S2335 Nasopleural Drainage of Empyema via Esophago-Pleural Fistula: A Novel Endoscopic Rescue Technique

Abstract

INTRODUCTION: Esophago-pleural fistulas (EPF) are rare entities. These can occur spontaneously or following surgical manipulation and can result in empyema formation. Treatment of empyema in this patient population is difficult, and a variety of techniques have been described. Here, we present a novel rescue technique for empyema management via endoscopy, when percutaneous and surgical techniques were not feasible. CASE DESCRIPTION/METHODS: A 90-year-old female presented with acute gastric volvulus requiring emergent partial gastrectomy and gastrostomy tube placement. Her clinical course was complicated by necrosis of the gastric cardia resulting in perforation and contamination of the mediastinum, requiring distal esophageal stump creation and multiple washouts. She was started on long term antimicrobial agents, with plans of maintaining esophageal discontinuity for six months prior to considering re-anastomosis. She was admitted five months later with high-grade fevers and leukocytosis of 21 k/uL. CT scan showed left-sided thick, loculated pleural effusion containing air, with a suggestion of EPF. She was unstable for surgical drainage. Due to complicated anatomy and dense fibrosis, a percutaneous chest tube could not be placed. An urgent transnasal endoscopy was performed using an ultra-slim scope. A small fistulous connection was noted between the distal esophageal stump and the left pleural cavity. The left pleural space was explored, and immediately upon entry, a large amount of purulent material was suctioned. After extensive lavage and cleaning with normal saline, a 16Fr nasopleural drain was placed over a soft tip 0.035 wire (450 cm) under fluoroscopic guidance. The drain was left on low intermittent suction. She had a remarkable clinical improvement within 24 hours. A week after conservative management, a percutaneous drain placement was successfully performed. Subsequently, the nasopleural drain was removed, and she was discharged on enteral nutrition via gastric tube. DISCUSSION: Empyema management ranges from conservative chest tube placement to aggressive surgical management. Endoscopic drainage is another option when percutaneous and surgical options are not possible. Our case demonstrates a novel rescue technique for the management of empyema in patients who already have an EPF and are not good candidates for conventional treatment. This technique can only be used short-term, as a bridge to definitive treatment.Figure 1.: A large amount of purulent material was found in the lower third of the esophagus. This was in continuity to the left pleural cavity.Figure 2.: This image demonstrates the irritation of the underlying mucosa, following extensive suctioning and lavage of purulent material.Figure 3.: A fluoroscopic view of the drain placement.