344 Multi-Modality Endotherapy of Esophagopleural Fistula (EPF) Using a Novel External Stent Anchoring Mechanism

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INTRODUCTION: Esophagopleural fistula (EPF) is a condition associated with high morbidity and mortality. The management of patients with chronic, recurrent, nonmalignant EPF remains controversial and challenging. CASE DESCRIPTION/METHODS: A 61-year-old man with a history of esophagopleural fistula (EPF) in diagnosed in 2013 treated with covered esophageal stent and subsequent decortication with resolution of symptoms and esophageal leak who presented to the hospital with sepsis. Chest CT revealed a fistula between the distal esophagus and right pleural space with large right-sided hydro-pneumothorax with resulting near complete collapse of the right lower and middle lobes. Chest tube was placed with external wound suction by luminal vacuum sponge. GI were consulted for endoscopic management. Upper Endoscopy revealed a 20 mm fistula in the lower third of the esophagus. The decision was made to close the fistula with endoscopic suturing and placement of esophageal stent. Three days following the procedure the esophageal stent migrated distally. This was repositioned endoscopically and anchored with repeat Overstitch of endoscopic clips. This again was displaced after 4 days. Due to the patient poor conditional status and the absence of offers for nonsurgical options, an alternative method of anchoring of esophageal was explored in the form of an external anchoring. This was done by loading the stent and suturing the proximal end at 12 and 6 o’clock, the stent was loaded back and then deployed in the patient esophagus under flurouscopic guidance. Then, the previously placed anchoring suture material was located and brought out of the mouth using a forceps. The sutures then were rerouted into each nostril using a nasal gastric tube. Then these anchoring sutures were loosely tied at/around the nasal septum using a soft rubber tube to protect the nasal septum. The procedure was technically successful and the patients was discharged from the hospital three days later. After one month, the patient’s nutritional status improved, and he underwent definitive thoracic surgery at an outside facility. DISCUSSION: Self-expandable metal stents are increasingly used in the management of esophageal fistulas but their efficacy is limited by high migration rate. Previously described methods to prevent stent migration include the use of endoscopic clips and endoscopic suturing. We describe external anchoring technique to maintain the esophageal stent in position in a case when endoscopic suturing failed. Watch the video: http://bit.ly/2YiObuS