Advertisement

Surgical Endoscopy

, Volume 28, Issue 12, pp 3500–3504 | Cite as

Gastro-bronchial fistula closed by endoscopic fistula plug (with video)

  • Ahmed SharataEmail author
  • Neil H. Bhayani
  • Christy M. Dunst
  • Ashwin A. Kurian
  • Kevin M. Reavis
  • Lee L. Swanström
Video

Abstract

Background

Fistulae between the tracheobronchial tree and the gastric conduit post-esophagectomy are a rare but sometimes fatal complication. Clinical presentation can range from asymptomatic to acute pulmonary decompensation. Traditional management options, such as esophageal exclusion alone or combined with transthoracic fistula division, and closure (with tissue interposition), are highly invasive, technically difficult, and associated with variable success rates. This video presents closure of highly complex, chronic esophagobronchial fistula (EBF) using simultaneous bronchoscopic and upper endoscopic techniques.

Methods

Diagnostic bronchoscopy and upper endoscopy are performed to assess the size and location of fistulae. Fistulae with sufficient luminal size to accommodate a biologic plug were selected for treatment. Steps of EBF plug insertion. (1) Wire across fistula with ends exposed through the mouth. (2) Delivery sheath passed across wire from bronchial side to esophageal side (3) Plug loaded on the esophageal side of the sheath. (4) Plug pulled into position across the fistula from esophageal to bronchial side. (5) Delivery sheath released from bronchial side.

Results

Two of four fistulae were suitable for plug therapy. A temporary covered-stent was placed to help maintain the plugs in place. Endoscopy at 1 month showed healing of the plugged fistula following stent removal. Respiratory symptoms were improved with no further episodes of pneumonia. Over course of 2 years, the patient has required three additional endoscopic procedures to control new fistulae from this broad area of exposed lung paranchyma, but the initial fistula plug repair is durable.

Conclusion

Post-esophagectomy fistula is a morbid complication and the surgical treatments available are highly morbid and have variable success rates. Due to the development of new endoscopic technologies, the endotherapy has assumed new prominence for treatment of enteric fistula. This complex case illustrates feasibility of endoscopic fistula treatment using dual scope, biologic plug application which effectively controlled this patient’s EBF symptoms.

Keywords

Fibrin Glue Gastric Conduit Endoscopic Clip Delivery Sheath Variable Success Rate 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Notes

Disclosures

Ahmed Sharata, Neil H Bhayani, Christy M Dunst, Ashwin A Kurian, Kevin M Reavis, and Lee L Swanstrom have no conflicts of interest or financial ties to disclose.

Supplementary material

Supplementary material 1 (MOV 61370 kb)

References

  1. 1.
    Wesselhoeft CW Jr, Keshishian JM (1968) Acquired nonmalignant esophagotracheal and esophagobronchial fistulas. Ann Thorac Surg 6(2):187–195 (Review)PubMedCrossRefGoogle Scholar
  2. 2.
    Bartels HE, Stein HJ, Siewert JR (1998) Tracheobronchial lesions following oesophagectomy: prevalence, predisposing factors and outcome. Br J Surg 85(3):403–406PubMedCrossRefGoogle Scholar
  3. 3.
    Hulscher JB, ter Hofstede E, Kloek J, Obertop H, De Haan P, Van Lanschot JJ (2000) Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae. J Thorac Cardiovasc Surg 120(6):1093–1096PubMedCrossRefGoogle Scholar
  4. 4.
    Poncet M (1896) Sur um cas de fistule trachea-oesophagienne origine actinomycosique. Bull Acad Med Paris 35:403Google Scholar
  5. 5.
    Wychulis AR, Ellis FH Jr, Andersen HA (1966) Acquired nonmalignant esophagotracheobronchial fistula. Report of 36 cases. JAMA 196(2):117–122PubMedCrossRefGoogle Scholar
  6. 6.
    Hardy JD, Tompkins WC Jr, Ching EC, Chavez CM (1973) Esophageal perforations and fistulas: review of 36 cases with operative closure of four chronic fistulas. Ann Surg 177(6):788–797PubMedCentralPubMedCrossRefGoogle Scholar
  7. 7.
    Balazs A, Kupcsulik PK, Galambos Z (2008) Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 34(5):1103–1107. doi: 10.1016/j.ejcts.2008.06.025 PubMedCrossRefGoogle Scholar
  8. 8.
    Schweigert M, Dubecz A, Beron M, Muschweck H, Stein HJ (2012) Management of anastomotic leakage-induced tracheobronchial fistula following oesophagectomy: the role of endoscopic stent insertion. Eur J Cardiothorac Surg 1(5):e74–e80. doi: 10.1093/ejcts/ezr328 CrossRefGoogle Scholar
  9. 9.
    Yankovic F, Castillo C, Saenz R, Navarrete C (2009) Endoscopic argon plasma coagulation in recurrent tracheoesophageal fistula. Clinical series and review of the literature. Gastroenterol Hepatol 2(9):600–604. doi: 10.1016/j.gastrohep.2009.06.012 CrossRefGoogle Scholar
  10. 10.
    Traina M, Curcio G, Tarantino I, Soresi S, Barresi L, Vitulo P, Gridelli B (2010) New endoscopic over-the-scope clip system for closure of a chronic tracheoesophageal fistula. Endoscopy 42(Suppl 2):E54–E55. doi: 10.1055/s-0029-1243824 PubMedCrossRefGoogle Scholar
  11. 11.
    Qadeer MA, Dumot JA, Vargo JJ, Lopez AR, Rice TW (2007) Endoscopic clips for closing esophageal perforations: case report and pooled analysis. Gastrointest Endosc 66(3):605–611 (Review)PubMedCrossRefGoogle Scholar
  12. 12.
    Shin JH, Song HY, Ko GY, Lim JO, Yoon HK, Sung KB (2004) Esophagorespiratory fistula: long-term results of palliative treatment with covered expandable metallic stents in 61 patients. Radiology 232(1):252–259 Epub 2004 May 27PubMedCrossRefGoogle Scholar
  13. 13.
    Balazs A, Galambos Z, Kupcsulik PK (2009) Characteristics of esophagorespiratory fistulas resulting from esophageal cancers: a single-center study on 243 cases in a 20-year period. World J Surg 33(5):994–1001. doi: 10.1007/s00268-009-9988-3 PubMedCrossRefGoogle Scholar
  14. 14.
    Buskens JC, Hulscher JBF, Fockens P, Obertop H, van Lanschot JJB (2001) Benign tracheo-neo-esophageal fistulas after subtotal esophagectomy. Ann Thorac Surg 72:221–224PubMedCrossRefGoogle Scholar
  15. 15.
    Hulscher JBF, ter Hofstede E, Kloek J, Obertop H, De Haan P, Van Lanschot JJB (2000) Injury to the major airways during subtotal esophagectomy: incidence, management, and sequelae. J Thorac Cardiovasc Surg 120:1093–1096PubMedCrossRefGoogle Scholar
  16. 16.
    Macchiarini P, Verhoye JP, Chapelier A, Fadel E, Dartevelle P (2000) Evaluation and outcome of different surgical techniques for post-intubational tracheoesophageal fistulas. J Thorac Cardiovasc Surg 119:268–276PubMedCrossRefGoogle Scholar
  17. 17.
    Hardy JD, Tompkins WC Jr, Ching EC, Chavez CM (1973) Esophageal perforations and fistulas: review of 36 cases with operative closure of four chronic fistulas. Ann Surg 177(6):788–797PubMedCentralPubMedCrossRefGoogle Scholar
  18. 18.
    Wychulis AR, Ellis FHJ, Andersen HA (1966) Acquired nonmalignant esophagotracheobronchial fistula. Report of 36 cases. JAMA 196:117–122PubMedCrossRefGoogle Scholar
  19. 19.
    Song SW, Lee HS, Kim MS, Lee JM, Kim JH, Zo JI (2006) Repair of gastrotracheal fistula with a pedicled pericardial flap after Ivor Lewis esophagogastrectomy for esophageal cancer. J Thorac Cardiovasc Surg 132(3):716–717PubMedCrossRefGoogle Scholar
  20. 20.
    Furst H, Hartl WH, Lohe F, Schildberg FW (2000) Colon interposition for esophageal replacement: an alternative technique based on the use of the right colon. Ann Surg 23:173–178CrossRefGoogle Scholar
  21. 21.
    DeMeester TR, Johansson KE, Franze I, Eypasch E, Lu CT, McGill JE et al (1988) Indications, surgical technique, and long-term functional results of colon interposition or bypass. Ann Surg 208:460–474PubMedCentralPubMedCrossRefGoogle Scholar
  22. 22.
    Schweigert M, Solymosi N, Dubecz A, Stadlhuber RJ, Muschweck H, Ofner D, Stein HJ (2013) Endoscopic stent insertion for anastomotic leakage following oesophagectomy. Ann R Coll Surg Engl 95(1):43–47. doi: 10.1308/003588413X13511609956255 PubMedCentralPubMedCrossRefGoogle Scholar
  23. 23.
    Balazs A, Kupcsulik PK, Galambos Z (2008) Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 34(5):1103–1107. doi: 10.1016/j.ejcts.2008.06.025 PubMedCrossRefGoogle Scholar
  24. 24.
    Hürtgen M, Herber SC (2014) Treatment of malignant tracheoesophageal fistula. Thorac Surg Clin 24(1):117–127. doi: 10.1016/j.thorsurg.2013.09.006 PubMedCrossRefGoogle Scholar
  25. 25.
    Puli SR, Spofford IS, Thompson CC (2012) Use of self-expandable stents in the treatment of bariatric surgery leaks: a systematic review and meta-analysis. Gastrointest Endosc 75(2):287–293. doi: 10.1016/j.gie.2011.09.010 PubMedCrossRefGoogle Scholar
  26. 26.
    Yankovic F, Castillo C, Saenz R, Navarrete C (2009) Endoscopic argon plasma coagulation in recurrent tracheoesophageal fistula. Clinical series and review of the literature. Gastroenterol Hepatol 32(9):600–604. doi: 10.1016/j.gastrohep.2009.06.012 PubMedCrossRefGoogle Scholar
  27. 27.
    Richter GT, Ryckman F, Brown RL, Rutter MJ (2008) Endoscopic management of recurrent tracheoesophageal fistula. J Pediatr Surg 43(1):238–245. doi: 10.1016/j.jpedsurg.2007.08.062 PubMedCrossRefGoogle Scholar
  28. 28.
    Merrifield BF, Lautz D, Thompson CC (2006) Endoscopic repair of gastric leaks after Roux-en-Y gastric bypass: a less invasive approach. Gastrointest Endosc 63(4):710–714PubMedCrossRefGoogle Scholar
  29. 29.
    Truong S, Böhm G, Klinge U, Stumpf M, Schumpelick V (2004) Results after endoscopic treatment of postoperative upper gastrointestinal fistulas and leaks using combined Vicryl plug and fibrin glue. Surg Endosc 18(7):1105–1108 Epub 2004 May 27PubMedCrossRefGoogle Scholar
  30. 30.
    Schubert D, Pross M, Nestler G, Ptok H, Scheidbach H, Fahlke J, Lippert H (2006) Endoscopic treatment of mediastinal anastomotic leaks. Zentralbl Chir 131(5):369–375 (German)PubMedCrossRefGoogle Scholar
  31. 31.
    Minami S, Gotoda T, Ono H, Oda I, Hamanaka H (2006) Complete endoscopic closure of gastric perforation induced by endoscopic resection of early gastric cancer using endoclips can prevent surgery (with video). Gastrointest Endosc 63(4):596–601PubMedCrossRefGoogle Scholar
  32. 32.
    Fujishiro M, Yahagi N, Kakushima N, Kodashima S, Muraki Y, Ono S, Kobayashi K, Hashimoto T, Yamamichi N, Tateishi A, Shimizu Y, Oka M, Ogura K, Kawabe T, Ichinose M, Omata M (2006) Successful nonsurgical management of perforation complicating endoscopic submucosal dissection of gastrointestinal epithelialneoplasms. Endoscopy 38(10):1001–1006PubMedCrossRefGoogle Scholar
  33. 33.
    Surace M, Mercky P, Demarquay JF, Gonzalez JM, Dumas R, Ah-Soune P, Vitton V, Grimaud J, Barthet M (2011) Endoscopic management of GI fistulae with the over-the-scope clip system (with video). Gastrointest Endosc 74(6):1416–1419. doi: 10.1016/j.gie.2011.08.011 PubMedCrossRefGoogle Scholar
  34. 34.
    Iacopini F, Di Lorenzo N, Altorio F, Schurr MO, Scozzarro A (2010) Over-the-scope clip closure of two chronic fistulas after gastric band penetration. World J Gastroenterol 16(13):1665–1669PubMedCentralPubMedCrossRefGoogle Scholar
  35. 35.
    Sharata A, Swanstrom LL (2013) Endoscopic tools and techniques for fistula and leaks. In: Marks JM, Dunkin BJ (eds) Principles of flexible endoscopy for surgeons. Springer, New York, pp 129–138Google Scholar
  36. 36.
    Bhayani NH, Swanström LL (2014) Endoscopic therapies for leaks and fistulas after bariatric surgery. Surg Innov 21(1):90–97. doi: 10.1177/1553350613497270

Copyright information

© Springer Science+Business Media New York 2014

Authors and Affiliations

  • Ahmed Sharata
    • 1
    • 2
    Email author
  • Neil H. Bhayani
    • 1
  • Christy M. Dunst
    • 2
  • Ashwin A. Kurian
    • 1
  • Kevin M. Reavis
    • 2
  • Lee L. Swanström
    • 2
  1. 1.Providence Portland Cancer CenterPortlandUSA
  2. 2.GMIS DivisionOregon ClinicPortlandUSA

Personalised recommendations