Closure of a persistent esophagopleural fistula assisted by a novel endoscopic suturing system.

Gastrointestinal fistulas may be successfully managed endoscopically [1]. Novel endoscopic techniques for full thickness tissue approximation may serve as adjuvants for assisting fistula closure [2,3]; an example is a flexible endoscopic suturing system [4]. We describe a case of a chronic esophageal fistula, treated previously with endoscopic clipping and esophageal stenting, which was successfully managed using a novel endoscopic suturing system [5]. A 66-year-old woman presented with a 3-month history of a chronic esophagopleural fistula secondary to Boerhaave syndrome. The fistulawas initially drained by thoracostomy and subsequently treated using endoscopic clipping followed by placement of a partially covered selfexpandable metal stent. Following removal of the stent 9 weeks later, a contrast esophagram revealed extravasation through a persistent esophagopleural fistulous opening 2cm above the esophagogastric junction (●" Fig.1). The fistula was 10mm in diameter, with free flow of contrast through a long fistulous tract. Endoscopic closure of the fistula was performed using a novel endoscopic suturing device (Overstitch; Apollo Endosurgery, Austin, Texas, USA) (●" Fig.2, ●" Video1) inserted through an esophageal overtube. A double-channel endoscope (Olympus GIF 2T160; Olympus, Center Valley, Pennsylvania, USA) fitted with the suturing device was advanced to the distal esophagus. Placement of a three-stitch running 3.0 polypropylene suture was successful at closing the fistula, and initial contrast instillation demonstrated no leak. Additionally, a partially covered stent was placed to cover the sutured defect. The stent was removed 4 weeks later, and a follow-up esophagogram showed a contrast leak, although the fistulawas smaller (5mm), and the flow less extensive. A second suturing procedure was planned to seal the remaining fistula opening (●" Fig.3), starting with Argon plasma coagulation of the orifice of the fistula, followed by 10mL human fibrin glue injection (Tisseel; Baxter, Westlake Village, California, USA). The fistula was closed again with three interrupted polypropylene 2.0 sutures using the suturing device in the same fashion as described Fig.1 Contrast examination depicting a 3-month esophagopleural fistula despite attempted closure with endoscopic clipping and stent placement. The chest drain (yellow arrow) was injected and fills a space around the esophagus, particularly in the region of the stent (white arrows), identifying a communication with the esophageal lumen. The clips found at the lower part of the image are from a previous cholecystectomy.