Esophagobronchial fistula closed by a cardiac septal occluder device

Esophageal–respiratory tract fistulas are rare but life-threatening conditions [1]. They may be congenital or secondary to esophageal and bronchogenic neoplasms, radiotherapy, or surgery. Currently, there is a changing paradigm for their management with surgery being replaced by conservative approaches including endoscopic therapy [2]. In fact, fully covered self-expandable metal stents (SEMSs) are currently the preferred therapeutic option; however, their clinical success rate is still poor and the rate of fistula reopening remains high [1] [2]. This has led to the appearance of therapeutic alternatives, such as the use of cardiac septal closure -devices and others [3] [4] [5].

We present the case of a 51-year-old man who had undergone prior chemoradiotherapy and esophagectomy for esophageal cancer. During follow-up, the patient developed mediastinal and brain metastases, as well as a severe cough and respiratory infections due to an esophagobronchial fistula ([Fig. 1] and [Fig. 2]). It was decided not to perform surgery but conventional endoscopic approaches were unsuccessful ([Fig. 3]). We therefore decided to use the Amplatzer septal occluder (St. Jude Medical, Plymouth, Minnesota, USA), a nitinol device commonly used to close cardiac septal defects ([Fig. 4]).

Fig. 1 Esophageal view of the fistulous orifice.

Fig. 2 Computed tomography (CT) scan image showing the fistula between the left bronchus and esophagus.

Fig. 3 Radiographic image showing a covered self-expandable metal stent (SEMS) in position, which proved to be an unsuccessful treatment.

Fig. 4 The Amplatzer septal occluder.

An upper gastrointestinal endoscopy was performed, which showed a 5-mm fistulous orifice located at the esophagogastric anastomosis. From the esophageal side, a guidewire was inserted through the fistula into the airway and then captured with a forceps to take it back out of the patient, in order to facilitate device positioning ([Video 1]). A 5-Fr catheter was then introduced and subsequently the occluder was released, firstly on the airway side and then on the esophageal side under endoscopic control ([Fig. 5] and [Fig. 6]). The procedure was safely completed. The patient experienced a significant improvement in his respiratory symptoms. A second occluder was inserted 4 weeks later because of the development of a new fistula and remained in place until his death 9 months later from progressive brain metastases.

Closure of an esophagobronchial fistula using an Amplatzer septal occluder device.

Fig. 5 Views of the occluder device following insertion into the fistula: a from the esophagus; b from the bronchus.

Fig. 6 Computed tomography (CT) scan image showing the correctly positioned occluder device.

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• References

• 1 Shin JH, Song HY, Ko GY et al. Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology 2004; 232: 252-259
• 2 Sharma P, Kozarek R. Role of esophageal stents in benign and malignant diseases. Am J Gastroenterol 2010; 105: 258-273
• 3 Repici A, Presbitero P, Carlino A et al. First human case of esophagus-tracheal fistula closure by using a cardiac septal occluder (with video). Gastrointest Endosc 2010; 71: 867-869
• 4 Khamaysi I, Suissa A, Yassin K et al. Closure of a persistent esophagopleural fistula using an over-the-scope clipping device. Endoscopy 2013; 45 (Suppl. 02) E29-E30
• 5 Rodriguez-Lago I, Schroeven M, Rodenstein D et al. Endoscopic closure of tracheoesophageal fistula with submucosal dissection and a biosynthetic mesh. Endoscopy 2015; 47 (Suppl. 01) E312-E313