Successful closure of a rare tracheogastroesophageal fistula with an endoloop and endoclips

Tracheoesophageal fistula after esophagectomy is a rare complication with a high mortality rate. Conventional treatment of tracheoesophageal fistulas includes surgical re-exploration, or endoscopic and bronchoscopic techniques with stent implantation or fibrin glue application [1] [2]. Here we report the successful treatment of a tracheogastroesophageal fistula with an endoloop-aided purse-string suture.

A 51-year-old man underwent thoracoscopic esophagectomy with gastric reconstruction for esophageal carcinoma. He subsequently developed symptoms of choking, especially after intake of liquid. Right lateral pneumonia was found 3 months later on computed tomography (CT) scanning, and esophagogastroduodenoscopy (EGD) revealed a tracheogastroesophageal fistula around the esophagogastric anastomosis at the fundus of the stomach, measuring about 20 × 16 mm ([Fig. 1 a]). A diagnosis of tracheogastroesophageal fistula was made.

Fig. 1 The procedure of purse-string suture for a tracheogastroesophageal fistula. a View of the tracheal fistula located in the gastric fundus and the fistula connecting the esophagus and stomach. b An endoloop was placed around the fistula orifice and anchored with nine endoclips. c The endoloop was then tightened to close the defect. d Three more endoclips were used to close the tiny leak.

We decided to perform a purse-string suture using an endoloop and endoclips to close the fistula. The endoloop (HX-400U-30; Olympus Medical Co.) was placed around the fistula orifice and anchored with nine endoclips (R-C/D-26-165/195C; Micro-Tech [Nanjing] Co. Ltd.) ([Fig. 1 b]). The endoloop was then tightened to close the defect ([Fig. 1 c]). A tiny leak was still seen after completion of the purse-string suture because of high tension. Subsequently, three additional endoclips were applied to completely close the tiny leak ([Fig. 1 d]). Eventually, the fistula was successfully closed and there were no bubbles when the wound was flushed ([Video 1]). After the endoscopic closure, no further symptoms of choking occurred during his period of hospitalization. EGD 3 months later showed that the fistula had completely healed ([Fig. 2]).

Video 1 Successful closure of a rare tracheogastroesophageal fistula with endoloop and endoclips.

Fig. 2 The fistula was completely healed and had disappeared 3 months after the endoscopic closure.

The method of purse-string suture with endoloop and endoclips has been previously reported for closure of a large Mallory – Weiss tear and a large gastric defect after complex endoscopic submucosal dissection [3] [4]. In our case, the method was proposed as a treatment option for tracheogastroesophageal fistula following esophagectomy to avoid surgical re-intervention. To our knowledge, this is the first report on the successful endoscopic closure of a tracheogastroesophageal fistula with an endoloop and endoclips.

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• References

• 1 Lambertz R, Holscher AH, Bludau M. et al. Management of tracheo- or bronchoesophageal fistula after Ivor-Lewis esophagectomy. World J Surg 2016; 40: 1680-1687
• 2 Schweigert M, Solymosi N, Dubecz A. et al. Endoscopic stent insertion for anastomotic leakage following oesophagectomy. Ann R Coll Surg Engl 2013; 95: 43-47
• 3 Abe S, Oda I, Mori G. et al. Complete endoscopic closure of a large gastric defect with endoloop and endoclips after complex endoscopic submucosal dissection. Endoscopy 2015; 47 (Suppl. 01) E374-E375
• 4 Ivekovic H, Rustemovic N, Brkic T. et al. The esophagus as a working channel: successful closure of a large Mallory-Weiss tear with clips and an endoloop. Endoscopy 2011; 43 (Suppl. 02) E170