Rendezvous Endoscopic Access and Treatment of Esophagopleural Fistula

Abstract

A 37 year old woman with metastatic esophageal adenocarcinoma with a previously placed PEG tube for dysphagia was admitted with shortness of breath. Chest CT scan revealed a large left hydropneumothorax. A chest tube was inserted and pleural fluid studies were notable for elevated amylase suggestive of an esophagopleural fistula. Barium swallow demonstrated contrast passing laterally toward the left lung base consistent with an esophagopleural fistula. The patient was a poor surgical candidate and was referred for endoscopic management. An upper endoscope was advanced to the esophagus. A friable, oozing, completely obstructing malignant lesion was found in the lower esophagus. A balltip catheter was inserted down the scope channel. Contrast injection revealed the esophagopleural fistula and severely narrow esophageal stricture with a small amount of contrast trickling into the stomach. Attempts to cross the stricture with various instruments were unsuccessful. Therefore, a decision was made to pursue rendezvous endoscopic retrograde gastroscopy via gastrostomy tract of the previously placed PEG tube. The balloon on the previously placed PEG tube was deflated. A guidewire was inserted into the PEG tube and coiled into the stomach under fluoroscopic guidance. The PEG tube was removed while the wire was left in place. Over the guidewire, serial dilation of the gastrostomy tract was performed to 42 Fr. A second upper endoscope was then inserted through the gastrostomy tract into the stomach and advanced retrograde to the distal esophagus. Using a balltip catheter preloaded with a 0.035” guidewire, the guidewire was advanced in a retrograde fashion across the stricture. With the endoscope in the proximal esophagus, the guidewire was grasped with biopsy forceps and pulled out through the mouth. An 18mm x 103 mm fully covered metal esophageal stent was inserted over the guidewire and deployed across the stricture under fluoroscopic and endoscopic guidance, with the distal flange deployed in the stomach and proximal flange about 2-3 cm proximal to the esophageal stricture. Repeat upper endoscopy from both antegrade and retrograde views confirmed good stent position. Contrast injection was performed which revealed passage of contrast from the esophagus to the stomach with no extravasation of contrast through the esophagopleural fistula. The proximal flange of the esophageal stent was sutured in three locations to the esophageal wall to prevent migration. The patient’s chest tube was removed on post-operative day 9 and she was discharged to home hospice. This case highlights the successful treatment of an esophagopleural fistula via a rendezvous endoscopic approach through a previously placed PEG tract when standard endoscopic access has failed.