Endoscopic Closure of Chronic Cervical Esophageal Fistulas: Initial Experience

Recent reports have emphasized an evolving role for endoscopic treatment of refractory benign esophageal conditions (GIE 2005:62;278-286). However, few report endoscopic treatment of extremely high surgical esophageal fistulas. Patients and Methods: Four patients (M:3/ F:1, age 44-60) presented with chronic cervical esophageal cutaneous fistulas 29 to 300 days post-operatively following anastomotic breakdown of attempted Zenker's diverticulectomy (n = 2), and cervical esophagogastrostomy after esophagectomy (n = 2). The fistulas were measured from the incisors at endoscopy at 15, 16, 18, and 22 cm and were associated with severe stricture in 2. Two patients had had no oral intake for >6 months. Patient treatment included: placement of removable plastic stents (Polyflex, Boston Scientific (n = 2) and silicone 10 mm salivary duct stents (n = 1)), and endoscopic cricopharyngeal myotomy with stapled suture lines (n = 1). Dilation (n = 2), fibrin-glue fistula sealant under the stents (n = 2), and a guiding NG tube before the endoscopic cricopharyngeal myotomy (n = 1) were also used. Results: Fistulas closed immediately in all but reopened in one upon stent migration. This was eventually sealed with repeat stent placement x2 and required fibrin-glue (Tisseal, Baxter) at the final procedure. The stents produced only brief patient discomfort and were otherwise well tolerated. Swallowing resumed in the stented patients within 24 hours with full liquids to soft diet. All four of the Polyflex stents migrated into the stomach (3 in 1 case and 1 in another), but were easily removed perorally via EGD. The final silicone salivary stent migrated distally to lie below the strictured anastomosis and was removed endoscopically through an existing G-tube site. No bleeding or aspiration occurred. All stents have now been removed (3 to a maximum 6 weeks after definitive closure) and patients are undergoing well-tolerated dilations when needed. Conclusions: Endoscopic closure of high cervical fistulas can be effectively performed using new techniques and technologies. These treatments were well tolerated, appeared to be safe, and produced excellent results in four extremely difficult post-operative chronic esophageal fistula patients. Removable esophageal stents were key to rapid closure but distal migration was universal. The initial use of fibrin-glue might accelerate sealing and prevent fistula reopening when this occurs.