Updates in Surgery | 2021
Endoscopic treatment of an esophagomediastinal fistula arising from a perforated ulcer in Zenker’s diverticulum
Abstract
We describe a case of esophagomediastinal fistula (EF) originating from an ulcer in a Zenker’s diverticulum, successfully treated with a two-step endoscopic approach. The patient was a 53-year-old woman who was admitted in a peripheral hospital for the treatment of a sepsis caused from an aspiration pneumonia. She reported a medical history of lupus erythematosus systemicus, Hashimoto’s thyroiditis, chronic renal failure in dialysis treatment, hypertension, heart failure (NYHA 2), Fahr’s disease (idiopathic basal ganglia calcification), cholelithiasis, and chronic symptoms of Zenker’s diverticulum that had been initially diagnosed with barium examination of the upper gastrointestinal tract. She recovered from pneumonia after receiving antibiotic therapy. One month after hospital discharge, the patients was referred to our centre for the treatment of the Zenker’s diverticulum. At admission, she complained of dysphagia and occasional episodes of coughing. There were no fever nor alterations of laboratory inflammation markers. CT scan of the chest showed a cervical esophageal diverticulum with a surrounding collection of fluid with gas bubbles extended up to the aortic arc (Fig. 1A, B). Barium swallow study revealed a Zenker’s diverticulum and an extravasation of contrast medium through an EF blind fistula arising from the diverticular wall (Fig. 1C). Upper endoscopy demonstrated a diverticulum in the cervical esophagus with an area of ulceration in the fundus of the pouch, from which originated a fistolous tract (Fig. 2). After a multidisciplinary discussion, taking into consideration the patient’s comorbidities, a surgical intervention was deemed to be of high risk; thus, we opted for an endoscopic approach. A diverticulotomy was performed towards the fundus of the diverticulum with a 1 cm tissue margin left using LigasureTM system, along with the placement of an endoclip at the end of the section to prevent microperforation or bleeding from the small remnant septum. During the endoscopy procedure, a biopsy of the ulcerated area was obtained. The histology examination revealed a picture of chronic inflammation. After 10 days, a new endoscopy was carried out, which showed a complete healing of the ulceration with regular passage of the endoscope through the esophagus. Since a 2-mm fistulous opening persisted in the Zenker’s diverticulum, fibrin glue was injected under pressure with a pushing catheter to close the fistula tract during the endoscopy. Both endoscopic procedures were performed with sedation and continuous monitoring, without general anesthesia. To note, the two endoscopic sessions were uneventful and the patient reported a rapid disappearance of dysphagia and cough after the treatment. Since the patient was chronically on steroids for her autoimmune disorders, the therapy could not be discontinued; however, to facilitate the closure of the fistula, steroids were reduced in dosage and administered intravenously. After 1 month, an endoscopy revealed a complete healing of the ulceration and a complete closure of the EM fistula orifice (Fig. 3A, B). After 6 months from the endoscopic procedures, the patient feeds regularly and does not refer any symptom related to esophageal motility. A barium swallow study demonstrated a normal transit of contrast medium through the esophagus, a reduction in diverticulum size, and a complete disappearance of the EM fistula (Fig. 3C, D). The patient had two main problems to solve: the Zenker’s diverticulum and the EF arising from its wall. EF are rare entities usually caused by trauma or chest surgery, with a various spectrum of clinical presentations [1]. We report a case, where the EM originated from an ulcer in a Zenker’s diverticulum, probably caused by chronic steroid therapy administered for the treatment of patient’s autoimmune diseases. Ulcers in the basis of a Zenker’s diverticulum have been rarely described, mostly as a consequence of aspirin on NSAID, and may be a source of spontaneous esophageal * Alessandro Fancellu [email protected]