Ali Osman, Singh Gurbani, Kolachana Sindhura, Khan Mohammed A, Kesar Varun
Department of Gastroenterology and Hepatology, University of Maryland Medical Center, Baltimore, USA.
Department of Gastroenterology and Hepatology, University of Maryland School of Medicine, Baltimore, USA.
Cureus. 2023 Apr 14;15(4):e37577. doi: 10.7759/cureus.37577. eCollection 2023 Apr.
A tracheoesophageal fistula (TEF) is a pathological connection between the trachea and esophagus, which can either occur congenitally or be acquired. An acquired TEF may occur secondary to malignancy, chemoradiotherapy, infection, or trauma. Hallmark symptoms typically associated with TEF include choking with food intake, productive cough, pneumonia, or failure to thrive. The management of TEF has predominantly involved surgical or endoscopic intervention such as esophageal or airway stenting, suturing, or ablation. More recently, the endoscopic over-the-scope clip (OTSC) has emerged as an effective method of TEF management. The OTSC grasps the mucosa overlaying lesion and seals the defect, thus making it an effective treatment option for the endoscopic closure of various GI defects such as fistulas, bleeding ulcers, and perforations. We report a case of a TEF, acquired secondary to underlying malignancy, and its successful treatment with the use of an OTSC placement. A 79-year-old female with a significant history of diffuse large B-cell lymphoma (DLBCL) currently undergoing chemotherapy was admitted to the hospital for aspiration pneumonia. She presented with persistent productive cough and subsequent limited oral intake ability while initially presenting for DLBCL six months prior with an enlarging right-sided neck mass. Her positron emission tomography-computed tomography (PET-CT) imaging showed a cavitary lesion in the superior mediastinum with increased fluorodeoxyglucose (FDG) lymphatic uptake. She had an esophagogram followed by an esophagogastroduodenoscopy (EGD), due to aspiration concerns, which demonstrated a fistula site with tracheal secretions about 20 cm from the incisors. An OTSC was used to close the esophageal opening and successful closure was confirmed using real-time fluoroscopic imaging by the unimpeded passage of contrast in the stomach without leakage. At follow-up, she was able to tolerate an oral diet without any significant difficulty or symptom recurrence. We present a case of successful endoscopic management of TEF with an OTSC that resulted in immediate fistula closure and improvement in the patient's quality of life. This particular case highlights the ability of OTSC to provide more durable and long-term closure than other management techniques due to its mechanism of grasping more tissue for approximation and its association with less morbidity compared to alternative surgical interventions. Although previous reports describing the technical feasibility and utility of OTSC in TEF repair support its use, there is still a paucity of data exploring the long-term efficacy of OTSC in TEF management; therefore, additional prospective studies are necessary.
气管食管瘘（TEF）是气管与食管之间的病理性连接，可先天性发生或后天获得。后天性TEF可能继发于恶性肿瘤、放化疗、感染或创伤。TEF的典型标志性症状包括进食时呛噎、咳痰、肺炎或发育不良。TEF的治疗主要涉及手术或内镜干预，如食管或气道支架置入、缝合或消融。最近，内镜下套扎夹（OTSC）已成为治疗TEF的一种有效方法。OTSC可夹住覆盖病变的黏膜并封闭缺损，因此是内镜下闭合各种胃肠道缺损（如瘘管、出血性溃疡和穿孔）的有效治疗选择。我们报告一例继发于潜在恶性肿瘤的TEF病例，以及使用OTSC置入成功治疗的情况。一名79岁女性，有弥漫性大B细胞淋巴瘤（DLBCL）病史且正在接受化疗，因吸入性肺炎入院。她最初因右侧颈部肿块增大于6个月前就诊于DLBCL，目前表现为持续咳痰及随后有限的经口进食能力。她的正电子发射断层扫描 - 计算机断层扫描（PET - CT）成像显示上纵隔有一个空洞性病变，氟脱氧葡萄糖（FDG）淋巴摄取增加。由于担心误吸，她先进行了食管造影，随后进行了食管胃十二指肠镜检查（EGD），结果显示距门齿约20 cm处有一个伴有气管分泌物的瘘口部位。使用OTSC封闭食管开口，并通过实时荧光透视成像确认成功封闭，即造影剂顺利进入胃内且无渗漏。随访时，她能够耐受经口饮食，没有任何明显困难或症状复发。我们展示了一例使用OTSC成功内镜治疗TEF的病例，该治疗立即封闭了瘘管并改善了患者的生活质量。这个特殊病例凸显了OTSC比其他治疗技术能提供更持久和长期封闭的能力，这归因于其抓取更多组织进行对合的机制以及与其他手术干预相比更低的发病率。尽管先前描述OTSC在TEF修复中的技术可行性和实用性的报告支持其应用，但仍缺乏探索OTSC在TEF治疗中长期疗效的数据；因此，需要更多的前瞻性研究。
