Supplementary Material for: Endoscopic Vacuum Therapy for Treating an Esophago-Pulmonary Fistula after Esophagectomy: A Case Report and Review of the Literature

An acquired esophago-respiratory fistula represents an abnormal connection between the esophagus and the respiratory system. It is usually caused by malignancy and infection, or it occurs as a complication after surgery or radiation therapy. It can be divided according to its anatomical level into esophago-tracheal fistula, esophago-bronchial fistula, and in the rarest case, esophago-pulmonary fistula (EPF). We present a case of EPF aggravating an anastomotic leak (AL) after the Ivor-Lewis operation for esophageal cancer. The leak was treated with endoscopic vacuum therapy (EVT) using the Eso-Sponge® system (B. Braun Melsungen AG, Melsungen, Germany). In the further course of treatment, an EPF was suspected by a new onset of severe cough after oral fluid intake. The suspicion was confirmed by injecting methylene blue dye into the paraesophageal-extraluminal cavity during endoscopy and attesting to its presence in the respiratory tract by simultaneous bronchoscopy. Furthermore, an oral contrast computed tomography scan showed the presence of contrast in the right lower lobe of the lung. This complication was treated conservatively with EVT and antibiotics. Nutrition was administered through the existing jejunostomy. Both fistulas and the paraesophageal cavity were fully healed, oral intake was maintained, and the patient was discharged. This rare life-threatening complication can be treated conservatively. Its management is challenging, controversial, and lacks a general consensus.

获得性食管呼吸道瘘（acquired esophago-respiratory fistula）指食管与呼吸系统之间形成的异常连通通道。该病多由恶性肿瘤、感染诱发，亦可作为手术或放射治疗后的并发症出现。按解剖位置可分为食管气管瘘、食管支气管瘘，极少数情况下为食管肺瘘（esophago-pulmonary fistula, EPF）。本文报告1例食管癌患者行Ivor-Lewis术后并发吻合口漏（anastomotic leak, AL），且该漏口因食管肺瘘而加重的病例。该吻合口漏采用内镜负压治疗（endoscopic vacuum therapy, EVT）联合Eso-Sponge®系统（德国梅尔松根贝朗医疗股份公司，B. Braun Melsungen AG, Melsungen, Germany）进行处理。在后续治疗过程中，患者经口摄入液体后新发剧烈咳嗽，临床怀疑并发EPF。通过内镜向食管旁腔外腔注射亚甲蓝染料，同时行支气管镜检查确认染料出现在呼吸道内，从而证实了该诊断。此外，口服对比剂计算机断层扫描（computed tomography, CT）结果显示患者右下肺叶内存在对比剂。该并发症采用内镜负压治疗联合抗生素行保守治疗，营养支持通过已建立的空肠造口通路提供。最终，所有瘘管及食管旁腔均完全愈合，患者恢复经口进食并顺利出院。这种罕见的致命性并发症可通过保守治疗实现治愈，但其临床管理颇具挑战性且存在争议，目前尚无统一诊疗共识。