Nasopleural Drainage of Empyema via Esophago-Pleural Fistula: A Novel Endoscopic Rescue Technique

Background: Esophago-pleural fistulas (EPF) are rare entities. These can occur spontaneously or following surgical manipulation and can result in empyema formation. Treatment of empyema in this patient population is difficult, and a variety of techniques have been described. Here, we present a novel rescue technique for empyema management via endoscopy, when percutaneous and surgical techniques were not feasible. Case Information: A 90-year-old female presented with acute gastric volvulus requiring emergent partial gastrectomy and gastrostomy tube placement. Her clinical course was complicated by necrosis of the gastric cardia resulting in perforation and contamination of the mediastinum, requiring distal esophageal stump creation and multiple washouts. She was started on long term antimicrobial agents, with plans of maintaining esophageal discontinuity for six months prior to considering re-anastomosis. She was unstable for surgical drainage. An urgent transnasal endoscopy was performed using an ultra-slim scope. A small fistulous connection was noted between the distal esophageal stump and the left pleural cavity. She had a remarkable clinical improvement within 24 hours. A week after conservative management, a percutaneous drain placement was successfully performed. Conclusion: Empyema management ranges from conservative chest tube placement to aggressive surgical management. Endoscopic drainage is another option when percutaneous and surgical options are not possible. Our case demonstrates a novel rescue technique for the management of empyema in patients who already have an EPF and are not good candidates for conventional treatment. This technique can only be used short-term, as a bridge to definitive treatment.