A serious esophageal–mediastinal fistula successfully treated by endoscopic debridement and continuous irrigation

A 62-year-old man was admitted to our hospital with chest pain, progressive dysphagia, and low grade fever for 3 days after eating duck meat. Endoscopy revealed a bone embedded in his upper esophagus ([Fig. 1] a). After removal of the bone, an esophageal perforation was identified ([Fig. 1] b). The patient developed a high grade fever and worsening chest pain 5 days later, and computed tomography and a further endoscopy showed an esophageal–mediastinal fistula and a mediastinal abscess with pus extravasation ([Fig. 1] c; [Video 1]). Esophagography confirmed the esophageal–mediastinal fistula was 8.0 × 5.0 cm ([Fig. 2]).

Fig. 1 Endoscopic images showing: a a bone embedded in the upper esophagus; b an esophageal perforation filled with pus; c necrotic tissue and extravasation of pus in the fistula 5 days after removal of the bone.

A serious esophageal mediastinal fistula is treated by endoscopic debridement and continuous saline irrigation.Video 1

Fig. 2 Esophagogram showing an esophageal–mediastinal fistula (8.0 × 5.0 cm).

To clean the fistula and control infection, we performed endoscopic debridement and inserted two tubes for continuous saline irrigation ([Video 1]). A small caliber tube was used for continuous infusion of saline (1000 mL/24 hours), while the other large caliber tube was used for continuous suction. Additionally, a two-cavity tube was used to provide jejunal nutrition and esophageal decompression ([Fig. 3] a). After 5 days, esophagography showed the fistula had decreased to 4.0 × 3.0 cm ([Fig. 3] b). We removed two tubes, keeping the small caliber tube for continuous irrigation ([Fig. 3] c), and allowed the patient to take an oral liquid diet. After 14 days, the final tube was removed and endoscopy confirmed that the fistula had healed ([Fig. 4]). The patient remained healthy at follow-up after 16 months.

Fig. 3 Images of the endoscopic debridement and continuous saline irrigation therapy showing: a two tubes inserted into the fistula cavity, a small caliber tube (blue arrow) for continuous saline infusion and a large caliber tube (red arrow) for continuous suction, plus a two-cavity tube (yellow arrow), with its distal end in the jejunum to provide nutrition and its proximal end in the esophageal lumen for decompression; b esophagogram after 5 days of therapy showing a reduction in the size of the fistula to 4.0 × 3.0 cm; c ongoing continuous saline irrigation via the small caliber tube only.

Fig. 4 Endoscopic view after 14 days of therapy showing the healed fistula cavity.

Esophageal–mediastinal fistulas and abscesses have a high mortality rate [1] [2]. Key treatments include pus drainage and infection control [3]. Endoscopic debridement effectively removes the necrotic tissue from the surface of the fistula, allowing the regeneration of fresh tissue and promoting healing. Continuous irrigation and suction can form a saline soak that facilitates the detachment and drainage of pus and necrotic tissue [4]. This case highlights this method as a rapid and effective therapy for esophageal–mediastinal fistulas and abscesses.

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Artikel online veröffentlicht:
17. April 2025

• References

• 1 Bemelman WA, Baron TH. Endoscopic management of transmural defects, including leaks, perforations, and fistulae. Gastroenterology 2018; 154: 1938-1946.e1
• 2 Righini CA, Tea BZ, Reyt E. et al. Cervical cellulitis and mediastinitis following esophageal perforation: a case report. World J Gastroenterol 2008; 14: 1450-1452
• 3 Wehrmann T, Stergiou N, Vogel B. et al. Endoscopic debridement of paraesophageal, mediastinal abscesses: a prospective case series. Gastrointest Endosc 2005; 62: 344-349
• 4 Zhao Y, Zhang JY, Ullah S. et al. Massive continuous irrigation (MCI) and endoscopic debridement as an alternative treatment strategy for refractory abscess-fistula complexes. J Dig Dis 2024; 25: 133-139