Endoscopic closure of a 6-cm long esophageal defect with tracheoesophageal fistula

A 68-year-old man with metastatic esophageal adenocarcinoma previously treated with esophagectomy and chemoradiation presented with new-onset dysphagia and cough. A recent good response to chemotherapy resulted in shrinkage of a 7-cm mediastinal metastasis. Chest computed tomography revealed a large esophageal defect. A barium swallow confirmed the presence of a tracheoesophageal fistula (TEF). Upper endoscopy showed a 6-cm defect on the anterior esophageal wall with a clear opening into the trachea ([Fig. 1], [Video 1]).

Fig. 1 Endoscopic view of a large esophageal defect and tracheoesophageal fistula (arrow) in the upper esophagus.

Video 1 Successful closure of a large tracheoesophageal fistula using combined modalities of endoscopic suturing and metal stent placement.

An upper gastroscope was advanced to the esophagojejunostomy. A 0.035-inch guidewire was passed through the scope and coiled within the jejunum. The scope was withdrawn while maintaining the position of the wire and a double-channel endoscope was fitted with an endoscopic suturing device. The defect was closed using two running sutures, with an average of 5 bites per suture. Immediately after suturing, the patient’s capnography improved significantly. Subsequently, a 23 mm × 12 cm fully covered self-expandable metal stent was successfully placed, with the proximal flange positioned at 2 cm above the esophageal defect and just distal to the upper esophageal sphincter ([Fig. 2]). The esophageal stent was secured with two sutures ([Fig. 3]). A subsequent esophagram showed no extravasation of contrast ([Fig. 4]). The patient tolerated an oral diet and was discharged home in a good condition.

Fig. 2 A fully covered self-expandable metal stent was successfully deployed traversing the defect.

Fig. 3 The proximal flange of the stent was sutured to the esophageal wall to prevent stent migration.

Fig. 4 Barium swallow test showing no extravasation of contrast confirming complete closure.

TEF is a rare yet life-threatening condition that develops in up to 5 % of patients with esophageal malignancy [1]. Management is challenging, and closure often requires a multidisciplinary approach and is associated with high rates of recurrence [2]. Surgery is associated with extremely high morbidity, and endoscopic therapy has been proposed as a minimally invasive and relatively safe modality that improves the quality of life in patients with TEF [3] [4]. The current case demonstrates that very large esophageal defects and fistulae can be successfully closed using a multi-modality approach of endoscopic suturing and stent placement.

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• References

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• 2 Ramai D, Bivona A, Latson W. et al. Endoscopic management of tracheoesophageal fistulas. Ann Gastroenterol 2019; 32: 24-29
• 3 Kovesi T, Rubin S. Long-term complications of congenital esophageal atresia and/or tracheoesophageal fistula. Chest 2004; 126: 915-925
• 4 Balazs A, Kupcsulik PK, Galambos Z. Esophagorespiratory fistulas of tumorous origin. Non-operative management of 264 cases in a 20-year period. Eur J Cardiothorac Surg 2008; 34: 1103-1107