Sharata Ahmed, Bhayani Neil H, Dunst Christy M, Kurian Ashwin A, Reavis Kevin M, Swanström Lee L
Providence Portland Cancer Center, 4805 NE Glisan Street, #6N60, Portland, OR, 97213, USA,
Surg Endosc. 2014 Dec;28(12):3500-4. doi: 10.1007/s00464-014-3631-6. Epub 2014 Jul 4.
Fistulae between the tracheobronchial tree and the gastric conduit post-esophagectomy are a rare but sometimes fatal complication. Clinical presentation can range from asymptomatic to acute pulmonary decompensation. Traditional management options, such as esophageal exclusion alone or combined with transthoracic fistula division, and closure (with tissue interposition), are highly invasive, technically difficult, and associated with variable success rates. This video presents closure of highly complex, chronic esophagobronchial fistula (EBF) using simultaneous bronchoscopic and upper endoscopic techniques.
Diagnostic bronchoscopy and upper endoscopy are performed to assess the size and location of fistulae. Fistulae with sufficient luminal size to accommodate a biologic plug were selected for treatment. Steps of EBF plug insertion. (1) Wire across fistula with ends exposed through the mouth. (2) Delivery sheath passed across wire from bronchial side to esophageal side (3) Plug loaded on the esophageal side of the sheath. (4) Plug pulled into position across the fistula from esophageal to bronchial side. (5) Delivery sheath released from bronchial side.
Two of four fistulae were suitable for plug therapy. A temporary covered-stent was placed to help maintain the plugs in place. Endoscopy at 1 month showed healing of the plugged fistula following stent removal. Respiratory symptoms were improved with no further episodes of pneumonia. Over course of 2 years, the patient has required three additional endoscopic procedures to control new fistulae from this broad area of exposed lung paranchyma, but the initial fistula plug repair is durable.
Post-esophagectomy fistula is a morbid complication and the surgical treatments available are highly morbid and have variable success rates. Due to the development of new endoscopic technologies, the endotherapy has assumed new prominence for treatment of enteric fistula. This complex case illustrates feasibility of endoscopic fistula treatment using dual scope, biologic plug application which effectively controlled this patient's EBF symptoms.
食管切除术后气管支气管树与胃管道之间的瘘是一种罕见但有时致命的并发症。临床表现从无症状到急性肺功能不全不等。传统的治疗方法，如单纯食管旷置或联合经胸瘘管分离及闭合（采用组织植入），具有高度侵袭性、技术难度大且成功率不一。本视频展示了使用同步支气管镜和上消化道内镜技术闭合高度复杂的慢性食管支气管瘘（EBF）。
进行诊断性支气管镜检查和上消化道内镜检查以评估瘘管的大小和位置。选择管腔大小足以容纳生物封堵物的瘘管进行治疗。EBF封堵物插入步骤。（1）将导丝穿过瘘管，两端经口腔露出。（2）将输送鞘管沿导丝从支气管侧穿过至食管侧。（3）将封堵物装载在鞘管的食管侧。（4）将封堵物从食管侧向支气管侧拉过瘘管至合适位置。（5）从支气管侧释放输送鞘管。
4个瘘管中有2个适合封堵治疗。放置了一个临时带膜支架以帮助将封堵物固定在位。1个月后的内镜检查显示在移除支架后封堵的瘘管愈合。呼吸症状改善，未再发生肺炎。在2年的病程中，患者需要另外进行3次内镜检查以控制来自这片广泛暴露肺实质区域的新瘘管，但最初的瘘管封堵修复效果持久。
食管切除术后瘘是一种严重的并发症，现有的手术治疗方法具有高度侵袭性且成功率不一。由于新内镜技术的发展，内镜治疗在肠瘘治疗中崭露头角。这个复杂病例说明了使用双镜、应用生物封堵物进行内镜瘘管治疗的可行性，该方法有效控制了该患者的EBF症状。
