Proximal Esophageal Anchored Stent: A Successful Endoscopic Approach in A “Troublesome” Location

1. Case Report A 71-year-old woman was admitted for the surgical treatment of a pulmonary adenocarcinoma of the right upper lobe. During anesthesia induction, a left Robertshaw endotracheal tube (ETT) was inadvertently placed in the esophagus. After successful bronchoscopic ETT repositioning, the patient underwent an uneventful VATS (Video-Assisted Thoracoscopic Surgery) right upper lobectomy and lymphadenectomy. High-flow (>1liter) output of particulate white fluid through the chest tube was noted on first post-operative day (POD). In the suspicion of chylothorax, an exploratory esophagogastroduodenoscopy and VATS were performed and a 4-cm longitudinal tear of the posterior wall of the esophagus was found just below the thoracic inlet. The lesion was repaired with a double layer, interrupted 4-0 polydioxanone suture and the chest drained. On POD#7, a barium swallow showed adequate resolution of the fistula. Nevertheless, after initiation of oral intake, the patient developed fever and dysphagia. Endoscopy showed a minimal, 2-mm residual esophageal dehiscence located 2 cm under the cricopharyngeal sphincter, and a CT-scan (Figure 1) showed a residual upper mediastinal collection. Immediate endoscopic clipping of the fistula was attempted but failed due to inadequate margin apposition. After multidisciplinary discussion and despite the very proximal location of the lesion, a fully-covered self-expandable metal stent (FCSEMS, 80x20 mm; Niti-S, Taewoong Medical, South Korea) was deployed in the esophagus and centered on the fistula. In order to avoid distal migration, the proximal end of the stent was sutured to the esophageal wall, just below the cricopharyngeus, using the OverStitch Endoscopic Suturing System (Apollo Endo-surgery, Austin, Texas) (Video). The FC-SEMS was left in place for two months and allowed complete resolution of the fistula. It was then removed endoscopically using a novel cutting device (Ensizor Flex, Austin, Texas) (Figure 2). The final examination revealed definitive healing of the esophageal wall (Figure 3). The patient is alive and well at 11-months follow-up. Esophageal perforation is a rare life-threatening complication of orotracheal intubation, occurring more frequently after difficult cases and double-lumen tube placement, which is a stiffer and sharper device than a standard, single-lumen tube [1, 2]. Endoscopic management of esophageal perforations allows avoiding repeated surgical revisions in patients who are often infected and debilitated. Esophageal lesions located in the proximal esophagus may be very difficult to approach with endoscopic techniques. Endoscopic stenting and anchoring with endo suturing systems may overcome these limitations and may be a further important tool for the interventional endoscopist.