A Case of Spontaneous Esophagopleural Fistula Successfully Treated by Endoscopic Stent Insertion
A 73-year-old man was admitted to Chungnam National University Hospital complaining right chest discomfort. He had 20 pack-years smoking history but had neither an operation history nor a medical history such as diabetes, hypertension, pulmonary tuberculosis, or hepatitis. Physical examination was unremarkable except for diminished respiratory sounds in the whole right lung field. The results of laboratory studies showed a white blood cell (WBC) count of 8,500/mm2; hemoglobin of 12.5 g/dL; and platelet count of 164,000/mm2. The serum biochemistry presented Na+ of 140 mEq/L; K+ 4.3 mEq/L; Cl- 107 mEq/L; aspartate aminotransferase 19.5 IU/L; alanine aminotransferase 12.4 IU/L; total bilirubin 0.9 mg/dL; and lactate dehydrogenase (LDH) 246 IU/L (all within normal ranges) with hypoalbuminemia (2.8 g/dL) and elevated serum creatinine level (1.65 mg/dL). Chest X-ray revealed right pleural effusion (). Pleural fluid analysis revealed pH of 7.0; red blood cell 3,200/mm3; WBC 4,800/mm3; total protein 4.0 g/dL; and LDH 2,246 IU/L compatible with exudative parapneumonic effusion, for which an antibiotic therapy was initiated with chest tube catheter insertion (). Thereafter food material was drained into the chest catheter. Esophagogram using gastrografin documented extravasation into the pleural cavity (). Finally, upper endoscopy confirmed a large fistulous tract measuring 12 mm (). Stent insertion was considered as the first treatment due to the large fistula and pleuritis. A 14-cm long, 18-mm diameter covered Choo stent (MITech, Seoul, Korea) was deployed under direct vision (). A repeat endoscopic and radiologic study demonstrated neither extravasation nor migration. Three months after the stent insertion, the stent was easily removed by pulling removal snare with an alligator forceps (). Stent removal was uncomplicated. The patient remained asymptomatic () at the subsequent follow-up 6 months after the stent removal.