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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