Esophago-bronchial fistula treated by the Over-The-Scope-Clipping (OTSC) system with argon beam electrocoagulation: A case report

Rationale:An esophago-bronchial fistula is one of the rare postoperative complications of esophageal cancer. There are various medical treatments, including suturing, endoscopic clip, and fibrin glue. However, these treatments often lead to unsatisfactory results, causing physicians to opt for surgical alternatives. The Over-The-Scope-Clipping (OTSC) system offers an alternative method for fistula closure. It can capture a large amount of tissue and is able to compress the lesion until it has fully healed. However, data indicating the efficacy of OTSC for esophago-bronchial fistula are limited.Patient concerns:A 64-year-old man presented with an esophago-bronchial fistula after surgery for esophageal cancer. We chose to use a stent as the first line of treatment, but the fistula did not close.Diagnoses:Intractable esophago-bronchial fistula associated with esophageal surgery.Interventions and Outcomes:On the 94th postoperative day, fistula closure with OTSC was performed, and no leakage of the contrast agent was observed during fluoroscopy. We also attempted to close the fistula by combining OTSC and argon plasma coagulation (APC) to burn off the scar tissue from around the fistula. The fistula gradually shrank after a total of 4 rounds of OTSC, and closure of the fistula was achieved on the 185th postoperative day. There were no adverse events during the treatment of this case.Lessons:We demonstrate that OTSC is useful in the management of esophago-bronchial fistulas, and may become a standard procedure for the endoscopic treatment of esophago-bronchial fistulas, replacing the use of stents, clips, or glue.     

Endoscopic palliative intubation of the esophagus invaded by lung cancer.

Thirty-two patients with esophageal involvement by lung cancer were managed by endoscopic intubation. In 22 patients with extrinsic esophageal strictures, the success rate of intubation was 91%, and 82% were discharged with their dysphagia relieved and esophageal patency restored. The mean survival rate was 4.4 months. In 10 patients with esophago-bronchial fistulas, 3 had the fistulous tract obliterated and lived a mean of 5 months. This low success rate of closing fistulas is due to failure to seal off the space between the stent and the fistula because of absence of tumor-associated stenosis. The overall morbidity rate was 28.1% (18.8% perforation, 6.3% hemorrhage, and 3.1% tracheal obstruction). The overall mortality rate was 18.8%. Although complications were more frequent than in primary esophageal tumors, endoscopic intubation was the only way to palliate this desperate condition and provided 66.6% of patients with relief of symptoms, nutritional improvement, and a mean survival time of 4.5 months.     

自体皮片移植术预防食管环周早癌内镜黏膜下隧道剥离术后食管狭窄的临床研究

目的 评价自体皮片移植术预防食管环周早癌内镜黏膜下隧道剥离术（ESTD）后食管狭窄的安全性和有效性。方法 2018年1月至2018年3月,5例食管环周早癌患者于解放军总医院接受ESTD联合自体皮片移植术。术后通过内镜随访,观察皮片生长情况,有无食管狭窄及并发症发生情况。结果 5例患者均成功实施了食管环周早癌ESTD和自体皮片移植术。无食管穿孔、出血、创面感染和支架移位等并发症发生。平均移植皮片成活率为86.0%。4例患者术后平均随访9.5个月,未发生食管狭窄;1例患者术后发生食管狭窄并进行了球囊扩张,术后随访8个月内未再发生狭窄。结论 自体皮片移植术可能是预防食管环周早癌ESTD术后食管狭窄的一种安全且有效的方法。     

Spontaneous esophageal rupture responding to simple suture closure, drainage, and percutaneous endoscopic gastrostomy (PEG): case report

Spontaneous esophageal rupture is a rare disease, and the diagnosis and treatment have not been fully established. Herein we present a 55-year-old man with spontaneous esophageal rupture who was successfully treated using simple suture closure, drainage, and intraoperative percutaneous endoscopic gastrostomy. He was brought to the emergency room after vomiting gastric contents and blood and then experiencing chest pain. On admission, vital signs were normal. Emergency endoscopy was performed for hemostasis, and spontaneous esophageal rupture was diagnosed. As chest computed tomography suggested intrathoracic perforation, surgery was performed about 8 h after onset. Surgery confirmed spontaneous esophageal rupture localized in the mediastinum. Simple suture closure, drainage, and intraoperative endoscopic gastrostomy were performed. On postoperative day (POD) 1, the patient was weaned off artificial ventilation, and enteral feeding through PEG was initiated. Oral intake was restarted on POD 10. The patient was discharged on POD 16.     

Treatment of malignant strictures of the cervical esophagus by endoscopic intubation using modified endoprostheses.

Endoscopic intubation has traditionally been considered unsuitable as a means of palliating cervical esophageal carcinomas involving or within 2 cm of the cricopharyngeus sphincter muscle because of the potential problems of foreign body sensation and proximal prosthesis migration. We attempted to palliate eight such patients, three of whom had tracheo-esophageal fistulas by the endoscopic placement of modified Celestin endoprostheses; the floppy funnel of the prosthesis was positioned above the cricopharyngeus in the hypopharynx. Prosthesis placement and fistula occlusion was possible in all patients. Six patients had a significant long-term improvement in their dysphagia, managing a semi-solid (5 patients) or liquid diet (1 patient); two patients did not improve, despite accurate prosthesis placement, because of marked tracheal aspiration. Six patients reported no foreign body sensation; one patient had minor discomfort, and another moderate throat discomfort. Distal prosthesis migration occurred in two patients (replaced in 1 patient). Endoscopic intubation of high cervical esophageal carcinomas with specially modified endoprostheses is feasible and can provide worthwhile palliation of dysphagia and symptoms due to a tracheo-esophageal fistula. Foreign body sensation and proximal prosthesis migration did not prove troublesome.     

Successful management of esophageal perforation due to an aortic arch aneurysm replacement

SUMMARY.  We present the successful management of an esophageal perforation after aortic arch aneurysm replacement in a 64-year-old patient. Four weeks after surgical repair of a perforated aortic arch aneurysm, a contained perforation of the thoracic esophagus on the prosthesis was detected. A subtotal esophagectomy and reconstruction by pull-up of the stomach together with the greater omentum and high intrathoracic esophagogastrostomy was performed. The aortic prosthesis was covered by omentum. After a prolonged postoperative course, the patient was discharged from the hospital on a full oral diet. She is well after 1 year without signs of infection.     

内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床应用价值

目的探讨内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床价值及食管支架置入术并发症的防治。方法回顾性分析163例晚期食管癌患者内镜下覆膜食管支架治疗食管癌性狭窄及食管气管瘘的临床资料,其中7例患者为食管癌性狭窄并食管-支气管瘘伴双下肺感染,19例患者为食管癌术后复发吻合口狭窄置入镍钛记忆合金覆膜支架。102例患者由于食管过于狭窄先行食管扩张,再进行内镜下放置食管支架,35例患者直接内镜下置入食管支架。结果 163例患者先后放置174个支架,均一次性置入成功,成功率为100%。163例患者均有不同程度胸痛不适,有32例支架再狭窄,其中19例单纯行支架内球囊扩张,11例于原支架上端内部分重叠再放置一支架,有26例行氩气刀再通治疗。7例患者出现支架移位,有2例支架进入食管瘘管内于次日在内镜下取出支架重新放置。所有病例均未出现食管破裂、食管血肿或出血等严重并发症,术后患者进食能力提高,食管气管瘘闭合。结论内镜下覆膜食管支架置入术是中晚期食管癌性狭窄简单、安全、有效的姑息治疗方法,能提高患者的生活质量,延长患者的生存期。     

Esophageal carcinosarcoma with intramural metastasis

A case of esophageal carcinosarcoma is described herein. A 58-year-old man presented with dysphagia and was admitted to our hospital. Imaging studies revealed a type 3 tumor in the upper intrathoracic esophagus with direct invasion to the left main bronchus. Analysis of a biopsy specimen revealed carcinosarcoma. The patient underwent esophageal bypass and chemoradiotherapy. Eight months after surgery, he died of esophago-bronchial fistula. Autopsy examination revealed liver metastasis, peritoneal dissemination and intramural metastasis. The sarcomatous component was predominant in the intramural and liver metastatic lesions.     

Predictive factors for esophageal stenosis after endoscopic submucosal dissection for superficial esophageal cancer

Endoscopic submucosal dissection (ESD) has been utilized as an alternative treatment to endoscopic mucosal resection for superficial esophageal cancer. We aimed to evaluate the complications associated with esophageal ESD and elucidate predictive factors for post‐ESD stenosis. The study enrolled a total of 42 lesions of superficial esophageal cancer in 33 consecutive patients who underwent ESD in our department. We retrospectively reviewed ESD‐associated complications and comparatively analyzed regional and technical factors between cases with and without post‐ESD stenosis. The regional factors included location, endoscopic appearance, longitudinal and circumferential tumor sizes, depth of invasion, and lymphatic and vessel invasion. The technical factors included longitudinal and circumferential sizes of mucosal defects, muscle disclosure and cleavage, perforation, and en bloc resection. Esophageal stenosis was defined when a standard endoscope (9.8 mm in diameter) failed to pass through the stenosis. The results showed no cases of delayed bleeding, three cases of insidious perforation (7.1%), two cases of endoscopically confirmed perforation followed by mediastinitis (4.8%), and seven cases of esophageal stenosis (16.7%). Monovalent analysis indicated that the longitudinal and circumferential sizes of the tumor and mucosal defect were significant predictive factors for post‐ESD stenosis (P < 0.005). Receiver operating characteristic analysis showed the highest sensitivity and specificity for a circumferential mucosal defect size of more than 71% (100 and 97.1%, respectively), followed by a circumferential tumor size of more than 59% (85.7 and 97.1%, respectively). It is of note that the success rate of en bloc resection was 95.2%, and balloon dilatation was effective for clinical symptoms in all seven patients with post‐ESD stenosis. In conclusion, the most frequent complication with ESD was esophageal stenosis, for which the sizes of the tumor and mucosal defect were significant predictive factors. Although ESD enables large en bloc resection of esophageal cancer, practically, in cases with a lesion more than half of the circumference, great care must be taken because of the high risk of post‐ESD stenosis.     

Esophageal perforation and postoperative fistulae of the upper digestive tract treated endoscopically with the application of Tissucol

We present three patients with serious gastro-esophageal complications which were treated with Tissucol. The first patient developed a rare postoperative oesophago-pleural fistula. The second suffered a traumatic esophageal perforation (possibly iatrogenic) that was discovered at the end of the removal procedure of an alimentary bolus impacted in the distal esophagus. Attempts to close the high output oesophago-pleural fistula with standard treatment were unsuccessful. It was closed with Tissucol at the third attempt, in conjunction with oesophago-jejunal stenosis by means of endoscopic dilatation. In the second patient, early Tissucol application after detection of pneumomediastinum was an effective complementary treatment to the conservative approach and rapidly closed the perforation. The third patient developed a low debit postoperative gastro-cutaneous fistula that did not resolve with conservative treatment. It was closed with only one session of Tissucol sealing. We consider that the endoscopic application of fibrin glue should become the first step in the conservative treatment of small esophageal perforations or postoperative esophageal pleural fistulae, especially in cases of high output fistulae. The success of this technique depends on the localization and selective catheterization of the fistula and on brushing the fistular opening. Total resolution of any distal stenosis is necessary to prevent reopening of the fistula.     

Diagnosis and endoscopic treatment of esophago-bronchial fistula due to gastric heterotopy

Heterotopic gastric mucosa patches are congenital gastrointestinal abnormalities and have been reported to occur anywhere along the gastrointestinal tract from mouth to anus. Complications of heterotopic gastric mucosa include dysphagia, upper gastrointestinal bleeding, upper esophageal ring stricture, adenocarcinoma and fistula formation. In this case report we describe the diagnosis and treatment of the first case of esophago-bronchial fistula due to heterotopic gastric mucosa in mid esophagus. A 40-year old former professional soccer player was referred to our department for treatment of an esophago-bronchial fistula. Microscopic examination of the biopsies taken from the esophageal fistula revealed the presence of gastric heterotopic mucosa. We decided to do a non-surgical therapeutic endoscopic procedure. A sclerotherapy catheter was inserted through which 1 mL of ready to use synthetic surgical glue was applied in the fistula and it closed the fistula opening with excellent results.     

Gastric seromuscular patch for intrathoracic perforation repair

AIM To observe the effect of repair of intrathoracic esophageal perforation with gastric seromuscularpatch.METHODS Twelve patients with intrathoracic esophageal perforation, none of whom were associated withcarcinoma, underwent primary repair with a gastric seromuscular patch and omental pedicle flap between1996 and 1999. Four perforations were iatrogenic and 8 were spontaneous. The interval from perforation tooperation was less than 12 hours in 4 patients, 12 to 24 hours in 3, and more than 24 hours in 5. The principleof repair included: ① To expose health mucosa and submucosa for the primary repair. The leading edge ofthe mucosa is grasped and the adjacent esophageal muscle is mobilized away from the submucosa until there isa 3 to 7 mm circumferential rim of normal submucosa. ② The gastric seromucular patch and omental pedicleflap require continuity of the right gastric piple, omental vessels and the rami. ③ To assure the blood flow ofthe esophagus when the necrotic mediastinal and esophageal tissue are debrided, the normal esophageal tissueoften extends well beyond the 3/4 diameter of the esophagus. ④ The mediastinal pleural is not closed inorder to drain. The catchers nasogastric tube decompression of the stomach is continued until thepostoperative ileus resolves.RESULTS Eleven of the 12 patients underwent primary repair, one patient had leak at the site of repairand died.CONCLUSION Meticulous repair of an intrathoracic esophageal perforation using a gastric seromuscularpatch is the preferred approach regardless of the duration of the injury.     

Sealing of esophageal perforation or ruptures with expandable metallic stents: A prospective controlled study on treatment efficacy and limitations

Esophageal perforations are surgical emergencies with high mortality rates. A variety of treatment strategies have been advocated. No single strategy has however, been fully applicable to deal with most situations. The aim of this study was to investigate if treatment with covered expandable metallic stents could offer a feasible option for the management of a leaking esophagus regardless of cause. Twenty-two consecutive patients with perforation or leakage from the intrathoracic esophagus were endoscopically treated with placement of a covered expandable metallic stent. Nine patients had esophageal cancer and 13 had benign underlying disease of whom two had a leakage from a surgical anastomosis. The leakage could be sealed in all but one patient. This patient died after an open esophageal diversion procedure. Twelve patients had an uneventful recovery, whereas three patients needed percutaneous drainage of abscesses and one drainage of the pleural cavity through a small thoracotomy. One patient required a conventional thoracotomy to drain the mediastinum. In total five (23%) patients died from the perforation within 30 days. Two of the deaths were unrelated and three (14%) related to the perforation. In patients with benign disease stents were removed or replaced after 3 weeks. In total 17 stents were successfully removed. Leakage from a damage esophagus can be effectively covered by expandable metallic stents seemingly regardless of the underlying cause and is likely to offer a good chance of survival even in severely ill patients.     

Options in the management of esophageal perforation: analysis over a 12‐year period

Controversies exist about the management of esophageal perforation in order to eliminate the septic focus. The aim of this study was to assess the etiology, management, and outcome of esophageal perforation over a 12‐year period, in order to characterize optimal treatment options in this severe disease. Between May 1996 and May 2008, 44 patients (30 men, 14 women; median age 67 years) with esophageal perforation were treated in our department. Etiology, diagnostic procedures, time interval between clinical presentation and treatment, therapeutic management, and outcome were analyzed retro‐ or prospectively for each patient. Iatrogenic injury was the most frequent cause of esophageal perforation (n= 28), followed by spontaneous (n= 9) and traumatic (n= 4) esophageal rupture (in three patients, the reasons were not determinable). Eight patients (18%) underwent conservative treatment with cessation of oral intake, antibiotics, and parenteral nutrition. Twelve (27%) patients received an endoscopic stent implantation. Surgical therapy was performed in 24 (55%) patients with suturing of the lesion in nine patients, esophagectomy with delayed reconstruction in 14 patients, and resection of the distal esophagus and gastrectomy in one patient. In case of iatrogenic perforation, conservative or interventional therapy was performed each in 50% of the patients; 89% of the patients with a Boerhaave syndrome underwent surgery. The hospital mortality rate was 6.8% (3 of 44 patients): one patient with an iatrogenic perforation after conservative treatment, and two patients after surgery (one with Boerhaave syndrome, one with iatrogenic rupture). No death occurred in the 25 patients with a diagnostic interval less than 24 hours, whereas the mortality rate in the group (n= 16 patients) with a diagnostic interval of more than 24 hours was 19% (P= 0.053). In three patients, the diagnostic interval was not determinable retrospectively. An individualized therapy depending on etiology, diagnostic delay, and septic status leads to a low mortality of esophageal perforation.     

Endoscopic treatment of thoracic esophageal anastomotic leaks by using silicone-covered, self-expanding polyester stents

BACKGROUND: Surgery, as well as conservative treatment, in patients with clinically apparent intrathoracic esophageal anastomotic leaks often is associated with poor results and carries a high morbidity and mortality. The successful treatment of esophageal anastomotic insufficiencies and perforations when using covered, self-expanding metallic stents is described. METHODS: The feasibility and the outcome of endoscopic treatment of intrathoracic anastomotic leakages when using silicone-covered self-expanding polyester stents were investigated. Twelve consecutive patients presented with clinically apparent intrathoracic esophageal anastomotic leak caused by resection of an epiphrenic diverticulum (n = 1), esophagectomy for esophageal cancer (n = 9), or gastrectomy for gastric cancer (n = 2), were endoscopically treated in our department. The extent of the dehiscences ranged from about 20% to 70% of the anastomotic circumference. After endoscopic lavage and debridement of the leakage at 2-day intervals (mean duration, 8.6 days), a large-diameter polyester stent (Polyflex; proximal/distal diameters 25/21 mm) was placed to seal the leakage. Simultaneously, the periesophageal mediastinum was drained by chest drains. OBSERVATIONS: All 12 patients were successfully treated endoscopically without the need for reoperation. A complete closure of the leakage was obtained in 11 of 12 patients after stent removal (median time to stent retrieval, 4 weeks, range 2-8 weeks). In one patient, a persistent leak was sealed endoscopically after stent removal by using 3 clips. Distal stent migration was obtained in two patients. CONCLUSIONS: The placement of silicone-covered self-expanding polyester stents seems to be a successful minimally invasive treatment option for clinically apparent intrathoracic esophageal anastomotic leaks.     

Clinical experience of esophageal perforation occurring with endoscopic submucosal dissection

Esophageal perforation occurring during or after endoscopic mucosal resection (EMR) or endoscopic submucosal dissection (ESD) is a rare, but serious complication. However, reports of its characteristics, including endoscopic imaging and management, have not been fully detailed. To analyze and report the clinical presentation and management of esophageal perforations occurred during or after EMR/ESD. Four hundred seventy‐two esophageal neoplasms in 368 patients were treated (171 EMR; ESD 306) at Northern Yokohama Hospital from 2003 to 2012. Esophageal perforation occurred in a total of seven (1.9%) patients, all of whom were male and had undergone ESD. The etiology of perforation was: three (42.9%) intraoperative; three (42.9%) balloon dilatation for stricture prevention; one (14.2%) due to food bolus impaction. All cases were managed non‐operatively based on the comprehensive assessment of clinical severity, extent of the injury, and the time interval from perforation to treatment onset. Conservative management included (i) bed rest and continuous monitoring to determine the need for operative intervention; (ii) fasting and intravenous fluid infusion/ tube feeding; and (iii) intravenous antibiotics. All defects closed spontaneously, save one case where closure was achieved by endoscopic clipping. Surgery was not required. Conservative management for esophageal perforation during advanced endoscopic resection is may be possible when there is no delay in diagnosis or treatment. Decision‐making should be governed purely by multidisciplinary discussion.     

内镜黏膜下隧道法剥离术治疗早期食管癌伴黏膜下层纤维化的临床观察

目的评价内镜黏膜下隧道法剥离术（endoscopic submucosal tunnel dissection,ESTD）治疗早期食管癌伴黏膜下层纤维化的效果和安全性。方法2015年6月—2018年2月间,在江苏省苏北人民医院消化内科采用ESTD或内镜黏膜下剥离术（endoscopic submucosal dissection,ESD）治疗,术后病理证实病灶＜1/3食管管周,且伴有黏膜下层纤维化的早期食管癌病例87例纳入回顾性分析,按纤维化程度分成轻度纤维化60例（ESTD 31例、ESD 29例）和重度纤维化27例（ESTD 16例、ESD 11例）,比较同一纤维化程度时两种手术方式的剥离速度、整块切除率、完全切除率,以及出血、肌层损伤、穿孔、颈部皮下气肿和术后狭窄的发生率。结果对于伴有轻度黏膜下层纤维化的早期食管癌患者,ESTD的整块切除率[96.8%（30/31）比82.8%（24/29）,P＜0.05]和完全切除率[96.8%（30/31）比75.9%（22/29）,P＜0.05]明显高于ESD,固有肌层损伤发生率明显低于ESD[6.5%（2/31）比17.2%（5/29）,P＜0.05],剥离速度、术中出血发生率、穿孔发生率、术后狭窄发生率与ESD比较差异均无统计学意义（P均＞0.05）,两种手术方式均无术后迟发性出血和颈部皮下气肿发生。对于伴有重度黏膜下层纤维化的早期食管癌患者,ESTD的剥离速度快于ESD[（12.3±2.8）mm2/min比（7.1±3.2）mm2/min],整块切除率、完全切除率、术后狭窄发生率与ESD相近,术中出血发生率[12.5%（2/16）比54.5%（6/11）]、固有肌层损伤发生率[18.8%（3/16）比54.5%（6/11）]、穿孔发生率[6.3%（1/16）比27.3%（3/11）]、颈部皮下气肿发生率[6.3%（1/16）比27.3%（3/11）]低于ESD,两种手术方式均无术后迟发性出血发生。术后12个月2例行ESD和1例行ESTD患者局部复发,术后24个月1例行ESTD患者发生异时癌。结论ESTD能安全、有效切除伴有黏膜下层纤维化的早期食管癌。对于伴有轻度黏膜下层纤维化者,ESTD的优势主要体现在治疗效果方面;对于伴有重度黏膜下层纤维化者,ESTD的优势主要体现在治疗安全性方面。     

内镜下应用氩离子血浆凝固术治疗早期食管癌及其癌前病变的临床研究

目的 探讨应用氩离子血浆凝固术治疗早期食管癌及其癌前病变的意义。方法1999年10月2003年1月内镜下应用氩离子血浆凝固术对13例早期食管癌及114例食管鳞状上皮异型增生进行治疗,氩离子血浆凝固术功率设定为28 W,氩气流量0.4 L／min。术后1个月、4个月及12个月进行内镜复查及治疗。结果 (1)氩离子血浆凝固术治疗早期食管癌及食管癌前病变的成功率分别为92.3％和100％,平均治疗次数分别为3次和2.2次。(2)本组127例合并症发生率为5.5％,其中早期癌与癌前病变合并症的发生率分别为30.7％和2.60％,合并症主要表现为出血、黏膜下血肿及发热等,经对症治疗后均治愈。本组无穿孔及狭窄发生。(3)4-12个月内镜复查并经病理证实3例早期癌复发,再次应用氩离子血浆凝固术治疗,2例治愈,1例病变未控改为手术治疗。癌前病变无复发。(4)本组术后平均随访时间为15.3个月,所有患者目前均无明显不适。结论 应用氩离子血浆凝固术可简便、安全、有效地治疗早期食管癌及癌前病变,具有较好的应用前景。     

Mediastinal Lymph Node Metastasis of Esophageal Cancer with Esophageal Stenosis Diagnosed via Transesophageal Endoscopic Ultrasound with Bronchoscope-guided Fine-needle Aspiration

An 80-year-old man underwent follow-up examinations after endoscopic submucosal dissection (ESD) for esophageal cancer. Computed tomography showed enlarged lymph nodes of the right recurrent nerve. The patient had esophageal stenosis due to repeated ESD for multiple esophageal tumors. The stenosis made the passage of an endoscopic ultrasound (EUS) scope through the esophagus difficult. Thus, an endobronchial ultrasound bronchoscope, which had a thinner diameter than that of the EUS scope, was used for transesophageal endoscopic ultrasound with bronchoscope-guided fine-needle aspiration. This technique led to the diagnosis of mediastinal lymph node metastasis of esophageal cancer.