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CC BY 4.0 · Endoscopy 2024; 56(S 01): E998-E999
DOI: 10.1055/a-2436-1041
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A multimodal endoscopic approach for esophageal fistula closure

Andrea Telese
1   Digestive Disease and Surgery Institute, Cleveland Clinic London, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN591481)
2   Division of Surgery and Interventional Science, University College London, London, United Kingdom of Great Britain and Northern Ireland
,
Benjamin Norton
1   Digestive Disease and Surgery Institute, Cleveland Clinic London, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN591481)
3   Department of Medicine, University College London Centre for Obesity Research, London, United Kingdom of Great Britain and Northern Ireland
,
Apostolis Papaefthymiou
1   Digestive Disease and Surgery Institute, Cleveland Clinic London, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN591481)
,
Alberto Murino
1   Digestive Disease and Surgery Institute, Cleveland Clinic London, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN591481)
,
Charles Murray
1   Digestive Disease and Surgery Institute, Cleveland Clinic London, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN591481)
,
Rehan Haidry
1   Digestive Disease and Surgery Institute, Cleveland Clinic London, London, United Kingdom of Great Britain and Northern Ireland (Ringgold ID: RIN591481)
2   Division of Surgery and Interventional Science, University College London, London, United Kingdom of Great Britain and Northern Ireland
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Several endoscopic options are available for the treatment of post-surgical fistulae including clipping, stenting, vacuum therapy, and endoscopic suturing. Choosing between these depends on multiple factors including defect size and site, etiology, and presence of associated cavity [1] [2] [3]. We present the case of a 59-year-old man with recurrent chest infections secondary to an esophago-jejunal anastomotic fistula. He had previously undergone a total gastrectomy and chemotherapy for gastric adenocarcinoma (T4aN1M1), followed by distal pancreatectomy, hepatic resection, and jejunal repair for primary pancreatic adenocarcinoma (T4aNxMx; R1) that left him with an esophago-jejunal anastomosis. He continued adjuvant chemo-immunotherapy; two years later he had evidence of progressive disease and developed respiratory symptoms.

Our endoscopic assessment demonstrated a 5–10 mm transmural anastomotic defect. The fistula was initially treated with argon plasma coagulation (FiAPC probe; Erbe Elektromedizin, Tübingen, Germany) and endoscopic suturing (OverStitch Sx; Apollo Endosurgery, Austin, Texas, USA) and an over-the-scope clip (OTS clip; Ovesco Endoscopy, Tübingen, Germany) to ensure closure. As respiratory symptoms persisted with evidence of recurrent fistula on barium imaging, a decision was made to place a vacuum-stent (VACStent GI; Möller Medical, Fulda, Germany) over a guidewire (Jagwire; Boston Scientific, Marlborough, Massachusetts, USA) under direct vision to cover the defect ([Video 1]). Following this, oral intake was gradually restored and the vacuum-stent was removed on the seventh day uneventfully using a distal attachment cap (DH-28GR Hood; Fujifilm, Tokyo, Japan) and a grasping device (Raptor; Steris, Mentor, Ohio, USA). Abundant granular tissue was noted and dynamic on-table esophagogram showed no leakage. Fistula closure allowed continuation of adjuvant therapy. After this treatment, respiratory symptoms instigated a barium swallow that showed fistula recurrence, and another vacuum-stent was placed under fluoroscopy ([Fig. 1]). The following day, a decision was made with the patient to continue vacuum-stent therapy at home for seven days. At removal, granulation tissue was present, and despite a suspicion of a small defect, dynamic on-table esophagogram showed no contrast leak. After vacuum-stent removal, the patient remained asymptomatic for fistula-related symptoms and a barium swallow showed no fistula recurrence. The patient continued his chemotherapy and a subsequent CT scan while asymptomatic for fistula-related symptoms demonstrated a possible fistulous tract ending in an atelectatic cavity. A later endoscopy with on-table esophagogram could not identify any fistula and no other fistula-related treatment was pursued. In the following follow-up the general status of the patient deteriorated but no other fistula-related intervention was required.

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Fig. 1 Fluoroscopic images. a Recurrence of anastomotic fistula following first vacuum-stent removal. b Submucosal radiopaque marking for second vacuum-stent placement. c Second vacuum-stent after deployment.

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Multimodal endoscopic approach for esophageal fistula closure.Video 1

A vacuum-stent can be an effective treatment of post-surgical fistula, provided the right support and infrastructure, and the vacuum-stent can be used as a community-based therapy to reduce the length of admission.

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Publication History

Article published online:
13 November 2024

© 2024. The Author(s). This is an open access article published by Thieme under the terms of the Creative Commons Attribution License, permitting unrestricted use, distribution, and reproduction so long as the original work is properly cited. (https://creativecommons.org/licenses/by/4.0/).

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