Endoscopic closure of esophageal fistula using a novel ”clips and loop” method

Fistula can develop rarely between the esophageal lumen and other mediastinal structures. The majority of cases are caused by malignancy. Benign causes include infections, other inflammatory conditions, postsurgical trauma, and prolonged periods of endotracheal intubation or tracheostomy tube placement. In most cases of fistula, surgery is required. There are, however, a number of reports in the literature of endoscopic methods of attempting fistula closure: the application of fibrin glue, use of covered esophageal stents, and clipping have been described, for closure of esophagotracheal, bronchoesophageal, and esophagopleural fistulas [1] [2] [3] [4].

We report the case of a patient who developed an esophagomediastinalbronchial fistula ([Fig. 1]) after a pulmonary resection (sleeve lobectomy).

Fig. 1 Esophagography with a water-soluble contrast agent shows an esophagomediastinal fistula.

An external mediastinal drain was inserted, and esophagogastroduodenoscopy (EGD) promptly identified a large fistula opening of 25 mm in diameter in the middle part of the esophagus ([Fig. 2]).

Fig. 2 Opening of the fistula.

Another EGD was done 2 days later, with attempted closure of the fistula by clipping. However placement of the clips using the traditional method was very difficult, because the edges of the fistula were fibrotic and because of the large diameter of the opening. For these reasons, five clips (Resolution; Microvasive, Boston Scientific, Natick, Massachusetts, USA) were positioned at the edges of the opening ([Fig. 3]) and an endoloop (Olympus, Tokyo, Japan) was looped and tightened round the heads of the clips in order to close the opening ([Fig. 4]).

Fig. 3 Clips positioned at the edges of the fistula opening.

Fig. 4 Endoloop attached to the heads of the clips.

Another EGD performed 1 month later revealed complete healing of the fistula with formation of scar tissue ([Fig. 5]).

Fig. 5 Endoscopic view showing complete healing of the fistula.

To the best of our knowledge, this is the first report of an endoscopic approach that combined clips and endoloop to treat a fistula. Because of the limited width of an open clip, it is difficult or impossible to close a large mucosal defect, so we believe that in such situations the technique described could be a useful procedure when traditional clip application fails.

Endoscopy_UCTN_Code_TTT_1AO_2AI

References

• 1 Ogunmola N, Wylie R, McDowell K. et al . Endoscopic closure of esophagobronchial fistula with fibrin glue.  J Pediatr Gastroenterol Nutr. 2004;  38 539-541
• 2 Chauhan S S, Long J D. Management of tracheoesophageal fistulas in adults.  Curr Treat Options Gastroenterol. 2004;  7 31-40
• 3 Mizobuchi S, Kuge K, Maeda H. et al . Endoscopic clip application for closure of an esophagomediastinaltracheal fistula after surgery for esophageal cancer.  Gastrointest Endosc. 2003;  57 962-965
• 4 Murdock A, Moorehead R J, Tham T C. Closure of a benign bronchoesophageal fistula with endoscopic clips.  Gastrointest Endosc. 2005;  62 635-638