Esophagopleural fistula and candidiasis: endoscopic stent management after steroid-induced perforation

A 61-year-old woman was presented with acute chest pain and dyspnea. Five months earlier, she had undergone endoscopic submucosal dissection (ESD) for circumferential early esophageal cancer (20–27 cm from incisors; [Fig. 1] a). To prevent refractory postoperative stenosis, an intensive anti-fibrosis regimen was administered, including submucosal triamcinolone (200 mg per injection; [Fig. 1] b) three times, and a 6-week tapering course of oral prednisone. Subsequently, the patient underwent two esophageal dilation procedures at 50 and 110 days post-ESD, each combined with a submucosal injection of 200 mg triamcinolone. Post-procedural contrast examination showed no leakage; however, acute symptoms emerged 20 days after the second dilation.

Fig. 1 a The wound of the circumferential early esophageal cancer (20–27 cm from incisors) after ESD excision. b Submucosal injection of 20 mL of triamcinolone acetonide 1 week post-ESD. c The fistulous orifice surrounded by extensive white plaques. d A chest CT scan demonstrating mediastinal emphysema and right pleural effusion. CT, computed tomography; ESD, endoscopic submucosal dissection.

Endoscopy disclosed a fistulous orifice at 25 cm surrounded by white plaques ([Fig. 1] c), and computed tomography (CT) revealed mediastinal emphysema with pleural effusion ([Fig. 1] d). Candida albicans was identified on culture, indicating severe candidal esophagitis as an opportunistic infection resulting directly from steroid-induced immunosuppression. We consider that the prolonged corticosteroid use critically impaired local tissue defense and integrity, ultimately leading to fungal invasion and delayed perforation.

A fully covered metal stent with an external traction string was deployed to prevent migration and assist retrieval ([Video 1]). Following adequate thoracic irrigation combined with drainage and initiation of imipenem-cilastatin, the stent was placed endoscopically, achieving complete fistula closure and no evidence of Iohexol contrast leakage ([Fig. 2] a, b). The stent was safely removed after 4 weeks via the external string. The patient recovered smoothly without stent migration or bleeding, and follow-up endoscopy and CT confirmed fistula healing ([Fig. 3] a, b).

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A case of esophagopleural fistula and candidiasis: endoscopic stenting as salvage therapy.Video 1

Fig. 2 a The fully covered metal stent properly positioned at the fistula site. b An Iohexol contrast esophagogram obtained after stent implantation, showing no evidence of leakage at the previous fistula site.

Fig. 3 a Endoscopic and b computed tomography (CT) demonstrated the complete healing of the fistula site.

This case underscores that steroid use in extensive ESD defects requires careful titration. Although steroids exert potent anti-fibrotic and immunosuppressive effects that help prevent stenosis [1] [2] [3] [4], they also impair tissue integrity and increase vulnerability to opportunistic infections [5]—a key contributor to delayed perforation. Therefore, clinical suspicion of fungal invasion warrants early endoscopy, aggressive antifungal therapy, and reevaluation of the corticosteroid use.

Our experience confirms that a string-attached fully covered stent provides triple advantages: reliable fistula closure combined with early oral feeding, migration prevention, and easy retrieval. Together with thorough drainage, it constitutes a safe, effective, minimally invasive approach to complex esophageal perforations.

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Contributorsʼ Statement

Yali Chen: Data curation, Formal analysis, Writing – original draft, Writing – review & editing. Ping Lei: Data curation, Investigation. Hui Guo: Data curation, Investigation. Shengzhi Teng: Data curation, Resources. Xin Zhou: Data curation, Resources. Zhining Fan: Methodology, Supervision. Zhonghua Jiang: Conceptualization, Data curation, Funding acquisition, Methodology, Resources, Supervision, Writing – review & editing.

Conflict of Interest

The authors declare that they have no conflict of interest.

• References

• 1 Miyake M. et al. Predictors of stricture after non-circumferential endoscopic submucosal dissection of the esophagus and single-dose triamcinolone injection immediately after the procedure. Gastrointest Endosc 2023; 98: 170-177
• 2 Ando Y. et al. Risk of stricture after endoscopic submucosal dissection in the cervical esophagus and efficacy of local steroid injection for stricture prevention (with video). Gastrointest Endosc 2024; 100: 1043-1049
• 3 Zhou S. et al. Efficacy of different steroid therapies in preventing esophageal stricture after endoscopic submucosal dissection: a comparative meta-analysis. Gastrointest Endosc 2024; 100: 1020-1033 e3
• 4 Carpentier D. et al. Local triamcinolone injection and selective add-on oral steroids to prevent esophageal post-endoscopic submucosal dissection stricture: a retrospective analysis in a Western center. Endoscopy 2024; 56: 811-819
• 5 Gock M. et al. Fatal esophageal perforation caused by invasive candidiasis. Ann Thorac Surg 2005; 80: 1120-1122

Publication History

Article published online:
20 January 2026