Successful Esophago-Pleural Fistula Closure via Esophageal Stent-in-Stent Anchored With Endoscopic Suturing

Abstract

Clinical Vignette: A 70-year-old male with a past medical history of metastatic distal esophageal squamous cell cancer status-post chemoradiation complicated by distal esophageal stricture, esophago-pleural fistula, and right-sided empyema with chest tube placement presented with an increase in purulent chest tube drainage. The patient was previously treated with a 23mm x 155mm esophageal fully covered self-expanding metallic stent (FCSEMS) for dysphagia secondary to stricture with no evidence of fistula or leak on esophagogram prior to discharge. Esophagogram during his most recent admission showed distal stent migration and a fistulous communication between the esophagus above the proximal end of the distally migrated stent (black arrow-head) and pleural cavity (esophago-pleural fistula; black arrows) [Image A]. The existing stent was pulled up proximally using a rattoothed forceps and repositioned to cover the esophageal fistulous opening. A second 23 mm x 120 mm FCSEMS was placed overlapping into the prior stent (stent-in-stent). The proximal end of this stent was anchored with endoscopic suturing. Follow-up esophagogram showed overlapping SEMS with no contrast leakage [Image B]. Discussion: Gastrointestinal leaks and fistula have classically been managed surgically; however, endoscopic techniques have emerged providing a viable and less invasive approach. Intrathoracic leaks, as illustrated on this patient's esophagogram, have a higher mortality rate compared to cervical leaks. Endoscopic approaches may involve a variety of closure devices including endoscopic clip placement (through-the-scope clips and over-the-scope clips), endoscopic suturing, endoscopic glue application, as well as luminal stenting as was chosen for this patient. SEMS, despite a known failure rate of up to 15%, remain a useful option. Most complications arise as a result of stent migration with recent studies demonstrating FCSEMS migration rates between 30-60%. Stent-anchoring methods, including endoscopic clipping and suturing, have been used to reduce the risk of migration. Endoscopic suturing has been shown to be more effective in preventing stent migration compared to endoscopic clipping. Here we present a case of successful esophago-pleural fistula closure via stent-in-stent placement, with stentanchoring using endoscopic suturing.Figure 1