Esophageal-pleural Fistula Research Articles

CARINAL RECONSTRUCTION FOR LUNG CANCER AND AIRWAY TUMORS: LONG-TERM RESULTS

Resection and reconstruction of the carina infiltrated by NSCLC or airway tumor is a technically demanding operation allowing oncologic radical treatment. Hereby we report the results of a 20-year experience from a high-volume center. Forty-one patients underwent carinal resection for NSCLC (n=32) or primary airway tumor (n=9). Right tracheal-sleeve pneumonectomy was performed in 19 patients, left tracheal-sleeve pneumonectomy in 6, isolated carinal resection in 4 and right tracheal-sleeve upper lobectomy in 12. In 8 patients Superior Vena Cava replacement was associated. Extra-Corporeal-Membrane-Oxygenation was used in 4 patients undergoing isolated carinal reconstruction. Nine patients received neoadjuvant chemotherapy. Complete resection (R0) was achieved in 97.5% of patients. Postoperative 30-day mortality was 7.3%(n=3). The major complication rate was 24.3%(n= 10). Airway complications were 7 (2 anastomotic fistula, 5 anastomotic stenosis requiring dilatation and stenting); other major complications included 1 esophageal-pleural fistula, 1 pneumonia and 1 pulmonary edema. Among the 32 NSCLC patients, 26 were pathologic stage III and 6 pathologic stage II. The recurrence rate was 34.2%(n=13); it was 41.3%(n=12) in NSCLC and 11.1% (n=1) in airway tumors. Three and 5-year Overall Survival (Kaplan-Meier) was 56.1% (NSCLC:50.8%;Airway:76.2%) and 50.5% (NSCLC:44.5%;Airway:76.2%), respectively. Disease-Free Survival was 61.7% (NSCLC:55.2%;Airway:85.7%) at 3 years and 55.5% (NSCLC:48.3%;Airway:85.7%) at 5 years. Carinal reconstruction for lung and airway tumors resection is a complex, oncologically reliable procedure allowing good long-term results in adequately selected patients. Wherever possible, these operations should include parenchymal sparing techniques allowing to spare healthy lung tissue without compromising the radicality of resection.

339. MANAGEMENT OF OESOPHAGO-PLEURAL FISTULAS WITH ENDOSCOPIC VACUUM THERAPY: A PROMISING APPROACH

Abstract Background Boerhaave syndrome is a rare and serious condition requiring prompt management to prevent severe complications and improve patient outcomes. One significant complication is an oesophago-pleural fistula. These fistulas often result in aspiration pneumonia, empyema, and mediastinitis. Conventional management with surgery has high complication and mortality rates. Endoscopic vacuum therapy (EVT) is a less invasive technique for the management of oesophageal fistulas, involving endoscopic placement of a vacuum-assisted sponge within the oesophageal defect, promoting healing via continuous wound drainage and tissue granulation. Methods We report the case of a gentleman who initially presented with Boerhaave syndrome, was treated with open oesophageal repair, and was re-admitted 3 weeks later for an oesophago-pleural fistula with pleural collections. EVT was administered to the oesophageal defect twice weekly for 29 days and the effectiveness of therapy was monitored with serial oesophagogastroduodenoscopies, contrast studies, and computed tomography scans of the thorax to monitor the resolution of the pleural collections. During this period, the fistula defect showed gradual granulation tissue growth, resulting in full closure of the mucosal defect. Results The use of EVT has shown to result in successful closure of fistulas, resolution of sepsis with reduced need for surgical intervention, and shorter hospital stays. EVT combines coverage of the oesophageal defect and adequate drainage of the cavity behind the defect, often without the need for additional external drain placement. These findings highlight the role of EVT as a valuable adjunct in the management of oesophageal fistulas, particularly in cases requiring rescue therapy. Limitations of EVT include risk of bleeding, fistula formation/recurrence, need for frequent endoscopic interventions, stricture formation, and inability for oral intake due to occlusion of the gastrointestinal tract. Conclusion EVT represents a paradigm shift in the management of oesophageal fistulas, offering a less invasive alternative with the ability to promote wound healing, control sepsis, and reduce the need for high-risk redo oesophageal surgery. Further prospective studies and trials are needed to reach a consensus about its technical aspects, such as pressure settings and procedure intervals; as well as to evaluate its efficacy as a potential first-line treatment for oesophageal fistulas.

Closure of esophageal-pleural fistula using a cardiac occluder in a patient with systemic scleroderma.

Closure of esophageal-pleural fistula using a cardiac occluder in a patient with systemic scleroderma.

Treatment of Esophageal-Pleural Fistula After Diverticulectomy Using Transluminal Vacuum Therapy in a Patient with HIV Infection

Abstract A clinical observation of the successful treatment of an HIV-infected patient with esophageal-pleural fistula and pleural empyema after diverticulectomy is presented, where the key tactical decision was the use of transluminal vacuum therapy together with adequate drainage of the pleural cavity and correct drug therapy. When analyzing the available literature, no publications concerning the treatment of HIV-infected patients with the discussed esophageal pathology were found.Aim of study To discuss the Results of treatment of postoperative esophageal-pleural fistula using transluminal vacuum therapy in a patient with HIV infection.

Enigma of Esophageal - Respiratory Fistula in Advanced Esophageal Cancer

Background: The incidence of malignant esophageal-respiratory fistulas in esophageal cancer patients is not so frequent. The fistula development in esophageal cancer may be due to advanced disease or a radiotherapy-related complication. Rarely, a pulmonary abscess may develop, which is the most dreadful complication resulting in dismal outcomes. Here, we reported 2-cases of esophageal-respiratory fistula; one with esophageal bronchial fistula and the other with esophageal pleural fistula.
 Case reports: A 46-year-aged man presented with complaints of difficulty in swallowing for 4 months. CECT chest showed an esophageal growth of 8.5 cm in the lower esophagus. The patient received palliative radiotherapy followed by palliative chemotherapy and showed some improvement in dysphagia. Nine months after the start of treatment, the patient’s dysphagia began to worsen, and he was put on oral metronomic chemotherapy. After 1-year of metronomic chemotherapy, the patient developed cough and chest pain and was diagnosed with an esophageal-pleural fistula with chest wall collection and pleural effusion. The patient was managed conservatively and later lost to follow-up. Another 65-year-old patient presented with dysphagia for 3-months. CECT chest showed an esophageal growth of 5.5 cm in the middle esophagus. The patient received palliative radiotherapy, after which the dysphagia improved. In 3rd month of follow up patient’s dysphagia worsened; barium swallow showed esophageal-bronchial fistula. The patient was managed symptomatically and later lost to follow-up.
 Conclusions: Fistula formation and subsequent abscess results in a poor prognosis. With advancing disease and compromised general condition of the patient, palliation of symptoms is a significant challenge. Treatment becomes difficult due to the rare occurrence of fistulas and the non-standardization of the treatment protocol. Invasive treatment includes esophageal-pulmonary resection, endoscopic placement of self-expandable covered stents, drainage of empyema and obliteration of empyema cavity, esophageal diversion, and non-invasive treatment includes best supportive care. However, even with appropriate treatment, the outcome is dismal.

Esophageal-Pleural Fistula: the Cause or Effect of Recurrent Pneumonia?

Esophageal-pleural (E-P) fistula is introduced to be an uncommon clinical finding maybe due to non-specific clinical pointers and vague radiologic clues. In this regard, the main drivers are esophageal traumatization, endoscopic dilation, irradiation and corrosive agent ingestion as well as major underlying esophageal diseases like carcinomas and tuberculosis. The presented case is a 51-year-old man with medical record of recurrent pneumonias resulted in right lobectomy who admitted to the medical institution with a significant empyema leading to chest tube insertion. It should be noted that the presence of food particles in the chest bottle in addition to the history of previous surgery raised suspicion of a post-surgical E-P fistula formation. Attempts were made to find fistula tract and insert an esophageal stent bypassing the fistula opening. However, investigations argued against E-P fistula as an ensuing event after surgery and arose the question that whether E-P fistula would be the cause or effect of pneumonia in the presented case?

Incessant Pleural Drainage - Can It Be a Masquerading Esophageal-Pleural Fistula?

Spontaneous esophageal-pleural fistula (EPF) is extremely rare. We present a case of a 52-year gentleman who presented with shortness of breath and decreased appetite, whose chest X-ray and ultrasonogram of thorax depicted a pleural effusion like picture. Intercostal drainage tubes were inserted to alleviate his dyspnea. Plain computerized tomography (CT) thorax initially revealed a pleural cyst, which was surgically drained. Subsequent CT thorax with contrast and barium swallow revealed EPF, which was confirmed with endoscopy. Pleural fluid analysis revealed candida as the cause of EPF. Candida as a cause of EPF that too in an nonimmunocompromised patient is very rare. Multidisciplinary approach is required to diagnose and prevent mortality in such cases.

Spontaneous Oesophagopleural Fistula as the Underlying Cause of Hydropneumothorax

Spontaneous Oesophagopleural Fistula as the Underlying Cause of Hydropneumothorax

Treatment of chronic esophageal-pleural fistula as a result of spontaneous rupture of the esophagus (Boerhaave’s syndrome) in patient with achalasia cardia using an endoscopic vacuum therapy

A patient with achalasia cardia after surgery for spontaneous rupture of the lower third of the esophagus developed failure of surgical suturing and a chronic esophago-pleural fistula. A control computed tomography of the chest with contrasting of the pleural cavity through the drainage revealed a filiform bronchial fistula. After the completion of endoscopic vacuum aspiration therapy, which consisted of four sessions, positive dynamics was noted in the form of the absence of air and fluid inflow through the drainage, as well as a significant decrease in the fistula orifice according to the endoscopic examination. A positive result was confirmed by X-ray, fistulography and computed tomography with contrasting—no contrast agent was received outside the esophagus and into the left bronchus. 5 months after discharge from the hospital, the patient underwent a combined course of endoscopic balloon dilatation with a good effect due to stage 3 achalasia cardia. According to computed tomography, endoscopic and X-ray examinations, there is no recurrence of the fistula.

IATROGENIC ESOPHAGEAL PLEURAL FISTULA POST-TRANSESOPHAGEAL ECHOCARDIOGRAM: A CASE REPORT

IATROGENIC ESOPHAGEAL PLEURAL FISTULA POST-TRANSESOPHAGEAL ECHOCARDIOGRAM: A CASE REPORT

УЛЬТРАЗВУКОВАЯ ДИАГНОСТИКА ПРИ ФОРМИРОВАНИИ ПИЩЕВОДНОПЛЕВРОКОЖНЫХ ФИСТУЛ

The aim of the study was to study the effectiveness of ultrasound diagnostics in the adhesion of pleural leaves in the formation of esophagopleurocutaneous fistulas. Material and methods. The data on treatment of 19 patients (9 - main group, 10 - control group) who were treated with esophageal perforation in the department of thoracic surgery of Brest Regional Clinical Hospital using diagnostic ultrasound were analyzed. Results. The technique of performing ultrasound examination was determined. The “zone of interest” was visualized in the B-mode with the definition of a hyperechoic line and drainage nearby. The displacement of the visceral pleura together with the lung tissue relative to the parietal pleura indicated the presence of pleural adhesions. Simultaneously detected sign "barcode" in the M-mode was a sign of pleural adhesion, which was maintained constantly during chest excursion. This method was used to determine the prevalence of the area of adhesions, and subsequently the issue of traction or removal of drainage in postoperative patients during the formation of a fistula was resolved. Conclusions. Ultrasound diagnostics in the formation of esophageal pleural fistula in patients with esophageal damage contributes to the detection of early complications, timely removal of drains and reduction of hospitalization time.

Esophagopleural fistula, hidrothorax. Presentation of a clinical case and review of the literature

Brenda Kintaitė1, Paulina Tekoriutė1, Ieva Petrauskaitė1, Monika Matuliauskaitė1, Aistė Šakalytė1, Julius Vidikas2 1 Lithuanian University of Health Sciences, Academy of Medicine, Faculty of Medicine, Kaunas, Lithuania 2 Lithuanian research center of health sciences Abstract Background: esophagopleural fistula is a rare pathological connection among digestive and respiratory systems. The are many different causes of it but usually, it is related to endoscopic and surgical interventions, oncological processes. The symptoms of this disease are non-specific, patients complain of retrosternal chest pain, fever, dyspnoea, dysphasia, cough. The most valuable test for diagnosing esophagopleural fistula is chest computed tomography (CT) with intravenous contrast. Possible treatments are conservative or invasive Aim: this study aimed to reveal the clinical manifestations and managements of esophagopleural – fistula, to review the latest scientific literature on this topic, and to acquaint doctors of various fields with the clinical features, diagnosis and treatment options of this rare pathology. Methods: a review of the literature using the PubMed database, a selection of scientific publications addressing the topic of esophageal pleural fistula, and a clinical case of the disease was presented. Conclusion: the esophagopleural junction is a rare complication with no specific clinical manifestations which complicates the diagnosis of pathology. A detailed history and prompt diagnosis are essential because esophagopleural fistula is associated with life-threatening complications and high mortality. Chest CT with intravenous contrast is the most accurate method for diagnosing this pathology. Although pleuroesophageal fistula can be treated conservatively in some cases, it is extremely rare for this treatment to be effective. Endoscopic treatment options and sometimes surgical interventions are much more common. Keywords: esophagopleural fistula, pneumohidrothorax, esophageal stents, stents.

Bevacizumab-induced esophageal pleural fistula during maintenance therapy without radiation in lung cancer

BackgroundEsophageal pleural fistula (EPF) is a rare but fatal complication associated with bevacizumab use; however, cases reports of EPF caused by bevacizumab have not been previously published.Case presentationA 66-year-old male patient diagnosed with stage IV lung adenocarcinoma on April 24, 2020 received 6 cycles of platinum-containing dual chemotherapy combined with bevacizumab followed by three cycles of bevacizumab monotherapy. Five days before admission, he experienced chest tightness, dyspnea, and right chest pain. Bed-side X-ray examination revealed a massive right hydrothorax, and food was found in the extracted pleural effusion. EPF was further confirmed by upper gastrointestinal radiography after oral administration of iohexol. The patient underwent jejunostomy as the distal esophagus could not be identified on gastroscopy, and eventually died of septic shock on January 16, 2021.ConclusionsIt is necessary to pay attention to EPF during bevacizumab use in patients with or without risk factors.

S3558 Esophageal Candidiasis Leading to Spontaneous Esophageal Rupture

Introduction: Spontaneous esophageal perforation (SEP) is a rare and potentially life-threatening condition usually caused by esophageal trauma due to instrumentation or prolonged vomiting and retching. SEP due to esophageal candidiasis (EC) is extremely rare. We present a case of SEP in a patient with EC despite treatment with systemic antifungals. Case Description/Methods: A 53-year-old woman with a history of stage IV lung adenocarcinoma treated with chemoradiotherapy and immunotherapy presented with fever, abdominal pain, diarrhea and hematochezia. Her symptoms were consistent with immune-checkpoint inhibitor colitis, similar to a recent episode that improved with corticosteroids. She has a history of radiation esophagitis in the form of superficial ulceration and stenosis affecting the proximal esophagus. High-dose intravenous corticosteroids were initiated. Due to minimal response, infliximab was administered. Colonoscopy was unremarkable and random biopsies were negative for cytomegalovirus (CMV). Upper endoscopy (EGD) revealed resolution of the initially seen ulceration and no evidence of stricture or stenosis. However, a new distal superficial esophageal CMV ulcer was found. CMV viral load was 6,810 IU/mL and was successfully treated with intravenous ganciclovir leading to viral clearance. EGD for ongoing hematochezia revealed severe esophageal candidiasis (EC) confirmed with histopathology (Figure 1). Despite completing a 14-day course of intravenous fluconazole was, she developed septic shock due to SEP leading to a hydropneumothorax (Figure 2 and 3). Pleural fluid culture was positive for C. albicans. At that stage, family decided to enroll her in home hospice where she died a few days later. Discussion: Although, EC is not uncommon in immunocompromised patients, it is usually treated successfully with antifungal agents in 80-90% of cases. Transmural invasive Candida infection, however, is exceptionally rare with only 4 confirmed cases in the literature. It may lead to esophageal perforation and esophageal-pleural fistula formation. A second-look EGD with culture and sensitivity is recommend in symptomatic patients with EC who fail to improve with treatment. However, there are no guidelines recommending a repeat EGD in immunocompromised patients who initially had minimal symptoms. Our case suggests that for those patients a repeat EGD should be done to ensure resolution of EC and discontinuation of immunosuppressive therapy should be considered.Figure 1.: Endoscopic picture showing mucosal yellow-white plaques throughout entire esophagus, consistent with candidiasis.Figure 2.: Non-enhanced CT (axial view) demonstrating right hydropneumothorax with loculated fluid components.Figure 3.: Esophagram with extravasation of contrast from superior upper esophagus extending into right upper chest.

The predictive value of fruit juice in the esophagus-pleural fistula

Esophageal-pleural fistula is a rare and challenging condition to diagnose and requires strong clinical suspicion in order to be recognized promptly. Chest computed tomography (CT) with contrast medium for oral contrast medium (OS) is the gold standard for diagnosis. The definitive therapy is purely surgical, except for a few selected cases that benefit from endoscopic therapy. Our case involves a 45-year-old woman who came to the Emergency Department with dyspnea and thoracalgia. Chest X-ray and high-resolution CT showed empyema and pleural effusion to the left hemithorax. The lack of improvement despite the therapy and a subsequent clinical finding gave rise to the suspicion of esophageal-pleural fistula, confirmed with CT with contrast medium for OS. In this case, we opted for endoscopy correction of the esophageal defects. The diagnostic delay and the pre-existing comorbidities (previous kidney transplant for chronic kidney disease from lupus nephritis, high blood pressure, familiarity with Ischemic cardiomyopathy) could justify the inauspicious course of our case.

P166 SPONTANEOUS ESOPHAGEAL RUPTURE – BOERHAAVE SYNDROME

Abstract Aim To study the most effective method of treatment in patients with spontaneous rupture of the esophagus. Background The timely diagnosis of Boerhaave syndrome presents great difficulties due to its rarity, a variety of clinical manifestations, often simulating different pathologies from other organs and are difficult to treat. Methods From 2003 to 2019 9 patients with Bourhave's syndrome were treated at the clinic, primary care was provided to 6 patients in the community. All patients were admitted to the clinic with external left-sided esophageal-pleural fistula, 1 patient had a spontaneous rupture of the esophagus in the cliniс, the defect of the esophagus wall defect was completed, which led to successful results. Results Treatment in the remaining patients was started with adequate enteral nutrition and effective drainage of the pleural cavity. As a result of the use of pleural double-lumen drainage with active sanation with antiseptics and subsequent aspiration, with the exception of feeding through the mouth in four patients, it was possible to eliminate the esophageal-pleural fistula, profuse bleeding and death of the patient. Against the background of ongoing conservative therapy in two patients, it was not possible to eliminate the esophago-pleural fistula. A left-sided thoracotomy was performed with excision of the fistula with the decortication of the lung and the extirpation of the esophagus with the formation of an esophagostomy. Subsequently, these patients underwent retrosternal colic esophagoplasty. Two patients underwent Lewis surgery with drainage of the pleural cavity. Conclusion Boerhaave syndrome has a very high mortality rate, however, with a timely diagnosis and adequate surgical tactics, it develops into the formation of an esophageal-pleural fistula. In this case, the most effective treatment is excision of the fistulous course with extirpation of the esophagus and subsequent esophagoplasty. The use of esophageal stents is possible in extremely depleted patients or in elderly patients, due to the frequent occurrence of hypergranular esophagitis. Esophageal stents should be removed as soon as possible when confidence in the elimination of the esophageal-pleural fistula occurs.

Endoscopic restenting of the esophagus after removal of three partially covered stents in a patient with an esophageal-pleural fistula

Endoscopic restenting of the esophagus after removal of three partially covered stents in a patient with an esophageal-pleural fistula

Rationale for the choice of operations in esophageal leiomyoma.

Operations on the esophagus occupy an important place in the surgery of the gastrointestinal tract, since this organ passes through three anatomical regions: the neck, thoracic and abdominal cavity. The main pathologies for surgical interventions are congenital malformations, injuries, foreign bodies, burns and scarr y strictures , neuromuscular diseases of the esophagus, hernia of the esophagus and reflux esophagitis, diverticula, acquired fistula, esophageal cancer, benign tumors and cysts. For the majority of these conditions clear recommendations o n diagnosis and treatment have been developed. In the literature, there is no consensus on indications for conservative or surgical treatment of patients with esophageal leiomyoma and the type of surgical intervention: 1) resection of the esophagus 2) removal of the tumor with part of the wall; 3) enucleation of the tumor; 4) endoscopic removal. Mortality after resection of the esophagus or its wall with plastic is 13%, and after enucleation of leiomyoma – 2%. In our clinical study, the analysis of the performed operations on patients with leiomyoma of the esophagus was performed. The aim – to make a retrospective analysis of different types of surgical interventions in patients with esophageal leiomyoma performed in the thoracic departments of the National Cancer Institute, Kiev City Clinical Cancer Center, Kiev Clinical Hospital N 17, Zhytomyr Regional Hospital, Vinnitsa Regional Hospital. Retrospective evaluation of 66 patients with morphologically confirmed esophageal leiomyoma was made . The following types of imagining were performed in patients: radiological examination of esophagus with solution of barium sulphate and radiography, computed tomography of the chest (CTc), computed tomography angiography (CTA), magnetic resonance contrast-enhanced imaging (MRI TO). Instrumental methods : esophagogastroduodenoscopy (EGD) with biopsy, endoscopic ultrasound, endoscopic ultrasound-guided fine needle aspiration biopsy (EUS-FNA). The type of surgical interventions: proximal gastrectomy (n=3); Garlock operation (n=2); Lewis operation (n=3), resection of the tumor with part of the esophageal wall (n=6); tumor enucleation (n=52). Complications after operations in the early period: postoperative bleeding - the source is not identified, failure of the esophageal wall seam. In the late postoperative period – esophageal pleural fistula in two patients and esophageal stenosis in one patient. Indication for removal of leiomyomas: severity of symptoms, tumor size more than 5 cm, multiple leiomyomas, transition onto the stomach, patient's persistent desire, increase of volume in dynamics, changes in mucosa over the mass . Indications for resection options for surgery: adhesion of the tumor with the mucosa for more than three centimeters, the inability to exclude the malignant process, the giant esophageal leiomyoma with the transition onto the stomach. Patients who underwent non-surgical operations had a shorter postoperative hospital stay, fewer complications and a better quality of life. According to our results, preoperative biopsy with intact mucosa is not informative, but also does not increase the number of perforations.

A Strange Connection: Spontaneous Esophageal-Pleural Fistula

Esophageal-pleural fistula (EPF) is a rare clinical entity with a high degree of morbidity and mortality. The unfamiliarity of this condition, along with non-specific clinical presentations and elusive imaging findings makes it a diagnostic challenge. Our goal in presenting this case is to increase the awareness of spontaneous EPF among clinicians. A 64-year-old man who presented with a mechanical fall was found to have a right-sided hydropneumothorax on his chest radiography. A chest tube was placed, after which the patient complained of pain at the site of the tube. He denied any other symptoms and remained afebrile, but was tachycardic and tachypneic. A computed tomographic image of the chest showed small right apical and anterior basal pneumothorax with right-sided chest tube traversing right upper lobe and a small pleural effusion. His chest tube drained approximately 4.5 liters of purulent-appearing fluid overnight and due to concern for empyema, patient was started on broad spectrum antibiotics. Fluid analysis was significant for a pH of 5.56, fluid protein of 0.9 grams/deciliter, glucose of 1088 milligram/deciliter, white blood cell count of 1750 cells/microliter and lactate dehydrogenase >1300 Units/liter. The patient's hospital stay was complicated by melena with a hemoglobin drop from 8.1 to 4.5 grams/deciliter. Urgent endoscopy revealed LA grade D esophagitis and a fistulous tract leading to the right pleural space. Within the tract, retained pills and the patient's chest tube were seen. An esophageal stent was placed. Follow-up barium esophagram showed contrast leakage into the pleural space. The patient was discharged after J-tube placement. Repeat esophagram 14 days later demonstrated improvement in contrast extravasation into the pleural space. Traditionally, cases of EPF have been associated with malignancy, infection or instrumentation, with only a handful of cases occurring spontaneously. Chest imaging is the primary modality in the diagnosis of EPF. Other diagnostic clues include a high output pleural effusion and elevated glucose in the pleural fluid, as seen in our patient. Food particles can also be identified in the pleural space. Management of EPF varies according to the site, size and severity of perforation. Conservative therapy includes drainage of the fluid with gastrostomy or jejunostomy placement for nutrition. Stenting or surgical intervention may be performed, depending on clinical judgment and expertise.1750_A Figure 1. Upper endoscopic view showing LA grade D esophagitis with normal GE junction (left) and opening of fistulous tract approximately 36 cm from entry site (right).1750_B Figure 2. Chest tube and retained pill within fistulous tract leading to right pleural space.1750_C Figure 3. Barium esophagram (left) demonstrating contrast extravasation (blue arrows) from distal esophagus into long narrow fistulous tract projecting over spinal column into right pleural space. Repeat study (right) 14 days later showing narrowing of fistulous tract (red) of contrast extravasation.

Endoscopic Vacuum Therapy for the Treatment of Upper Gastrointestinal Transmural Defects

Upper gastrointestinal transmural defects are associated with a high morbidity and mortality. Stents are the first-line endoscopic approach, however, their efficacy varies considerably and are associated with important adverse events (AEs). Endoscopic vacuum therapy (EVT) is a new approach to this condition. We performed a single-center retrospective study that evaluated patients with upper gastrointestinal transmural defects that underwent EVT between May 2017 and May 2018. EVT was performed using the Endo and Eso-Sponge system (B. Braun, Melsungen, Germany). Continuous negative pressure of 100 mmHg, generated by an electronic vacuum pump system was applied. Whenever possible the sponge was placed in an intracavitary position. Sponge replacement was performed every 3-7 days. Five patients (3 males) with a median age of 58 years were referred for EVT due to anastomotic leak after distal esophagectomy (n=2), gastrojejunal leak following Roux-en-Y gastric bypass (n=1), gastropleural fistula post-sleeve gastrectomy (n=1) and esophageal-pleural fistula after esophageal diverticulectomy (n=1). In 80% of cases, the size of the cavity was greater than 20 mm and there was an associated cavity in 100%. EVT was used as the first-line endoscopic treatment in 1 patient and in the remainder after stent failure. After a median of 5 procedures (IQR 4-6), complete closure of the defect was seen in 2 patients (40%). In another patient, after almost complete reduction of the cavity, effective closure was achieved after application of an OTSC (Ovesco, TSymbolbingen, Germany). These 3 patients were discharged after a median of 43 days (IQR 39-50) since the beginning of EVT therapy. In the remaining 2 patients, there was a decrease in dimensions of the defect, without closure, with placement of a biodegradable stent in one and need of revision surgery in the other patient. EVT is a promising approach in the treatment of upper gastrointestinal transmural defects, even after stent failure. It appears to be most effective when performed intracavitarily. Despite the need for multiple procedures, it can lead to complete closure of the defect, avoiding the need for surgery.Symbol