bronchial connection treated with stent plus pyration valve we have no disclosures gastrointestinal respiratory tract fistulas such as esophageal bronchial fistulas are a rare but life-threatening complication the management includes surgery that is challenging and associated with a high rate of morbidity endoscopic management often involves multiple procedures and is more effective for acute leaks than chronic fistulas however there are limited reports on the successful management of esophageal pleural fistulas with endoscopy here we present a 34 year old male with a complex medical and surgical history including opacity status post gastric sleeve done outside the country a decade ago which was complicated by an esophageal pleural fistula immediately proximal to the esophageal jejunal anastomosis the initial management which involved a combined esophageal gastrointestinal and a bronchoscopy approach with pyration valve deployment at the fistula site was successful on subsequent endoscopy a six millimeter fistula with the magnetized pyration valve into the 2 by 3 centimeter pleural cavity that also had the fluid material was observed at the esophageal anastomosis the food and the magnetized pyration valve were removed and contrast injection did not reveal any communication with the bronchopulmonary tissue on scrawling CT post-operative changes of gastectomy and esophageal jejunostomy were present there was a persistent cavity in the lower left chest posteriorly which is shown in the blue arrow the cavity contains air and fluid which lays dependently there was also a persistent linear tract shown in the black arrow extending from the anterior aspect of the cavity towards the region of the esophageal jejunal anastomosis this is the diagram showing the concept of the procedure the fistula was stented with a viable stent to appropriately cover the defect and next a pyration valve was deployed within the stent the viable stent which is a fully covered self-expanding metal stent that has wire loops called as fins was used as it prevents migration and this pyration valve which is a one-way valve was placed in a manner that umbrella part was facing the gut lumen so that it does not allow solid food material to pass through it any liquid that escapes around the valve and enters the cavity eventually is pushed out into the gut lumen by the positive pressure during expiration on upper endoscopy we decided to stand this fistula with the 8 by 6 viable stent which is a will be fully covered self-expanding metal stent we can see the placement of the stent here shown here is the placement of the stent in the fistula tract communicating with the bronchial side of the fistula confirmed with the bubbles seen here on the endoscopic view here we are carefully manipulating this stent to appropriately cover the fistula tract site you next a size 9 pyration valve was deployed with the help of an interventional pulmonologist within the stent as a one-way valve under direct visualization with the help of live fluoroscopy as well as the endoscopic view of the esophageal site of the stent through the gastroscope after procedure the stent patency was confirmed by fluoroscopy visualized here the blue arrow is pointing towards the viable stent and the yellow arrow is pointing towards the spiration valve shown here is the spiration valve with the yellow arrow within the stent the broad size of the valve was placed facing towards the esophagus which does not allow solid material to pass through however liquid does cross through it but eventually with breathing the liquid is drained out to the gut through the valve system final manipulation of the stent to allow appropriate length of the stent to further suture to ensure satisfactory position of the stent you the suture was placed with the help of overstitch device on the four-week follow-up there were no symptoms reported and the x-ray was negative and an esophagram revealed the stent in the esophageal cavity with filling of the cavity around the stent and no contrast was extravasated through the stent after one hour in conclusion we successfully describe a novel endoscopic technique of deploying a one-way valve that is aspiration valve inside a stent to manage a refractory esophageal pleural fistula

endoscopic approach

esophageal pleural fistula

Spiration valve

self-expanding metal stent

minimally invasive solution