Published online Jun 6, 2020. doi: 10.12998/wjcc.v8.i11.2359
Peer-review started: March 11, 2020
First decision: April 14, 2020
Revised: April 27, 2020
Accepted: May 14, 2020
Article in press: May 14, 2020
Published online: June 6, 2020
Processing time: 86 Days and 22.9 Hours
Fistulization is a rare complication of esophageal diverticula. Patients with this condition often require surgery, which unfortunately can be invasive and traumatic. Endoscopic therapy is an alternative method for treating esophageal fistula. Hereby we introduce a new endoscopic technique that uses an esophageal pedicle flap to close esophageal fistulas.
A 49-year-old male patient, complaining of backache and choking, was formerly diagnosed with chronic bronchopneumonia. Chest computed tomography and esophagram confirmed the presence of esophageal diverticulum and mediastinal esophageal fistula. The patient was then treated by covering the fistulas using a pedicled flap that was acquired through endoscopic submucosal dissection of a patch from the proximal esophageal mucosa. Then the pedicle flap was reversed 180° to cover the fistula. Titanium clips were used to fix the flap. The procedure ended with percutaneous endoscopic gastrostomy for enteral nutrition. The patient was followed up to evaluate the size reduction of the fistula. Cough, backache, and fever were alleviated within a week. Forty-five days after the surgery, endoscopic examination showed that the fistulas were reduced in size. The larger one reduced from 0.5 cm to 0.2 cm, while the smaller one was fully closed.
Transplantation of a pedicle flap obtained from the esophageal mucosa endoscopically is minimally invasive for the treatment of fistula.
Core tip: Transplantation of muscle flaps or omental ones for esophageal leakage or fistula from outside the wall is reported to be effective. But surgical intervention often has postoperative morbidities and is contraindicated when the patient has poor health conditions. We developed this endoscopic pedicle grafting method based on the hypothesis that a mucosal flap could induce epithelization. Our single case study showed that the flap can heal a small fistula orifice and can reduce large one. It exhibits the potential to cure selected esophageal fistulas when surgery is not viable.