Esophagopleural Fistula Research Articles

S3372 Difficult to Stomach: A Case of Esophagopleural Fistula Complicated by Stent Migration

S3372 Difficult to Stomach: A Case of Esophagopleural Fistula Complicated by Stent Migration

Endoscopic vacuum therapy of a refractory esophagopleural fistula in a patient with Boerhaave syndrome, using an innovative hybrid stent.

Endoscopic vacuum therapy of a refractory esophagopleural fistula in a patient with Boerhaave syndrome, using an innovative hybrid stent.

Esophagopleural Fistula due to Ingestion of Corrosive Substance

Esophagopleural Fistula due to Ingestion of Corrosive Substance

Esophagopleural Fistula and Empyema Secondary to Esophageal Rupture Resulting From Ligation of Esophageal Varices: A Case Report

The treatment of esophageal varicesusually requires invasive procedures for the administration of sclerotherapy and ligation. Among the main related complications are pleuropulmonary location, esophageal fistula toward the pleura, and the development of pleural infection (empyema). In rarecases, the condition is caused by esophageal perforation.10,12We present here a report on a patient with left esophagopleural fistula and empyema as complications of sclerotherapy and the ligation of esophageal varices.

Management of a malignant esophagopleural fistula after stent failure with a suturing pexy: time to seal the leak.

Video 1Suturing pexy to seal a leak around an esophageal stent in the setting of a malignant esophago-pleural fistula.

Esophagopleural fistula complicated by pyopneumothorax in a patient with gray zone lymphoma

Esophagopleural fistula complicated by pyopneumothorax in a patient with gray zone lymphoma

Association Between Cardiovascular Substructure Dose and Death Without Progression after Chemoradiation for Locally Advanced Non-Small Cell Lung Cancer

<h3>Purpose/Objective(s)</h3> Prior work has focused on associations between radiotherapy dose to cardiovascular (CV) substructures and either overall survival (OS) or cardiac events. Death without progression (DWP) is a potentially more specific endpoint than OS for understanding radiation toxicity and easier to record than cardiac events. We assessed associations of CV substructure dose with DWP and OS after chemoradiation (CRT) for locally advanced NSCLC (LA-NSCLC). <h3>Materials/Methods</h3> We retrospectively reviewed records of 187 patients with LA-NSCLC who received definitive CRT (median 66.6 Gy) from 2008-2016 at a single institution. CV substructures, including both atria (BA), right atrium, left atrium (LA), both ventricles (BV), right ventricle (RV), left ventricle, pericardium, aorta, superior vena cava, and pulmonary artery, were defined on radiation simulation scans using a deep learning auto-segmentation model. Dose-volume histogram (DVH) metrics to CV substructures (mean dose, volume receiving ≥5 Gy [V5], V30, V50), whole heart, lung, and esophagus were extracted. DWP was modelled with Fine-Gray method; disease progression was a competing event. OS was modelled with Cox regression. For each CV substructure, associations between each DVH metric and DWP and OS were assessed, and the candidate DVH metric with the lowest p value was promoted to multivariable analysis. Multivariable models with the same baseline covariates but different DVH metrics were generated and ranked by Akaike information criterion (AIC) to select "best" models. Cutpoint analyses were done with Contal and O'Quigley method. <h3>Results</h3> 98 patients (52%) received proton therapy and 89 (48%) received photon therapy (68/89 intensity-modulated radiation therapy). At median follow-up of 28.8 months, 143 (76%) patients had died; overall, 25 (13%) experienced DWP. Causes of DWP included respiratory failure due to heart failure, COPD, pneumonia, or aspiration (n=10), out-of-hospital cardiopulmonary arrest (n=4), undifferentiated sepsis (n=2), probable radiation pneumonitis (n=1), esophagopleural fistula (n=1), and unknown (n=7). On multivariable analysis for DWP, best model included RV mean dose (AIC 222); 2^nd best included BV V5 (AIC 231). 3-year cumulative incidence of DWP was 21.3% vs 5.6% for RV mean dose ≥5.5 Gy vs <5.5 Gy (p=0.001). On multivariable analysis for OS, best model included LA V5 (AIC 1277.8); 2^nd best included BA V5 (AIC 1278.5). 3-year OS was 25.6% vs 46.3% for LA V5 ≥74.5% vs <74.5% (p=0.002). Associations were stronger among and driven by the photon subgroup. Proton therapy delivered lower dose to multiple CV substructures (e.g., RV mean dose, median 0.03 Gy vs 7.7 Gy; and LA V5, median 46.1% vs 78.1%; both p<0.0001). <h3>Conclusion</h3> Radiation dose to CV substructures showed different associations with DWP and OS. These results suggest DWP may be a meaningful endpoint for understanding CRT toxicity in LA-NSCLC.

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.

S2409 A Case of Esophago-Pulmonary Fistula From Esophageal Candidiasis Diagnosed on Endoscopy

Introduction: Esophago-pulmonary fistulas (EPFs) are abnormal connections between the esophagus and lungs that are rarely seen despite the proximity of the 2 structures. They are associated with high morbidity and mortality. Fistulization between the esophagus and lungs is a known complication of pneumonectomy procedures, but other causes include malignancies and infection. Case Description/Methods: A 61-year-old male with a history of tobacco and alcohol use disorder, diabetes mellitus, and esophageal candidiasis, with both Candida glabrata and Candida albicans isolated on biopsies from an otherwise normal endoscopy 4 months prior presented with presumed septic shock and melena. Blood cultures were positive for C. glabrata. Esophagogastroduodenoscopy (EGD) was done and revealed a fistulous tract leading to a bronchial bifurcation consistent with an esophago-pulmonary fistula with necrotic and friable tissue surrounding it (Figure A and B), in addition to grade D esophagitis. Subsequent CT chest showed definite right and possible left esophago-pleural fistulization with associated right loculated pleural effusion and small left pleural effusion (Figure C). No evidence of pulmonary malignancy or pulmonary tuberculosis was noted on imaging. Serum interferon gamma release assay and 3 sets of sputum acid fast bacillus testing for tuberculosis testing were negative. Thoracic Surgery were consulted but the procedure offered was multistage and did not align with patient's goals of care. The patient continued to decline despite antifungal and antibiotic treatment and was ultimately transitioned to hospice care. Discussion: While formal tissue diagnosis was not obtained in this case due to patient’s tenuous condition, the etiology of EPF was presumed to be invasive esophageal candidiasis infection, especially in the absence of malignancy on imaging and recent EGD. Interestingly, fistulas related to empyema were commonly reported in the pre-antibiotic era. A CT scan of the chest is useful for early diagnosis of EPF. While different modalities help establish the diagnosis of EPF, clinical suspicion remains key in initiating appropriate investigation.Figure 1.: A and B: Lower third of esophagus with necrotic tissue surrounding esophago-pleural fistula (arrows). C: (Axial CT showing an air-fluid level within the distal esophagus with loss of the fat plane between the esophagus (arrow) and the loculated right pleural effusion (dashed arrows), compatible with an esophago-pleural fistula).

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

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

Management of an esophagopleural fistula after resection of giant submucosal tumor of the cardia.

A 24-year-old woman was admitted with a large mass derived from the muscularis propria of the esophagus and the cardia. Submucosal tunneling endoscopic resection was performed. The size of the specimen was 10 × 10 cm, and the postoperative pathology was leiomyoma with red degeneration. After the tumor was removed, a huge tunnel cavity was left. We used metal clips to clamp the tunnel entrance ([Video 1]).

Diagnostic and Therapeutic Challenges in Treating an Esophago-Pleural Fistula Following Lung Transplantation

Introduction Esophago-pleural fistula (EPF) is a rare surgical complication with important morbidity and mortality. Generally, EPFs present as a recurrent or chronic respiratory infection, empyema, or hemorrhage. Diverse diagnostic and multimodal treatment strategies can be considered including stenting, endoluminal clipping, as well as surgical repair. We present the diagnostic and therapeutic challenges of a unique case of EPF after bilateral lung transplantation (BLTx). Case Report A 62-year-old male with scleroderma and secondary pulmonary arterial hypertension underwent BLTx under VA-ECMO for acute deterioration of his underlying lung fibrosis. Early recovery was uncomplicated with weaning from ECMO on post-operative day (POD) 2, successful extubation on POD 3 and discharge to the ward on POD 13. However, 2 days later he developed acute respiratory distress due to a right-sided pneumothorax. Chest drainage did not suffice and on POD 18 a thoracoscopic exploration for empyema was performed. On POD 26, semi-digested food was seen in the chest tube. Esophagogastroscopy with methylene blue confirmed leakage and two separate EPFs. Nil per os policy was started. On POD 32 endoluminal clipping was attempted and esophagogastroscopy showed healing of the upper fistula, though persistence of the lower one. Additional clipping of the distal EPF was performed. Despite clinical improvement, a new esophagogastroscopy on POD 71 revealed a new fistula between the endoluminal clips. Ultimately, the EPF was primarily closed and covered with an intercostal muscle flap trough right-sided thoracotomy on POD 105. Nine days after surgical closure, a contrast esophagogram showed no residual leakage. The patient experienced a slow but gradual recovery and oral intake was started successfully. At 2.5 years post-BLTx, the patient has a normal oral intake and spirometry shows a good pulmonary function without signs of rejection or chronic lung allograft dysfunction. Summary Post-operative EPF is a life-threatening situation, especially in immunocompromised patients. A low threshold of clinical suspicion and esophagogastroscopy are warranted to impede the diagnosis of EPF. In our experience, minimal invasive endoscopic strategies should be considered first, however, surgical treatment with primary suture and muscle coverage has the highest chance to be effective. Esophago-pleural fistula (EPF) is a rare surgical complication with important morbidity and mortality. Generally, EPFs present as a recurrent or chronic respiratory infection, empyema, or hemorrhage. Diverse diagnostic and multimodal treatment strategies can be considered including stenting, endoluminal clipping, as well as surgical repair. We present the diagnostic and therapeutic challenges of a unique case of EPF after bilateral lung transplantation (BLTx). A 62-year-old male with scleroderma and secondary pulmonary arterial hypertension underwent BLTx under VA-ECMO for acute deterioration of his underlying lung fibrosis. Early recovery was uncomplicated with weaning from ECMO on post-operative day (POD) 2, successful extubation on POD 3 and discharge to the ward on POD 13. However, 2 days later he developed acute respiratory distress due to a right-sided pneumothorax. Chest drainage did not suffice and on POD 18 a thoracoscopic exploration for empyema was performed. On POD 26, semi-digested food was seen in the chest tube. Esophagogastroscopy with methylene blue confirmed leakage and two separate EPFs. Nil per os policy was started. On POD 32 endoluminal clipping was attempted and esophagogastroscopy showed healing of the upper fistula, though persistence of the lower one. Additional clipping of the distal EPF was performed. Despite clinical improvement, a new esophagogastroscopy on POD 71 revealed a new fistula between the endoluminal clips. Ultimately, the EPF was primarily closed and covered with an intercostal muscle flap trough right-sided thoracotomy on POD 105. Nine days after surgical closure, a contrast esophagogram showed no residual leakage. The patient experienced a slow but gradual recovery and oral intake was started successfully. At 2.5 years post-BLTx, the patient has a normal oral intake and spirometry shows a good pulmonary function without signs of rejection or chronic lung allograft dysfunction. Post-operative EPF is a life-threatening situation, especially in immunocompromised patients. A low threshold of clinical suspicion and esophagogastroscopy are warranted to impede the diagnosis of EPF. In our experience, minimal invasive endoscopic strategies should be considered first, however, surgical treatment with primary suture and muscle coverage has the highest chance to be effective.

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.

Esophagopleural fistula treated with muscular ventricular septal defect occluder

Esophagopleural fistula treated with muscular ventricular septal defect occluder

Iliocostalis Muscle Rotational Flap: A Novel Flap for Esophagopleural Fistula Repair

Summary:Intrathoracic fistulas present major challenges to reconstructive surgeons. Reconstruction with muscle flaps have been shown to improve patient outcomes; however, there are patients for whom one or more of the commonly used muscle flaps is not available for several reasons. We describe the use of an iliocostalis muscle rotational flap for the repair of a caudally located esophagopleural fistula in the setting of definitive chemoradiotherapy for treatment of nonsmall-cell lung cancer and reirradiation with photons for local recurrence 5 years later. Our repair remained intact through the nearly 12-month follow-up period during which the patient tolerated a regular diet. This report demonstrates that the iliocostalis lumborum muscle is a viable option for repair of intrathoracic fistulas that are located in the distal esophagus, even in the setting of previous thoracotomy and radiation, and should be part of the reconstructive surgeon’s armamentarium in the management of intrathoracic fistulas.

Iatrogenic Esophagopleural Fistula After the Management of Acute Variceal Hemorrhage With Minnesota Tube Placement

ABSTRACTAn esophagopleural fistula (EPF) is a rare condition. EPFs are typically of spontaneous, iatrogenic, or neoplastic origin. A 50-year-old man with hepatitis C and alcoholic cirrhosis presented with a history of recurrent variceal hemorrhage requiring esophageal banding, Minnesota tube placement, and a transjugular intrahepatic portosystemic shunt. His hospital course after esophageal perforation and EPF was complicated by acute respiratory failure and empyema, necessitating intubation and thoracostomy tube placement. To the best of our knowledge, this is the first reported case of EPF secondary to Minnesota tube placement. The EPF completely healed after endoscopic repair.

Endoluminal vacuum therapy in the management of an esophago-pleural fistula as a complication of Boerhaave syndrome in a patient with eosinophilic esophagitis

BackgroundBoerhaave syndrome is an uncommon condition that represents about 15% of all esophageal perforation. A subset of these patients has eosinophilic esophagitis, a chronic inflammatory disease of the esophagus, that carries a risk of perforation of about 2%. Esophageal perforations can rarely result in the development of an esophago-pleural fistula. Treatment of esophago-pleural fistula represent a challenge due to lack of high quality evidence and scarce reported experience. Endoluminal vacuum-assisted therapy could have a role in the management by using the same principle applied in external wounds which provide wound drainage and tissue granulation.Case presentationWe report a unique case of a 24-year-old man with eosinophilic esophagitis complicated with an esophageal rupture who developed an esophago-pleural fistula and was successfully managed with a non-surgical approach using endoluminal vacuum-assisted therapy. To our knowledge this could be the first experience reported in a patient with eosinophilic esophagitis.ConclusionEndoluminal vacuum-assisted therapy might be an effective and novel strategy in patients with eosinophilic esophagitis and esophago-pleural fistula as a consequence of Boerhaave syndrome. Appropriately designed studies are required.

MA06.01 Death From Intercurrent Disease After Proton- Versus Photon-Based Chemoradiotherapy for Non-Small Cell Lung Cancer

Patients with locally advanced non-small cell lung cancer (LA-NSCLC) treated with chemoradiotherapy (CRT) often have cardiopulmonary comorbidities and receive significant radiation dose to normal structures. One way to reduce normal tissue exposure is with proton beam therapy (PBT). We sought to determine if PBT was associated with a reduced risk of death from intercurrent disease in this patient population. We retrospectively reviewed the records of 187 patients with LA-NSCLC who received definitive CRT with either PBT (n=98) or photon therapy (n=89) between December 2008 and November 2016 at a single academic center. No patient received consolidation immunotherapy as this cohort predated the results of the PACIFIC trial. Baseline patient-, tumor-, and treatment-related parameters were collected. Primary endpoint was death from intercurrent disease (DID), defined as death in the absence of disease progression. DID was compared between PBT and photon therapy groups using the cumulative incidence function and Gray’s test and modelled using the Fine-Gray method. Disease progression was considered a competing event. Secondary endpoint was overall survival (OS), assessed using the Kaplan-Meier method and Cox regression. The PBT group was older (median 69 years vs 62 years, p<0.001), had a more extensive smoking history (median 40 pack-years vs 30 pack-years, p=0.043), and had a greater burden of pre-CRT cardiovascular events (54.1% vs 34.8%, p=0.008). Median radiotherapy dose in both groups was 66.6Gy (range, 52.2-74Gy). The PBT group experienced lower mean heart dose (MHD) (median 6.7Gy vs 15Gy, p<0.001), total lung V5Gy (median 35.9% vs 48.2%, p<0.001), contralateral mean lung dose (median 0.97Gy vs 5.9Gy, p<0.001), and mean esophageal dose (MED) (median 22.1Gy vs 26.5Gy, p=0.003). Median follow-up was 28.8 months (range, 3.6-131.6 months). Following CRT, 25 patients (13.4%) experienced DID. Presumed causes of DID included: respiratory failure due to congestive heart failure, COPD, pneumonia, or aspiration (n=10), out-of-hospital cardiopulmonary arrest of unclear etiology (n=4), undifferentiated sepsis (n=2), probable radiation pneumonitis (n=1), esophagopleural fistula (n=1), and unknown (n=7). 3-year cumulative incidence of DID was 7.1% in the PBT group versus 14.6% in the photon therapy group (p=0.098). PBT (subdistribution hazard ratio [sHR] 0.25, p=0.0042), MHD (sHR 1.06/Gy, p=0.0018), and MED (sHR 1.05/Gy, p=0.019) were associated with a reduced, increased, and increased risk of DID, respectively, after controlling for age and ECOG performance status in three separate 3-variable regression models. OS was similar between the PBT and photon therapy groups (median 29 months vs 28.8 months, p=0.6; HR 1.09, p=0.6). MHD (HR 1.02/Gy, p=0.013) was associated with worse OS after controlling for age, ECOG performance status, baseline pulmonary comorbidity, and internal gross tumor volume. Patients receiving MHD >10Gy vs ≤10Gy experienced higher 3-year cumulative incidence of DID (15.6% vs 6.7%, p=0.049) and inferior OS (median 22.9 months vs 34.1 months, p<0.001). In this cohort of patients treated with definitive CRT for LA-NSCLC, PBT was associated with reduced cardiac, pulmonary, and esophageal dose and reduced risk of DID on multivariable analysis. These results suggest PBT may have a clinically meaningful benefit in this population.

Esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy for esophageal squamous cell carcinoma.

BackgroundThe literature regarding esophageal fistula after definitive concurrent chemotherapy and intensity modulated radiotherapy (IMRT) for esophageal squamous cell carcinoma (ESCC) remains lacking. We aimed to investigate the risk factors of esophageal fistula among ESCC patients undergoing definitive concurrent chemoradiotherapy (CCRT) via IMRT technique.MethodsA total of 129 consecutive ESCC patients receiving definitive CCRT with IMRT between 2008 and 2018 were reviewed. The cumulative incidence of esophageal fistula and survival of patients were estimated by the Kaplan–Meier method and compared between groups by the log-rank test. The risk factors of esophageal fistula were determined with multivariate Cox proportional hazards regression analysis.ResultsMedian follow-up was 14.9 months (IQR, 7.0–28.8). Esophageal perforation was identified in 20 (15.5%) patients, resulting in esophago-pleural fistula in nine, esophago-tracheal fistula in seven, broncho-esophageal fistula in two, and aorto-esophageal fistula in two patients. The median interval from IMRT to the occurrence of esophageal fistula was 4.4 months (IQR, 3.3–10.1). Patients with esophageal fistula had an inferior median overall survival (10.0 vs. 17.2 months, p = 0.0096). T4 (HR, 3.776; 95% CI, 1.383–10.308; p = 0.010) and esophageal stenosis (HR, 2.601; 95% CI, 1.053–6.428; p = 0.038) at baseline were the independent risk factors for esophageal fistula. The cumulative incidence of esophageal fistula was higher in patients with T4 (p = 0.018) and pre-treatment esophageal stenosis (p = 0.045). There was a trend toward better survival after esophageal fistula among patients receiving repair or stenting for the fistula than those only undergoing conservative treatments (median survival, 5.9 vs. 0.9 months, p = 0.058).ConclusionsT4 and esophageal stenosis at baseline independently increased the risk of esophageal fistula in ESCC treated by definitive CCRT with IMRT. There existed a trend toward improved survival after the fistula among patients receiving repair or stenting for esophageal perforation.

Endoscopic closure of an esophago-pleural fistula resulting from a perforated esophageal ulcer due to systemic sclerosis:filling and shielding using polyglycolic acid sheets and fibrin glue

A woman in her 70s with systemic sclerosis experienced dyspnea, and consequently, she was diagnosed with an esophago-pleural fistula, which was caused by a perforated esophageal ulcer. We administered conservative treatments including continuous pleural drainage and total parenteral nutrition. The fistula was closed but recurred, at which point we attempted to close the fistula by filling and shielding using polyglycolic acid (PGA) sheets and fibrin glue (FG). We were able to safely and smoothly fill and shield the fistula using the PGA sheets with a guidewire. We show that endoscopic closure of an esophago-pleural fistula using this technique is an effective, low-invasive treatment for gastrointestinal perforation and refractory fistulas.