Esophagopleural Fistula Following The Treatment Of Acute Esophageal Variceal Bleeding With Endoscopic Banding And Minnesota Tube Placement

INTRODUCTION: An esophagopleural fistula (EPF) is defined by an abnormal connection between the esophagus and pleural space. The most common etiologies include prior pneumonectomy, esophageal foreign body, and sequelae related to malignancies of the esophagus, lung, and mediastinum. Ingested substances can extend into the mediastinal or pleural spaces with resultant local or systemic inflammatory responses. CASE DESCRIPTION/METHODS: We present a case report of a 50-year-old male with hepatitis C and alcoholic cirrhosis who developed iatrogenic EPF in the setting of multiple endoscopies and Minnesota tube placement for refractory variceal hemorrhage. The patient was repeatedly hospitalized for recurrent variceal hemorrhages, necessitating repeated esophageal banding and ultimately Minnesota tube placement prior to a planned TIPS. His postoperative hospital course was complicated by acute hypoxic respiratory failure and empyema, requiring intubation and thoracostomy tube placement. Pleural fluid cultures grew E. faecium and C. albicans. A water soluble esophagram demonstrated an esophageal leak with contrast seen extending into the left pleural space (Figure 1A). Subsequent unenhanced thoracoabdominal CT confirmed the presence of an EPF (Figure 1B). Endoscopic evaluation revealed the presence of food debris at the esophageal defect. This was treated with lavage, debridement, and placement of dual esophageal stents. An enteric tube was placed for tube feeds. Inspection of the pleural drainage catheter several days later revealed the presence of tube feeds. Subsequent endoscopy showed proximal migration of the esophageal stents, necessitating stent removal, endoscopic suturing (Figure 2B), and the placement of a nasojejunal feeding tube. Despite these interventions, the esophageal leak persisted (Figure 3B), and another endoscopic stent exchange was required. The patient then improved clinically and was subsequently discharged. At three month follow up, imaging demonstrated resolution of the EPF and the patient underwent stent removal. DISCUSSION: To our knowledge, this is the first case of EPF secondary to Minnesota tube placement. Our case report highlights that EPF can be a potential complication of Minnesota tube placement for treatment of variceal bleeding. Respiratory failure or infection following Minnesota tube placement should raise suspicion for EPF and merits investigation with contrast esophagram or CT.Figure 1.: Initial imaging performed at our institution. (A) Water soluble constrast esophagram demonstrating a distal esophageal defect with contrast extending into the left pleural space (dashed white arrows). The esophagus proximal to the fistula is opacified by contrast (solid white line). (B) Unenhanced thoracoabdominal CT demonstrates an esophagopleural fistula (solid white arrow) with abundant spillage of oral contrast into the left pleural space (dashed white arrows).Figure 2.: Endoscopic images demonstrating (A) initial discovery of the thoracostomy tube (yellow arrow) visualized through fistula and (B) subsequent closure after endoscopic suture (white arrow) placement.Figure 3.: (A) Portable AP frontal chest radiograph demonstrates the presence of a metallic stent overlying the distal esophagus (arrows). Note also the presence of a percutaneous left basilar pleural drain, TIPS catheter over the right upper abdominal quadrant, and a large-bore left thoracostomy tube. (B) Water soluble esophagram demonstrating persistent continuity between the distal, stented esophagus (solid white arrow) and the left pleural cavity (dashed white arrow).