Treatment of thoracogastric–mediastinal–pleural–airway fistula with esophageal stent, vascular plug, and tissue glue

Thoracogastric airway fistula is a rare and serious complication post-esophageal cancer surgery with an incidence of about 0.2% to 1.9% [1]. Due to the complexity of these fistulas, endoscopic and conservative treatments often fail. Most patients are too frail for surgery, making intervention-based closure therapy a crucial treatment option [2] [3].

An 81-year-old man who had esophageal squamous cell carcinoma surgery over 6 years ago recently experienced choking while eating and gastrointestinal bleeding ([Fig. 1]). A chest computed tomography (CT) scan showed a connection between the lower thoracogastric region and the mediastinum and airway in the chest ([Fig. 2]).

Fig. 1 Fistula located in the lower thoracic stomach was observed via gastric endoscopy.

Fig. 2 Preoperative chest computed tomography showed a thoracogastric tract connecting the left lower lobe bronchus through the mediastinum.

Angiography revealed thoracogastric contrast medium leaking into the mediastinum and the left lower lobe bronchus ([Video 1]). A vertebral artery catheter was guided through the mediastinum into the bronchus of the fistula cavity. A stiff guidewire was then exchanged, followed by the insertion of an 8F sheath. A 6×6-mm vascular plug was deployed through the sheath to occlude the fistula tract. First, the initial segment was released on the tracheal side, followed by angiography to confirm its fit and blockage. Next, the second segment was released on the digestive tract side and inserted into a tissue glue and iodized oil emulsion (1:3). A pigtail catheter was placed in the mediastinal abscess cavity, and a water membrane with a hard guidewire was positioned in the jejunum. An esophageal stent (20×120 mm) and its delivery system were introduced and released after proper positioning ([Fig. 3]). Finally, a jejunal nutrition tube was externally placed. The esophageal stent was removed 4 months after surgery due to displacement. Gastroscopic fistula healing was observed ([Fig. 4]).

Final gastroscopic evaluation confirmed satisfactory fistula closure.Video 1

Fig. 3 Post-occlusion fluoroscopy confirmed complete occlusion of the fistula tract, stabilization of the esophageal stent, vascular plug, and tissue glue, and visible abscesses and drains.

Fig. 4 Gastroscopic evaluation demonstrated satisfactory closure of the fistula 5 months post-treatment.

Previous studies on tracheoesophageal fistula closure with Amplatzer devices primarily utilized occluders alone [2] [4]. We propose using a vascular plug combined with tissue glue for complete fistula occlusion, offering new solutions for challenging cases that are unsuitable for stents or endoscopic methods.

Endoscopy_UCTN_Code_TTT_1AO_2AI

Publikationsverlauf

Artikel online veröffentlicht:
16. Januar 2025

• References

• 1 Sahebazamani M, Rubio E, Boyd M. Airway gastric fistula after esophagectomy for esophageal cancer. Ann Thorac Surg 2012; 93: 988-990
• 2 Lee HJ, Jung ES, Park MS. et al. Closure of a gastrotracheal fistula using a cardiac septal occluder device. Endoscopy 2011; 43 (Suppl. 02) E53-E54
• 3 Li Z, Li Y, Li Z. et al. Three-dimensional printing-assisted interventional therapy for thoracogastric right main bronchial fistula. Endoscopy 2024; 56: E262-E263
• 4 Guturu P, Bilal M, Rangasetty U. et al. Endoscopic closure of esophagopleural fistula with Amplatzer atrial septal defect closure device. Am J Gastroenterol 2019; 114: 198