Esophagopleural Fistula Research Articles

Abstract 15549: Esophagopleural Fistula Associated Regional Pericarditis Mimicking Inferior Myocardial Infarction

Introduction: Regional pericarditis is a rare clinical entity that may mimic myocardial infarction (MI) and occurs most frequently after myocardial injury. We describe a unique case of regional pericarditis secondary to esophagopleural fistula (EPF) in a patient presenting to the catheterization lab for suspected ST-segment MI. Results: A 75-year-old man with non-small cell lung cancer presented with hypotension, weakness, dyspnea, and chest pain. The initial electrocardiogram (ECG: Figure 1) revealed normal sinus rhythm with inferior lead ST- segment elevations, a chest X-ray showed a left pleural effusion, and troponin I was <0.01 ng/ml. The patient underwent emergent coronary angiography showing no evidence of obstructive coronary disease. Subsequently, the patient reported palpitations and new onset dysphagia. An ECG revealed atrial fibrillation with rapid ventricular response. A barium esophagram (Figure 2) was performed to evaluate the dysphagia and revealed the presence of an EPF with fluid collection adjacent to the inferior heart border. The patient was treated for pericarditis with colchicine and definitive treatment with esophageal stenting was performed. Conclusions: We describe a case of regional pericarditis secondary to EPF masquerading as inferior MI. Given the prevalence and severity of MI, remaining cognizant of its mimickers such as regional pericarditis is important in clinical practice. This case report highlights the utility of maintaining a broad differential and performing a thorough history and physical both at initial presentation and when new information challenges the initial diagnosis.

ESOPHAGOPLEURAL FISTULA AFTER MULTI-HEART VALVE SURGERY AND CORONARY ARTERY BYPASS GRAFTING

SESSION TITLE: Medical Student/Resident Critical Care Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: October 18-21, 2020 INTRODUCTION: Esophageal perforation is an uncommon complication that carries significant morbidity and mortality (as high as 67.7% and 19.9%, respectively)1. It is commonly associated with advanced esophageal carcinoma, chemical injury after ingestion, radiation therapy, iatrogenic injury 55% , spontaneous perforation , foreign body and traumatic penetrating injury.2 CASE PRESENTATION: We present the case of a 67-year-old female with history of coronary artery disease, aortic stenosis, mitral and tricuspid insufficiency who underwent a 2-vessel CABG, tricuspid valve repair, aortic and mitral valve replacements. The patient’s micrognathia prevented intraoperative transesophageal echocardiography. On postoperative day 14, the patient developed a fever with a right sided pleural effusion requiring a chest tube. Over a period of 24 hours chest tube drainage turned milky white from straw colored. Fluid cultures grew multi-drug resistant pseudomonas, and the patient was started on appropriate antibiotics. On day 24, pink fluid resembling the patient’s strawberry supplement shakes was present in the chest tube drain. CT esophagram found contrast in the dependent portion of the right subpleural space, consistent with an esophagopleural fistula (figure 1). EGD showed a 5 cm esophageal opening starting approximately 30 cm from the incisors. This was treated with an esophageal stent, J-tube feedings and antibiotics. DISCUSSION: This case has several notable features in its presentation and its etiology remains unclear. The patient had no significant risk factors preoperatively that would have predisposed her to esophageal perforation. She did not have cirrhosis with esophageal varices or alcoholic history prominent in Booerhaves nor did she have a previous esophageal cancer history. The patient also had no transesophageal echocardiogram (TEE) performed or intra-operative trauma to the esophagus. If there had been an intraoperative occult injury of the esophagus, then it would have been anticipated much earlier. CONCLUSIONS: An esophagopleural fistula is a rare complication that can present after cardiothoracic surgery. As in this case, it can present as late as 4 weeks postoperatively. CT esophagram is the diagnostic method of choice and treatment requires prompt intervention with either a GI or thoracic specialist.3 Reference #1: 1.Schweigert, Michael, et al. “Spotlight on Esophageal Perforation: A Multinational Study Using the Pittsburgh Esophageal Perforation Severity Scoring System.” The Journal of Thoracic and Cardiovascular Surgery, vol. 151, no. 4, 2016, pp. 1002–1011 Reference #2: 2.Gimenez, Ana, et al. “Thoracic Complications of Esophageal Disorders.” RadioGraphics, vol. 22, 2002, pg 1001-1002 Reference #3: 3.Michel L, Grillo H C, Malt R A. Operative and nonoperative management of esophageal perforations. Ann Surg 1981; vol 194: 57–63 DISCLOSURES: No relevant relationships by Meghan Brennan, source=Web Response No relevant relationships by Edward McGough, source=Web Response No relevant relationships by Miguel Rovira, source=Web Response

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

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.

S1913 Esophagopleural Fistula Following the Treatment of Acute Esophageal Variceal Bleeding With Endoscopic Banding and Minnesota Tube Placement

S1913 Esophagopleural Fistula Following the Treatment of Acute Esophageal Variceal Bleeding With Endoscopic Banding and Minnesota Tube Placement

Therapeutic misadventure after use of cardiac septal occluder in an esophagopleural fistula

Therapeutic misadventure after use of cardiac septal occluder in an esophagopleural fistula

Refractory esophagopleural fistula post-lobectomy successfully treated by endoscopic submucosal dissection and over-the-scope clip.

Refractory esophagopleural fistula post-lobectomy successfully treated by endoscopic submucosal dissection and over-the-scope clip.

Emulsified stromal vascular fraction tissue grafting: a new frontier in the treatment of esophageal fistulas

A 54-year-old woman was admitted in an acute life-threatening condition with right pleural empyema in Boerhaave syndrome during chemotherapy. After right pleural surgical toilette, a Micro-Tech fistula occluding stent (A 30, B24-mm, Micro-Tech, Nanjing, China) was placed and fixed with Apollo overstitch during gastroscopy to occlude the perforation of the distal part of the esophagus. After resolution of the sepsis, the patient was discharged with normal oral intake. Two months later, stent removal was attempted, but the patient’s clinical condition dramatically worsened, and a gastrografin esophagogram showed persistence of a 2-cm esophagopleural fistula (A).

Perforación esofágica y fístula esófago-pleural durante la realización de CPRE

Perforación esofágica y fístula esófago-pleural durante la realización de CPRE

Proton beam re-irradiation for gastrointestinal malignancies: a systematic review.

Radiotherapy (RT) is part of the standard of care management of most gastrointestinal (GI) cancers. Even with advanced RT, systemic therapy, and surgical techniques, locoregional recurrences or second primary cancers can still occur within previously irradiated fields, which can present challenges in delivering effective and safe treatment. Options for reirradiation are often limited, but given the favorable dosimetric aspects of proton-beam RT, it may provide an effective and safe re-irradiation option for patients with recurrent or second primary GI cancers. We conducted a systematic review as per the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement protocol, assessing for reports of proton-beam reirradiation for recurrent or second primary GI cancers, primarily via PubMed. From the initial 373 articles identified, 7 articles were ultimately included in the analysis. The 7 included studies reported on proton-beam re-irradiation for the following disease sites: esophageal (n=2), pancreas (n=1), liver (n=2), rectal (n=1), and anal (n=1). Study sizes varied from as few as 1 to as many as 83 patients. Across studies, in patients who presented with tumor-related symptoms, palliation (stability/improvement) was achieved in 80-100% of the cases. Local control rates, with variable follow-up, ranged from 36-100%. All median overall survival values, when reported, were greater than 1 year. Across both liver studies, there were no cases of radiation-induced liver disease (RILD) from proton-beam re-irradiation. Across all studies, there were 2 acute (esophagopleural fistula in esophageal cancer, small bowel perforation in pancreatic cancer) and 1 late (esophageal ulcer in esophageal cancer) grade 5 toxicities, all favored to be due to progressive disease, rather than proton-beam re-irradiation. Two studies (1 esophageal, 1 rectal) generated comparison photon plans. One found that proton therapy reduced mean heart and lung doses, spinal cord dose, and lung V5Gy as compared to photon treatment, while resulting in higher lung V20Gy and V30Gy. The other found that protons decreased bowel V10Gy, V20Gy, and the dose to 200 and 150 cc of bowel, as compared to photons. Based upon the published experiences, proton-beam re-irradiation for recurrent or second primary GI cancers appears effective for palliation, with good disease-control, limited toxicity, favorable dosimetry, and overall compares well with published non-proton-beam experiences. Given short follow-up, additional studies are warranted to determine if dosimetric advantages from proton therapy will translate into comparative toxicity benefits.

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.

344 Multi-Modality Endotherapy of Esophagopleural Fistula (EPF) Using a Novel External Stent Anchoring Mechanism

INTRODUCTION: Esophagopleural fistula (EPF) is a condition associated with high morbidity and mortality. The management of patients with chronic, recurrent, nonmalignant EPF remains controversial and challenging. CASE DESCRIPTION/METHODS: A 61-year-old man with a history of esophagopleural fistula (EPF) in diagnosed in 2013 treated with covered esophageal stent and subsequent decortication with resolution of symptoms and esophageal leak who presented to the hospital with sepsis. Chest CT revealed a fistula between the distal esophagus and right pleural space with large right-sided hydro-pneumothorax with resulting near complete collapse of the right lower and middle lobes. Chest tube was placed with external wound suction by luminal vacuum sponge. GI were consulted for endoscopic management. Upper Endoscopy revealed a 20 mm fistula in the lower third of the esophagus. The decision was made to close the fistula with endoscopic suturing and placement of esophageal stent. Three days following the procedure the esophageal stent migrated distally. This was repositioned endoscopically and anchored with repeat Overstitch of endoscopic clips. This again was displaced after 4 days. Due to the patient poor conditional status and the absence of offers for nonsurgical options, an alternative method of anchoring of esophageal was explored in the form of an external anchoring. This was done by loading the stent and suturing the proximal end at 12 and 6 o’clock, the stent was loaded back and then deployed in the patient esophagus under flurouscopic guidance. Then, the previously placed anchoring suture material was located and brought out of the mouth using a forceps. The sutures then were rerouted into each nostril using a nasal gastric tube. Then these anchoring sutures were loosely tied at/around the nasal septum using a soft rubber tube to protect the nasal septum. The procedure was technically successful and the patients was discharged from the hospital three days later. After one month, the patient’s nutritional status improved, and he underwent definitive thoracic surgery at an outside facility. DISCUSSION: Self-expandable metal stents are increasingly used in the management of esophageal fistulas but their efficacy is limited by high migration rate. Previously described methods to prevent stent migration include the use of endoscopic clips and endoscopic suturing. We describe external anchoring technique to maintain the esophageal stent in position in a case when endoscopic suturing failed. Watch the video: http://bit.ly/2YiObuS

Neonatal and infantile fistulas: spectrum of findings on conventional contrast imaging with surgical correlation

BackgroundNeonatal and infantile fistulas are diverse and include many types. Conventional contrast images are used to delineate the fistulous tracts. The aim of this study is to illustrate the conventional radiological spectrum of neonatal and infantile fistula with surgical correlation.MethodsNeonates and infants with suspected fistulas were included in this study. The patients may be presented by cutaneous fistula with discharge, profuse oral secretion and cyanosis on feeding, or imperforate anus. After full clinical data were taken, plain X-ray, contrast imaging, and abdominal sonography were done to the patients. Treatment was tailored according to the case.ResultsOur study included 34 patients (25 boys and 9 girls): one case of branchial fistula; 2 cases with thyroglossal fistula; 10 cases of tracheo-esophageal, esophago-cutaneous, and esophago-pleural fistulas; 3 cases with vitello-intestinal fistula; one case with urachal fistula; 12 cases with recto-urinary, recto-vaginal, and recto-perineal fistula; 4 cases with peri-anal fistulas; and finally one case with iatrogenic urethra-cutaneous fistula. Radiological findings were well correlated with the surgical data.ConclusionMany types of neonatal and infantile fistulas were shown in this series including tracheo-esophageal, recto-urinary, and other neonatal fistulas. Radiological and surgical data were well matched.

Successful treatment of esophagopleural fistula following pulmonary resection for primary lung cancer: a case report

BackgroundWe report a rare case of esophagopleural fistula (EPF) developing during the postoperative period after pulmonary resection for primary lung cancer.Case presentationA 71-year-old male who underwent video-assisted thoracoscopic right lower lobectomy with lymph node dissection for primary lung cancer developed severe stabbing pain in his right shoulder and high fever 3 days after the operation. The fever persisted, the cough became more productive, and a plain chest X-ray showed slight a few infiltrative opacities in the right lung field. Intravenous antibiotic therapy was initiated. The patient developed a right pneumothorax 5 days after the operation, and contaminated discharge from the right chest tube was noted. A chest computed tomography showed right-sided empyema, while bronchoscopic examination revealed no evidence of a bronchopleural fistula. Open-window thoracostomy (OWT) was performed. Finally, 2 days after the OWT, the patient was diagnosed as having an EPF, because the right chest cavity was found to be contaminated with food materials. Ample purification of the right chest cavity was achieved by repeated dressing changes, and the EPF was finally closed by omentopexy. The post-surgical course was uneventful. Five weeks after the omentopexy, an esophagogram revealed no leakage of the contrast medium from the esophageal wall. The patient was discharged 13 weeks after the omentopexy.ConclusionWhile EPF following pulmonary resection is a rare complication, it can lead to critical situations and the diagnosis is difficult. Prompt OWT and omentopexy were found to be effective treatment procedures for EPF following lung surgery.

Endoscopic Closure of Esophagopleural Fistula With AMPLATZER Atrial Septal Defect Closure Device

Endoscopic Closure of Esophagopleural Fistula With AMPLATZER Atrial Septal Defect Closure Device

Treatment of esophagopleural fistula in patient with lung and mediastinal neurofibromatosis

Treatment of esophagopleural fistula in patient with lung and mediastinal neurofibromatosis

Self-expandable metallic stent application for the management of upper gastrointestinal tract disease.

The aim of the present study was to share our experiences of the use of self-expandable metallic stent for the upper gastrointestinal tract disease. We retrospectively reviewed the medical records of 18 patients who underwent self-expandable metallic stent implantation procedure for anastomosis stricture, anastomosis leak, or spontaneous fistula of the upper gastrointestinal tract at two different surgery clinics. Self-expandable metallic stent implantation procedures were performed while keeping the patient under sedation and the correct stent localization was verified using fluoroscopy. The stent localization and possible stent migration were checked using X-ray films taken a few days after the stenting procedure. Overall, 25 self-expandable metallic stents were implanted in 18 patients (malignant, 13; benign, 5) aged between 19 and 89 years. The indications for self-expandable metallic stent implantation were as follows: malignant gastric stricture (inoperable; n=6), malignant esophageal stricture (inoperable; n=4), staple line leak (laparoscopic sleeve gastrectomy; n=4), esophagojejunostomy anastomotic leak (total gastrectomy+Roux-en-Yesophagojejunostomy; n=2), and stricture (total gastrectomy+Roux-en-Yesophagojejunostomy; n=1), and esophagopleural fistula (pulmonary tuberculosis; n=1). A favorable outcome was achieved in a single session in 15 patients, whereas more than two sessions of stenting were necessary in the remaining three patients. Among the patients who underwent esophagojejunal anastomosis (n=3), self-expandable metallic stents were successfully deployed in a single session in two patients to relieve anastomosis leak (n=1) and anastomosis stricture (n=1); the remaining patients underwent four self-expandable metallic stent implantation procedures to relieve anastomosis leak and subsequent recurrent strictures. No complications developed during the stenting procedure. Three of the four patients who developed mortality had advanced stage esophageal cancer, whereas one patient had morbid obesity and developed staple line leakage. Endoscopic self-expandable metallic stent implantation under fluoroscopic guidance is a low-morbidity and effective procedure for the management of advanced stage tumors of the gastrointestinal tract and the elimination of postoperative complications.

Tracheopleural and esophagopleural fistula complicating corrosive-induced esophageal cancer

Tracheopleural and esophagopleural fistula complicating corrosive-induced esophageal cancer

Spontaneous Esophagopleural Fistula in A High Risk Individual (Trumpet Blower)

A middle aged male patient, trumpet blower by occupation presented with progressive dyspnea with chest heaviness for 2 weeks and low grade fever for 1 week. It started with sudden severe retrosternal chest discomfort and episodic vomiting during practicing trumpet blowing. Patient was toxic with high fever, tachycardia and tachypnoea. Clinicoradiologically patient was diagnosed as left sided hydropneumothorax. Intercostal chest tube was inserted at left 5th. intercostal space at midaxillary line following which pus and air came out. Pleural fluid was acidic with high amylase level and polymicrobial growth. Repeat chest x-ray showed partial resolution of left sided hydropneumothorax. From 4th. day food particles were noticed in the drainage bag. For screening 0.1% sterile methylene blue was given orally which came in ICD tube and bag within 24 hours. Subsequently barium swallow esophagus, CT thorax with oral and intravenous contrast and upper gastrointestinal endoscopy confirmed left sided esophagopleural fistula.Bangladesh J Medicine Jan 2017; 28(1) : 41-45

An unusual case of spontaneous esophagopleural fistula

Esophago-pleural fistula (EPF) is an uncommon condition, despite of an anatomical proximity of these structures. Causes of EPF include pneumonectomy for suppurative or tubercular disease of lung and carcinoma lung, malignancy of esophagus. Benign EPF is rare and may be due to trauma or infection. The most common infectious cause is tuberculosis. Spontaneous development of fistula between esophagus and pleura is rarely described in literature. We, hereby present a spontaneous case of such a rare entity in a middle-aged male.

Spontaneous esophagopleural fistula in a high-risk individual (trumpet blower)

A middle-age male patient, trumpet blower by occupation, presented with progressive dyspnea with chest heaviness since 2 weeks and low grade fever since 1 week. It started with sudden severe retrosternal chest discomfort and episodic vomiting while practicing trumpet blowing. Patient was toxic with high fever, tachycardia, and tachypnoea. Clinicoradiologically, patient was diagnosed as left-sided hydropneumothorax. Intercostal chest (ICD) tube was inserted at left 5th. intercostal space at midaxillary line following which pus and air came out. Pleural fluid was acidic with high amylase level and polymicrobial growth. Repeat chest X-ray showed partial resolution of left-sided hydropneumothorax. From 4th Day, food particles were noticed in the drainage bag. For screening, 0.1% sterile methylene blue was given orally which came in ICD tube and bag within 24 hours. Subsequently, barium swallow esophagus, CT thorax with oral and intravenous contrast, and upper gastrointestinal endoscopy confirmed left-sided esophagopleural fistula.