Post written by Amy Tyberg, MD, from the Division of Gastroenterology and Hepatology, Weill Cornell Medical College, New York, New York, USA
This case describes a patient with obstructive esophageal cancer dependent on PEG feeding for nutrition who developed an esophagopleural fistula at the level of the malignant stenosis with resultant hydropneumothorax requiring chest tube drainage.
Wire access across the stenosis to facilitate stent placement was not feasible using a traditional antegrade approach but was able to be achieved by advancing the endoscope through the PEG tract into the distal esophagus and passing the wire retrograde across the stenosis. Esophageal stent placement could then be performed with subsequent resolution of the hydropneuomothorax and chest tube removal.
Esophageal stent placement is a standard of care treatment for esophagopleural fistulas. However, when the fistula is within the region of stenosis, obtaining wire access to facilitate stent placement can be impossible. In this case, a novel approach was used to facilitate wire access across a tight malignant stricture via advancement of the endoscope through a PEG tract and retrograde advancement of the wire from the distal to proximal esophagus after which an esophageal stent could be deployed.
By using this approach, the hydropneumothorax resolved and the patient was able to be discharged to hospice without a chest tube in place, improving her morbidity and subsequently her quality of life post-hospitalization. We believe this is a technique that should be considered in cases where traditional antegrade endoscopy fails to cross a tight stenosis.