P0651 - A Case Report: Over-the-Scope Clip Closure of an Esophageal-Pleural Fistula Secondary to an Esophageal Stent Placement

Justin Chuang, MD¹, Naveena Luke, MS¹, Khushbu Patel, MS¹, Sami Ghazaleh, MD², Jordan Burlen, MD¹, Azizullah Beran, MD², Dipen Patel, MD, MBA¹, Christian Nehme, MD¹, Sehrish Malik, MD², Ziad Abuhelwa, MD¹, Saif-Eddin Malhas, MD¹, Wasef Sayeh, MD¹, Amna Iqbal, MD¹, Ali Nawras, MD², Muhammad Aziz, MD², Nithin Kesireddy, MD^1
1University of Toledo, Toledo, OH; ²University of Toledo Medical Center, Toledo, OH

Introduction: Esophageal fistula is defined as the pathological connection between the esophagus and another structure. Currently, the most common treatment for esophageal fistula is airway stenting. However, several case series have demonstrated the superiority of the OTSC (over-the-scope clip) system for fistula closure. We report an interesting case requiring multiple stent placements and multiple OTSC placements in esophageal-pleural fistula due to underlying malignancy.

Case Description/Methods: A 57-year-old male with a stage IV esophageal cancer with esophageal stent presented with three days of back pain, chest pain, and shortness of breath. Imaging revealed a right sided pleural effusion and pneumothorax requiring two thoracostomy tube placements. Due to bilious output from the chest tube, upper gastrointestinal series with gastrografin was performed. This demonstrated a fistula at the proximal aspect of the pre-existing esophageal stent (Fig 1A).

A self-expandable metallic stent (SEMS) was utilized to bridge the fistula to the pre- existing esophageal stent . A repeat esophagram two days later revealed Barium extravasation and continuous esophageal leak. OTSC clip was then deployed at the fistula. A SEMS was also implanted through the patient’s pre-existing stent. CT scan and endoscopic images showed persistent esophageal perforation and contrast extravasation from the fistula. (Fig 1B).

With the ongoing deterioration of the patient’s health, the initial OTSC and SEMS combination was removed. After removal, a second OTSC was placed over the fistula, allowing for complete suction of the fistula into the OTSC clip cap (Fig 1C). We followed this by deploying another SEMS through the pre-existing stent and clipped them together. The proximal end of this new stent fully covered the fistula, creating a complete seal. Follow up CT scan demonstrated an improved appearance of the pleural fluid and gas with no signs of drainage from the site of the previous fistula.

Discussion: Over-the-scope clip (OTSC) technique is appealing for its speed, accessibility with insertion, and lasting closure of fistulas. This case is notable in that successful pleural-esophageal fistula closure secondary to existing esophageal stent erosion was achieved by utilizing a properly positioned OTSC with a stent-within-stent combination management. Table 1 are documented EPF closures by OTSC found in the literature.


Figure: Figure 1; A: Upper GI series with gastrografin showing contrast extravasation due to esophageal-pleural fistula. B: Endoscopic images confirming esophageal fistula adjacent to the proximal end of the esophageal stent. C: Placement of OTSC clip over fistula allowing for complete closure of the fistula

Study	Type	Etiology for cause of EPF	Number of attempts with OTSC	Complications	Successful OTSC placement
Kim 2015	Case Report	Traffic accident	1	none	Y
Khamaysi 2013	Case Report	Variceal sclerotherapy	2	Initially recurrent pleural drainage	Y
Correia 2014	Retrospective Study	Mallory-Weiss tear	1	none	Y
Beoletto 2020	Case Report	Pneumonectomy	1	none	Y
Zhang 2013	Case Report	Pneumonia	1	none	Y

Table: Table 1: Documented EPF closures by OTSC found in the literature


Disclosures:
Justin Chuang indicated no relevant financial relationships.
Naveena Luke indicated no relevant financial relationships.
Khushbu Patel indicated no relevant financial relationships.
Sami Ghazaleh indicated no relevant financial relationships.
Jordan Burlen indicated no relevant financial relationships.
Azizullah Beran indicated no relevant financial relationships.
Dipen Patel indicated no relevant financial relationships.
Christian Nehme indicated no relevant financial relationships.
Sehrish Malik indicated no relevant financial relationships.
Ziad Abuhelwa indicated no relevant financial relationships.
Saif-Eddin Malhas indicated no relevant financial relationships.
Wasef Sayeh indicated no relevant financial relationships.
Amna Iqbal indicated no relevant financial relationships.
Ali Nawras indicated no relevant financial relationships.
Muhammad Aziz indicated no relevant financial relationships.
Nithin Kesireddy indicated no relevant financial relationships.


Justin Chuang, MD¹, Naveena Luke, MS¹, Khushbu Patel, MS¹, Sami Ghazaleh, MD², Jordan Burlen, MD¹, Azizullah Beran, MD², Dipen Patel, MD, MBA¹, Christian Nehme, MD¹, Sehrish Malik, MD², Ziad Abuhelwa, MD¹, Saif-Eddin Malhas, MD¹, Wasef Sayeh, MD¹, Amna Iqbal, MD¹, Ali Nawras, MD², Muhammad Aziz, MD², Nithin Kesireddy, MD¹. P0651 - A Case Report: Over-the-Scope Clip Closure of an Esophageal-Pleural Fistula Secondary to an Esophageal Stent Placement, ACG 2021 Annual Scientific Meeting Abstracts. Las Vegas, Nevada: American College of Gastroenterology.