A 48-year-old man was admitted to our hospital following the onset of cough, fever,
and shortness of breath. Clinical history included psychotic syndrome and recurrent
erosive esophagitis.
In the emergency room, a chest radiograph showed right pleural effusion. However,
despite full conservative management, his condition worsened rapidly. A computed tomography
scan revealed communication between the distal esophageal lumen and the right pleural
space ([Fig. 1]). Subsequent upper endoscopy showed extensive ulceration of the esophageal wall,
with a small orifice at its distal part ([Fig. 2]).
Fig. 1 Computed tomography scan image of massive right pleural corpuscolated effusion. A
small esophago-pleural fistula could be identified (arrow).
Fig. 2 Endoscopic view of large ulceration of the esophageal wall, with an orifice, about
8 mm in size, in its distal part.
An over-the-scope clip (OTSC, 12 mm, traumatic type; Ovesco Inc., Tübingen, Germany)
was deployed over the orifice ([Video 1]). To ensure complete occlusion of the defect, a colonic partially covered metal
stent (Niti-S, 22 mm × 10 cm; Taewoong Medical, Inc., Gyeonggi-do, South Korea) was
positioned, protecting the orifice against gastroesophageal reflux ([Fig. 3]).
Computed tomography scan and endoscopic view identified an esophago-pleural fistula.
Combined treatment with an over-the-scope clip (Ovesco Inc., Tübingen, Germany) and
stent placement was performed. Two months later, an upper tract radiograph and an
upper endoscopy revealed complete healing of the fistula.
Fig. 3 A radiographic image confirmed that both the over-the-scope clip and the partially
covered (colonic) self-expandable metal stent were in place.
The patient improved during the subsequent 30 days, and 2 months later, the metal
stent was removed using a “stent-in stent” technique. Subsequent upper endoscopy showed
complete healing of the esophageal wall even though the OTSC was no longer in place.
Primary benign esophago-pleural fistula is a rare but challenging condition, burdened
by a high mortality and often requiring surgical treatment [1]. Self-expandable metal stents are well known therapeutic techniques used in the
management of leaks and fistulas involving the esophageal wall or anastomosis [2]. Furthermore, the OTSC represents a new endoscopic approach for the closure of upper
gastrointestinal leaks and fistulas [3]. However, as in the case described above, a tailored and multimodal approach (stent
and OTSC) could be safer and more effective than a single modality, avoiding the need
for surgery [4]
[5].
Endoscopy_UCTN_Code_TTT_1AO_2AC
