprandial back pain. Investigations confirmed a fistulous tract at the site of oesphageo-jejunal anastomosis into the right pleura which was tracking into the posterior thoracic wall.

Initial attempts with naso-jejunal feeding as well as three attempts of fibrin glue injection failed to heal the fistula. Malnutrition and poor functional status precluded surgical intervention. Hence, endoscopic closure of fistulous tract was attempted.

After careful inspection, the tract was vigorously brushed using biliary cytology brush, to encourage formation of granulation tissue to assist healing. Argon plasma coagulation was then applied to the area around fistula opening. Surgifoam was then placed into the tract, followed by Fibrin glue injection. An OVESCO anchor was used to pull the opening of fistula and a 12T OVESCO clip was applied to the edges of the defect with constant soft suction to achieve watertight closure. Following deployment of an over the scope OVESCO clip, technical success was confirmed by direct endoscopic visualization and by fluoroscopic confirmation, showing no contrast extravasation.

Results:

Once normal feeding was established, the patient was discharged. She has been followed up at 2 weeks and a few months, with no evidence of recurrence of the fistula.

Conclusion:

Although surgery remains the preferred treatment for anastamotic fistulae, recent advances in endoscopic techniques have provided a safer and more effective alternative. This case demonstrates the safety and effectiveness of a multimodal endoscopic approach in the managing complex fistulae.