Esophagopleural fistula treated endoscopically with argon beam electrocoagulation and clips

Abstract

Fistulas of the esophagus can extend into the pleural cavity, mediastinum, or bronchial tree and can be caused by trauma and bacterial infections, in particular mycobacterial disease. However, they most frequently occur as a result of malignancies of the esophagus, lungs, or mediastinum, either as a primary complication or after treatment of these cancers with radiotherapy or chemotherapy. Under these circumstances, palliation can be obtained by esophageal stenting, preferably with a self-expandable coated stent. 1 Morgan PRA Ellul JPM Denton ERE Glynos M Mason RC Adam A. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology. 1997; 204: 527-532 PubMed Google Scholar , 2 Raijman I Lynch P. Coated expandable esophageal stents in the treatment of digestive-respiratory fistulas. Am J Gastroenterol. 1997; 92: 2188-2191 PubMed Google Scholar , 3 Spivak H Katariya K Lo AY Harvey JC. Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis. J Surg Oncol. 1996; 63: 65-70 Crossref PubMed Scopus (21) Google Scholar Although clinically successful in more than 95% of patients, 1 Morgan PRA Ellul JPM Denton ERE Glynos M Mason RC Adam A. Malignant esophageal fistulas and perforations: management with plastic-covered metallic endoprostheses. Radiology. 1997; 204: 527-532 PubMed Google Scholar , 4 Bethge N Sommer A Vakil N. Treatment of esophageal fistulas with a new polyurethane-covered, self-expanding mesh stent: a prospective study. Am J Gastroenterol. 1995; 90: 2143-2146 PubMed Google Scholar the use of these stents has disadvantages. Esophageal perforations and lethal hemorrhages occur in 2% to 5% of cases. 5 Swain CP Gong F Murfitt J. Difficulties with placement of esophageal metal stents and development and testing of new delivery method and covered stents. Gastrointest Endosc. 1995; 41 ([abstract]): 358 Abstract Full Text PDF Google Scholar , 6 May A Hahn E Ell C. Self-expanding metal stents for palliation of malignant obstruction in the upper gastrointestinal tract. J Clin Gastroenterol. 1996; 22: 261-266 Crossref PubMed Scopus (107) Google Scholar , 7 Kozarek RA Ball TJ Brandabur JJ Patterson DJ Low D Hill L et al. Expandable versus conventional esophageal prostheses: easier insertion may not preclude subsequent stent-related problems. Gastrointest Endosc. 1996; 43: 204-208 Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar Stent migration and food impaction occur frequently, necessitating endoscopic reintervention in more than 10% to 15% of patients within 3 months. 6 May A Hahn E Ell C. Self-expanding metal stents for palliation of malignant obstruction in the upper gastrointestinal tract. J Clin Gastroenterol. 1996; 22: 261-266 Crossref PubMed Scopus (107) Google Scholar Other therapeutic options, in selected cases, are the use of tissue glue, with success in about 50% of patients, 8 Hirao M Shimada M Kaneko T Mizunoya S Okagawa K. Two cases of esophageal fistula, in which a fibrin glue preparation was effective. J Jpn Assoc Thor Surg. 1994; 42: 2144-2149 Google Scholar , 9 Cellier C Landi B Faye A Wind P Frileux P Cugnenc P-H et al. Upper gastrointestinal tract fistulae: endoscopic obliteration with fibrin sealant. Gastrointest Endosc. 1996; 4: 731-733 Abstract Full Text Full Text PDF Scopus (59) Google Scholar or surgery, which has high morbidity (30%) and mortality (10%) rates even in specialized centers. 3 Spivak H Katariya K Lo AY Harvey JC. Malignant tracheo-esophageal fistula: use of esophageal endoprosthesis. J Surg Oncol. 1996; 63: 65-70 Crossref PubMed Scopus (21) Google Scholar , 10 Fernando HC Benfield JR. Surgical management and treatment of esophageal fistula. Surg Clin North Am. 1996; 76: 1123-1135 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar