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DOI: 10.1055/s-2004-826085
Successful Endoscopic Management of Iatrogenic Mediastinal Infection and Subsequent Esophagomediastinal Fistula, Following Endosonographically Guided Fine-Needle Aspiration Biopsy
U. Will, M. D.
Department of Internal Medicine III, City Hospital
Straße des Friedens 122 · 07548 Gera · Germany
Fax: +49-365-8282402
Email: uwe.will@waldklinikumgera.de
Publication History
Submitted 23 January 2004
Accepted after Revision 17 August 2004
Publication Date:
19 January 2005 (online)
Complications following endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) biopsy are rare. A 75-year-old man underwent EUS-FNA biopsy of an enlarged mediastinal lymph, which histologic investigation revealed to be a metastasis of a hepatocellular carcinoma. The patient developed the postinterventional complication of suppurative infection within the mediastinum. Under EUS guidance, a pigtail catheter and a soft tube were inserted to respectively drain and rinse the mediastinal lesion for 8 days. The remaining esophagomediastinal fistula was closed by gathering the fistula margins, using band ligations and an Endoloop. The fistula healed with no further complaints or dysphagia. Infection is a possible complication of endoluminal FNA biopsy. An endoscopically guided therapeutic approach can be favored as the initial treatment of choice and as a reasonable alternative that avoids surgical intervention.
#Introduction
Complications of endoscopic ultrasound-guided fine-needle aspiration (EUS-FNA) are rare and the management of endosonographic complications is challenging, in particular when minimally invasive tools are exclusively used.
#Case report
A 75-year-old man was referred for diagnosis of a mediastinal mass suspected at computed tomography (CT) to be a tumor. No pathological finding was identified at bronchoscopy. Endoscopic ultrasound (EUS) revealed an enlarged mediastinal lymph node (2 cm diameter, below the tracheal bifurcation; Figure [1]) which was punctured twice using a 0.8-mm needle. The cytologic examination showed tumor cells, and at histologic investigation, including immunhistochemistry, metastasis of a hepatocellular carcinoma was diagnosed.
Figure 1 Esophageal endoscopic ultrasound (EUS) revealed an enlarged mediastinal, echo-poor periesophageal lymph node, with smooth contours and an homogeneous structure.
Following the intervention, the patient developed fever (38.6 °C) indicating pneumonia. Antibiotic treatment with ceftriaxone was therefore initiated.
The patient underwent gastroscopy 3 weeks later because of dysphagia, and this revealed a prominent thickening of the mucosa in the upper third of the esophagus, but no lesion. EUS demonstrated a periesophageal inhomogeneous lesion (Figure [2]), and puncture resulted in aspiration of pus. Under EUS guidance, a 8.5-French double-pigtail catheter was inserted (Figure [3]), and in addition, using a guide wire, a 7-French tube was placed into the lesion to rinse it.
Figure 2 EUS demonstrated a periesophageal inhomogeneous lesion with mixed echogenicity and liquid structures.
Figure 3 Endoscopic view of the esophageal lumen and a 8.5-French double pigtail catheter inserted into the lesion under EUS guidance.
Follow-up gastroscopy identified an esophagomediastinal fistula which could be passed with the endoscope and which led to the cavity of the mediastinal lesion (Figure [4 a]). Two band ligations were placed at the lateral margins of the fistula mouth (Figure [4 b]), and the ”pseudopolyps” thus formed were gathered together to definitively close the fistula, being held in place by an Endoloop. The fistula healed with total closure, which was confirmed by gastroscopy 4 weeks later, and with no further complaints. Simultaneously, antibiotic treatment using piperacillin-tazobactam and vancomycin was initiated.
Figure 4 Esophagoscopic views. a The esophageal mouth of the esophagomediastinal fistula. b Two band ligations placed at the lateral margins of the esophageal fistula mouth, forming ”pseudopolyps”. c The pseudopolyps gathered together to close the fistula, and held in place by an Endoloop. d Suture in esophagus 4 weeks after the intervention.
The patient died of the metastatic carcinoma nearly 6 months after the intervention, with no signs of infection or dysphagia. No re-intervention was needed before he died.
#Discussion
The sensitivity and specificity of EUS-FNA biopsy in mediastinal lymph nodes has been reported to range from 82 % to 95 % [1] [2] [3]. The frequency of complications is rare, being 0.5 % - 2 % [4]. At our institution, only five nonfatal complications in 457 EUS-FNA procedures have been observed (a complication rate of approximately 1 %).
Puncture from the esophageal lumen is potentially infectious because of the microbes residing at the mucosa. The EUS-FNA procedure was the cause of the suppurative infection of the mediastinum in our patient. Temporary drainage of the mediastinal lesion and repeated rinsing after EUS drainage turned out to be successful, but following this a esophagomediastinal fistula persisted. This fistula was closed using a combination of band ligation of the margins and holding them together with an Endoloop. In very ill patients with suppurative mediastinitis or a persistent esophagomediastinal fistula, a minimally invasive endosonographic and endoscopic approach, using this new technique, can be successful.
#References
- 1 Fritscher-Ravens A, Petrasch S, Reinacher-Schick A. et al . Diagnostic value of ultrasonography-guided fine-needle aspiration cytology of mediastinal masses in patients with intrapulmonary lesions and nondiagnostic bronchoscopy. Respiration. 1999; 66 150-155
- 2 Gress F G, Savides T J, Sandler A. et al . Endoscopic ultrasonography, fine needle aspiration biopsy guided by endoscopic ultrasonography and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study. Ann Intern Med. 1997; 127 604-612
- 3 Silvestri G A, Hoffmann B J, Bhutani M S. et al . Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg. 1996; 61 1441-1443
- 4 Wiersema M J, Vilman P, Giovanni M. et al . Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology. 1997; 112 1087-1095
U. Will, M. D.
Department of Internal Medicine III, City Hospital
Straße des Friedens 122 · 07548 Gera · Germany
Fax: +49-365-8282402
Email: uwe.will@waldklinikumgera.de
References
- 1 Fritscher-Ravens A, Petrasch S, Reinacher-Schick A. et al . Diagnostic value of ultrasonography-guided fine-needle aspiration cytology of mediastinal masses in patients with intrapulmonary lesions and nondiagnostic bronchoscopy. Respiration. 1999; 66 150-155
- 2 Gress F G, Savides T J, Sandler A. et al . Endoscopic ultrasonography, fine needle aspiration biopsy guided by endoscopic ultrasonography and computed tomography in the preoperative staging of non-small-cell lung cancer: a comparison study. Ann Intern Med. 1997; 127 604-612
- 3 Silvestri G A, Hoffmann B J, Bhutani M S. et al . Endoscopic ultrasound with fine-needle aspiration in the diagnosis and staging of lung cancer. Ann Thorac Surg. 1996; 61 1441-1443
- 4 Wiersema M J, Vilman P, Giovanni M. et al . Endosonography-guided fine-needle aspiration biopsy: diagnostic accuracy and complication assessment. Gastroenterology. 1997; 112 1087-1095
U. Will, M. D.
Department of Internal Medicine III, City Hospital
Straße des Friedens 122 · 07548 Gera · Germany
Fax: +49-365-8282402
Email: uwe.will@waldklinikumgera.de
Figure 1 Esophageal endoscopic ultrasound (EUS) revealed an enlarged mediastinal, echo-poor periesophageal lymph node, with smooth contours and an homogeneous structure.
Figure 2 EUS demonstrated a periesophageal inhomogeneous lesion with mixed echogenicity and liquid structures.
Figure 3 Endoscopic view of the esophageal lumen and a 8.5-French double pigtail catheter inserted into the lesion under EUS guidance.
Figure 4 Esophagoscopic views. a The esophageal mouth of the esophagomediastinal fistula. b Two band ligations placed at the lateral margins of the esophageal fistula mouth, forming ”pseudopolyps”. c The pseudopolyps gathered together to close the fistula, and held in place by an Endoloop. d Suture in esophagus 4 weeks after the intervention.