A 49 year-old man underwent a recent esophagectomy for esophageal cancer. His postoperative course was complicated by a fistula between the trachea and the intra-thoracic stomach. A previously placed tracheal stent was unsuccessful at sealing the fistula. Using argon plasma coagulation, the perimeter of the opening is ablated in order to de-epithelialize the tissue and promote complete sealing of the fistula after approximating its edges. Endoscopic hemoclips are placed around the border of the fistula, and a detachable snare–or endoscopic polyloop–is used to approximate the edges of the defect.
Following this, a flexible guidewire is placed within the intra-thoracic stomach. The endoscope is withdrawn, and the site of the fistula can be identified by the hemoclips. Under simultaneous endoscopic and fluoroscopic guidance, a fully-covered Wallflex esophageal stent is inserted over the guidewire. Three arrows on the left of the screen mark the most proximal and distal borders of the stent. The single right-sided arrow continues to mark the site of the fistula. As the stent is slowly deployed, the bottom arrow shows the distal border of the stent beginning to open. Continued deployment results in gradual release of the stent from the delivery catheter up to its most proximal edge. A retrieval loop is visible at the proximal stent border.
Upon post-deployment inspection, the endoscopic hemoclips are visible through the transparent covering of the Wallflex stent. Fluoroscopic images confirm adequate stent placement. Two arrows on the left of the screen mark the proximal and distal stent border. The single right-sided arrow again shows the site of the fistula completely covered by the stent.
CAT scan of the chest several weeks after stent placement confirms the absence of contrast extravasation into the bronchial tree. The site of the previous fistula can be identified by the presence of hemoclips adjacent to the esophageal stent.
Jonathan Buscaglia, MD, Stony Brook University Medical Center