Staged multimodal endoscopic vacuum therapy for a complex gastro-pleuro-broncho-cutaneous fistula: A case report

Abstract

BACKGROUND

Endoscopic vacuum therapy (EVT) has emerged as a secure and efficient organ-preserving option for gastrointestinal perforations, leaks, and fistulas, with high closure rates and low mortality.

CASE SUMMARY

A 41-year-old woman with a history of Roux-en-Y gastric bypass and diaphragmatic repair with biological mesh developed a left-sided empyema due to a gastric pouch fistula complicated by pulmonary abscess and rib osteomyelitis. Multiple thoracic surgical interventions failed, leading to severe malnutrition and persistent pleural drainage. A complex gastro-pleuro-broncho-cutaneous fistula was diagnosed, and salvage EVT was performed using a staged approach, including percutaneous and transluminal EVT combined with bronchial endoscopic treatment. Complete fistula closure was achieved, with restoration of oral intake and significant weight gain at two-month follow-up.

CONCLUSION

This case highlights the successful use of a staged multimodal EVT strategy to achieve definitive closure of a complex gastro-pleuro-broncho-cutaneous fistula.

Key Words: Gastro-pleuro-broncho-cutaneous fistula; Endoscopic vacuum therapy; Complex fistula; Staged therapy; Case report

Core Tip: This case demonstrates the successful resolution of a complex gastro-pleuro-broncho-cutaneous fistula using a staged endoscopic vacuum therapy (EVT) approach. Following failed surgical interventions, a sequential strategy involving initial percutaneous EVT followed by transluminal EVT was implemented. Concurrently, the bronchial defect was managed with argon plasma coagulation and a custom collagen-cellulose plug. This multidisciplinary technique achieved complete fistula closure and nutritional restoration, suggesting that staged EVT is a promising, organ-preserving salvage option for refractory, multi-system fistulas.

INTRODUCTION

Gastrointestinal perforations, leaks, and fistulas are challenging complications for surgery and endoscopy, driving mortality rates up to 35%[1]. Endoscopic vacuum therapy (EVT), which applies continuous negative pressure to drain collections, accelerate granulation and foster defect contraction, achieves closure rates from 80% to 100%, with lower mortality than stenting or repeat surgery[1-3]. Here we report a gastro-pleuro-broncho-cutaneous fistula that develops after an empyema in a patient with prior Roux-en-Y gastric bypass and diaphragmatic repair with biological mesh. We describe a stepwise application of EVT, initially percutaneous and later transluminal, supplemented by multimodal strategy, such as bronchial edge ablation and deployment of a collagen-cellulose plug, to cure a chronic, multisystem fistula after multiple failed thoracic operations, thereby underscoring EVT’s expanding role as a minimally invasive, organ-preserving solution for complex fistulas once deemed surgical dead-ends.

Although EVT has been increasingly reported for upper gastrointestinal leaks[2,3], its role in the management of complex fistulas involving the pleural and bronchial systems remains poorly described. Reports addressing a stepwise EVT strategy combined with bronchial endoscopic interventions in post-bariatric surgery patients are particularly scarce. This case aims to illustrate such an approach in a highly refractory clinical scenario.

CASE PRESENTATION

Chief complaints

A 41-year-old woman with a history of Roux-en-Y gastric bypass was hospitalized for a chronic gastro-pleuro-broncho-cutaneous fistula, associated with weight loss and malnutrition refractory to conventional thoracic surgical management.

History of present illness

A 41-year-old woman with a history of Roux-en-Y gastric bypass (2007) and diaphragmatic repair with biological mesh (2007) presented in the emergency department with a 5-day history of cough, dyspnea, and fever. Chest computed tomography revealed a 131 mL heterogeneous pleural effusion with gas abutting the mesh in the left hemithorax, prompting urgent thoracotomy, which uncovered a new gastric pouch fistula draining into the pleural cavity and complicated by pulmonary abscess, infected mesh, and rib osteomyelitis. Over six months, despite three staged thoracic surgical interventions, including left lower lobe wedge resection with partial costectomy, mesh explantation, primary pouch closure, extensive lavage, and pleural drainage (Figure 1), the patient deteriorated to severe malnutrition [65 kg to 46 kg; body mass index (BMI) 25.4 to 17.9], profound weakness, and persistent pleural output (> 300 mL/day from the anterior drain), despite aggressive enteral and parenteral nutritional support.

Figure 1 Anterior pleural drain attached to a collection bag, and the posterior drain managed with a dressing in physical examination.

History of past illness

The patient underwent diaphragmatic repair with biological mesh in 2007 for complicated empyema secondary to pneumonia, three months after bariatric surgery.

Personal and family history

The patient underwent Roux-en-Y gastric bypass in 2007.

Physical examination

During intensive care unit (ICU) evaluation, the patient was prostrated, afebrile, and eupneic on room air, with severe malnutrition (46 kg; BMI 17.9) despite full enteral and parenteral nutritional support, and had two left-sided thoracic drains with high output of approximately 300-500 mL/day.

Laboratory examinations

Initial laboratory findings demonstrated hypoalbuminemia (3.0 g/dL). Other laboratory parameters were within normal limits, including complete blood count, metabolic panel, liver enzymes.

Imaging examinations

An upper gastrointestinal endoscopy was performed under general anesthesia in the operating room (Video 1), revealing the following findings: Roux-en-Y gastric bypass anatomy; 4 cm gastric pouch with visible 1 cm fistula at the cranial portion of the staple line; 2.5 cm marginal ulcer, involving 50% of the circumference of the gastrojejunal anastomosis with previous placed metal clips. The complex fistula was completely evaluated through the cutaneous orifice with the fluoroscopic guidance (Figure 2).

Figure 2 Fistulography. A: With the scope through the cutaneous orifice; B: Highlighting the broncho-pleural fistula.

MULTIDISCIPLINARY EXPERT CONSULTATION

Given the severity and chronicity of the condition, as well as the patient’s inability to tolerate adequate nutritional support or further surgical intervention, a multidisciplinary team comprising gastroenterology, thoracic surgery, general surgery, infectious disease, and clinical nutrition specialists decided to pursue salvage EVT as a minimally invasive alternative aimed at promoting cavity granulation, fistula closure, and nutritional recovery.

FINAL DIAGNOSIS

This constellation of findings confirmed a transmural fistulous tract originating from the excluded stomach, traversing the diaphragm into the left pleural cavity, with further extension into the bronchial tree and to the abdominal wall, consistent with a gastro-pleuro-broncho-cutaneous fistula, as illustrated in Figure 3.

Figure 3 Anatomical illustration of the gastro-pleuro-broncho-cutaneous fistula.

TREATMENT

EVT was initiated and consisted of every 5-7 days endoscopic sessions for vacuum catheter exchange. Initially, a cutaneous orifice approach was employed, in which previously placed surgical drains were gradually removed and replaced with a custom-modified sponge-based vacuum catheter guided by endoscopy, similar to those used in plastic surgery, manually modified with two independent sponge suction tips (Video 2). During the early phases of EVT, nutritional optimization remained a priority, with parenteral nutrition used to ensure adequate intake while minimizing gastrointestinal stimulation of the fistula.

The distal tip sponge was positioned in the cavity and the proximal tip into the thoracotomy wound with an extra external sponge, to enable simultaneous internal and external closure of the fistulous tract, with a continuous negative pressure of -125 mmHg (Figure 4A). A negative pressure of -125 mmHg was selected based on previous EVT protocols, aiming to optimize granulation while minimizing tissue ischemia[1,3,4].

Figure 4 Endoscopic vacuum therapy and adjunctive therapies. A: Single endoscopic vacuum therapy tube with double drainage, inside the cavity and outside the cutaneous coverage with the two independent sponge suction tips; B: External sealed sterile occlusive dressing with external surgical thread; C: Endoscopic view of post bronchial fistula edge ablation using argon plasma coagulation; D: Custom-designed conical plug composed of collagen and cellulose.

During the first two weeks of EVT, the patient remained in the ICU, receiving intravenous meropenem due to polymicrobial secretion cultures with prolonged hospitalization. The treatment resulted in significant cutaneous orifice closure, switching to a single tip sponge EVT (Video 3 and Supplementary Figure 1), which was positioned into the cavity by guidewire, followed by transfer to the general ward once clinically stable.

After three weeks of therapy, the approach was transitioned to a transluminal route, with a nasal insertion of the EVT catheter through the gastric fistula tract into the pleural cavity (Video 4). The thoracotomy site was managed with a sealed sterile occlusive dressing with an external surgical thread, serving as guidewire for the next approach (Figure 4B).

At the same time, bronchial fistula edge ablation was performed using argon plasma coagulation (APC) via endoscopy through the cutaneous orifice (Figure 4C), followed by the placement of a custom-designed conical plug composed of Surgicel^® and Surgisis^® (Figure 4D), manually molded to seal the bronchial opening. This plug was inserted in the bronchial fistula percutaneously using biopsy forceps and navigated with an endoscopic view at the cavity (Video 5). Bronchial edge ablation was performed to disrupt epithelialization and promote secondary healing, while the collagen-cellulose plug functioned as a temporary scaffold, facilitating tissue integration and definitive closure.

Two weeks later, bronchial fistula closure was confirmed through fluoroscopy, with the formation of a bronchial residual cavity (Figure 5). At six weeks, the gastrocutaneous fistula tract had become linear and narrowed to a 10 mm diameter. As cavity control was achieved and the fistula progressively collapsed, enteral nutrition was gradually reintroduced and advanced, allowing full discontinuation of parenteral support, transitioning to liquid oral intake once transluminal EVT and bronchial closure resulted in clinical stability.

Figure 5 Fistulography showing significant reduction in the cavity with total closure of the bronchial fistula.

Final management involved the placement of an 18 Fr gastrostomy balloon catheter, with the balloon anchored intragastrically to achieve effective occlusion of the tract (Video 6 and Supplementary Figure 2). After a total of eight EVT sessions conducted over approximately six weeks, the patient was discharged with tolerance of a soft oral diet and close outpatient follow-up.

OUTCOME AND FOLLOW-UP

At the 1-month follow-up, the patient reported good oral intake tolerance, with a weight gain of 6 kg, progressing from 49 kg to 55 kg (BMI 19.1 to 21.5) since hospital discharge. Follow-up endoscopic evaluation demonstrated further narrowing of the gastro-pleural fistula to the abdominal wall, with a diameter of 6 mm, and improved coaptation of the external cutaneous orifice (Figure 6).

Figure 6 Physical examination of the external cutaneous orifice.

Considering the favorable evolution, the decision was made to remove the gastrostomy catheter and transition to exclusive external management with a sealed occlusive curative. The patient was advised to progress to a full oral diet as tolerated. During the 2-month follow-up, she continued to show excellent dietary acceptance, with a total weight gain of 15 kg from discharge, reaching 64 kg (BMI of 25.0) and normalization of serum albumin level (3.8 g/dL). Physical examination and endoscopic reassessment confirmed complete closure of the cutaneous orifice, forming a scar, with formation of a small, epithelialized gastric recess at the site of the previously treated cavity (Video 7). The rapid nutritional recovery and sustained fistula closure highlight not only technical success but also meaningful functional and quality-of-life improvement, as shown in the timeline (Figure 7).

Figure 7 Timeline of clinical management and key interventions. EVT: Endoscopic vacuum therapy; APC: Argon plasma coagulation; ICU: Intensive care unit.

DISCUSSION

The management of complex gastro-pleuro-broncho-cutaneous fistulas, particularly in patients with altered gastrointestinal anatomy post-Roux-en-Y gastric bypass, presents significant clinical challenges. Traditional surgical interventions in such scenarios are frequently associated with high morbidity and mortality rates, particularly in patients with compromised nutritional status and multiple comorbidities[1,3]. Alternative endoscopic approaches, such as covered stents, over-the-scope clips, or endoscopic suturing, were considered unsuitable due to the chronicity, cavity size, and associated bronchial communication.

EVT has emerged as a promising minimally invasive alternative for managing transmural defects of the gastrointestinal tract. This approach promotes healing through continuous negative pressure, facilitating drainage, reducing bacterial contamination, and stimulating granulation tissue formation. Its efficacy has been demonstrated in diverse clinical contexts, including esophageal leaks, gastric perforations, and postoperative fistulas[1,4]. In this context, EVT provided continuous drainage and active cavity collapse, which static closure methods would unlikely achieve. This staged, multimodal approach is best suited for patients with complex, chronic, or refractory fistulas involving the gastrointestinal tract with extension to adjacent compartments, particularly after failed surgical management and in those considered poor candidates for further operative intervention, provided they are hemodynamically stable and able to tolerate repeated endoscopic procedures.

In the presented case, EVT was innovatively applied in a stepwise manner. Initially, a percutaneous approach was utilized, enabling external drainage and progressive removal of surgical drains. Subsequently, a transluminal route was adopted, inserting the vacuum catheter nasally into the gastric fistula tract. This transition facilitated internal drainage and significantly promoted cavity healing.

The management of the bronchial component involved endoscopic APC of the fistula edges, which disrupts the epithelialized margins, combined with the placement of a custom-designed collagen and cellulose plug to facilitate tissue ingrowth and stabilization. This strategy aligns with previously described literature, demonstrating successful outcomes using endoscopic interventions, including biological plugs and sealants, for broncho-pleural fistulas[5,6].

The patient’s clinical evolution was highly favorable, characterized by significant weight gain and improved nutritional status over a three-month follow-up period. Endoscopic evaluations confirmed the successful closure of the fistulous tract, forming a stable gastric recess. Although this approach is largely limited to tertiary or quaternary referral centers, given the need for advanced therapeutic endoscopy expertise, fluoroscopic guidance, ICU support during early treatment phases, and close multidisciplinary collaboration involving gastroenterology, thoracic surgery, pulmonology, infectious disease, nutrition, and wound care teams, these outcomes underscore EVT’s potential as an effective therapeutic option for managing complex fistulas, even in patients presenting significant comorbid conditions. Moreover, because serum albumin levels were intermittently influenced by ongoing infection, inflammatory burden, and critical illness, thereby limiting their reliability as isolated nutritional markers, weight gain and restoration of oral intake were used as the primary pragmatic and clinically meaningful indicators of nutritional recovery in this complex setting.

Importantly, the success achieved in this complex clinical scenario highlights the fundamental role of multidisciplinary management. Complex fistulas often necessitate coordinated interventions across various medical specialties, including gastroenterology, thoracic surgery, general surgery, infectious disease management, clinical nutrition, and wound care specialists. This collaborative approach facilitates comprehensive care, optimizes patient outcomes, and significantly enhances the management efficacy of severe and refractory gastrointestinal conditions[3,4].

CONCLUSION

This case demonstrates the successful utilization of EVT as the central component with supportive interventions in treating a complex gastro-pleuro-broncho-cutaneous fistula refractory to surgery. The progressive staged and multimodal approach, transitioning from percutaneous to transluminal EVT, combined with targeted endoscopic interventions for the bronchial fistula, resulted in complete fistula closure and significant clinical improvement. This case contributes valuable evidence supporting EVT as a viable and minimally invasive alternative to traditional surgical interventions for complex gastrointestinal fistulas, expanding therapeutic options in critically ill patients previously considered unsuitable for further intervention.