Post written by Mayank Goyal, MD, from the the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, and the University of Missouri-Kansas City, Kansas City, Missouri, and Navtej Buttar, MD, from the Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA.

We report the case of a 34-year-old man with a complex surgical history who developed a refractory esophagopleural fistula (EPF) after Roux-en-Y esophagojejunostomy. Prior interventions, including endoscopic stenting and valve placement, were unsuccessful.

We performed a novel combined endoscopic and bronchoscopic approach in which a fully covered biliary stent was placed endoscopically, and an endobronchial 1-way valve was deployed within the stent under combined endoscopic, bronchoscopic, and fluoroscopic guidance. This allowed egress of secretions and air from the pleural cavity while preventing food entry, functioning effectively as a pressure-sensitive 1-way valve. The cavity decompressed over time, and follow-up confirmed complete resolution of the abscess and closure of the fistula.

EPF is a rare but serious condition with high morbidity and mortality. Many patients are poor surgical candidates, and traditional endoscopic therapies often have limited success, especially in chronic cases. This video highlights a novel, minimally invasive technique combining endoscopic and bronchoscopic expertise, demonstrating a new therapeutic option for patients with refractory EPFs.

Endoscopists can learn the feasibility of deploying an endobronchial valve within a covered stent to create a functional 1-way drainage system. This technique features:

• The importance of a multidisciplinary approach with interventional pulmonology.
• Technical considerations for stent selection, valve sizing, and deployment under combined visualization.
• The potential for durable fistula closure without surgery in carefully selected patients.

This case expands the armamentarium of endoscopic techniques for complex esophageal fistulas. By combining tools from both GI and pulmonary disciplines, we successfully managed a high-risk patient who otherwise lacked viable options. We believe this approach may be applicable to other refractory fistulas and encourage further exploration of combined techniques in complex GI defects.

Image taken after procedure shows the biliary fully covered metal stent (blue arrow) and the endobronchial valve (yellow arrow).

Read the full article online.

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