Successful combined laparoscopic and thoracoscopic surgery for esophago‐mediastinal fistulae

Minimally invasive surgeries have been developed, not only for gastrointestinal cancer, but also for benign or emergency cases. We report the case of a 62‐year‐old male who underwent laparoscopic and thoracoscopic combined surgery for an esophago‐mediastinal fistula caused by a press‐through package. In the initial laparoscopic phase, transhiatal dissection of the lower thoracic esophagus and harvesting of the greater omentum were performed. In the thoracoscopic phase, resection of the fistula and esophageal wall closure were performed. Thereafter, the greater omentum was lifted via the esophageal hiatus and wrapped around the repaired part of the esophagus for reinforcement. The total operative time was 371 min, with 163 and 208 min for the laparoscopic and thoracoscopic phases, respectively. In total, 20 ml of blood was lost. No perioperative complications or recurrences were observed. Laparoscopic and thoracoscopic combined omentoplasty was effective for refractory esophago‐mediastinal fistula.


| INTRODUCTION
Minimally invasive techniques have been developed as endoscopic surgery has increased in popularity. Thoracoscopic esophagectomy for esophageal cancer is typically performed for esophageal diseases. 1 Conversely, endoscopic surgeries for nonroutine or emergency cases, such as spontaneous esophageal rupture, have been reported recently. 2 In this case report, we report a case of a patient with refractory esophago-mediastinal fistula after endoscopic removal of the press-through package (PTP). The patient underwent laparoscopic omentum flap harvesting and thoracoscopic fistula closure, followed by omentoplasty. To our knowledge, this is the first case of laparoscopic and thoracoscopic combined esophagomediastinal fistula surgery.

| CASE PRESENTATION
The patient was a 62-year-old male with a height of 164 cm, weight of 62 kg, and body mass index (BMI) of 23.1 kg/m 2 . The patient swallowed the PTP, which was removed endoscopically at another hospital. However, it injured the lower thoracic esophagus and caused mediastinitis. Although medical treatment relieved the acute phase of his illness, he developed refractory mediastinitis within 6 months. Cushing's disease was diagnosed during this period. Therefore, he underwent pituitary tumor resection and was administered hydrocortisone 30 mg/day after the operation. He was referred to our hospital for surgical treatment of refractory mediastinitis. Esophagoscopy revealed a fistula in the esophageal anterior wall 36 cm from the incisor teeth (Figure 1). At the same time, an esophagogram demonstrated leakage of contrast medium. Computed tomography (CT) revealed a thickened esophageal wall and refractory mediastinitis caused by esophago-mediastinal fistula on the ventral side ( Figure 2).
Based on his clinical history and imaging results, we decided to perform radical surgery. The first phase of the operation was laparoscopic manipulation. The patient was placed in a supine position with the legs open (the ports were placed as shown in Figure S1). Initially, the abdominal esophagus was isolated and transhiatal dissection of the lower thoracic esophagus was performed where possible. After the greater omentum was separated from the transverse colon and stomach (Figure 3), it was gently retracted through the hiatus into the right pleural cavity by puncturing the mediastinal pleura. In the second phase, the thoracoscopic technique via the right F I G U R E 1 A fistula in the esophageal anterior wall 36 cm from the incisor teeth F I G U R E 2 A thickened esophageal wall and refractory mediastinitis F I G U R E 3 The greater omentum was separated from the stomach F I G U R E 4 The omentum was wrapped around the esophagus thoracic wall was performed in the prone position ( Figure S1). A guidewire was inserted endoscopically into the fistula, which was a landmark for dissection around the lower esophagus. After identification of the fistula, it was resected, and the esophageal wall was closed with a 3-0 V-Loc (Minneapolis, MN, USA). For reinforcement, the lifted omentum was wrapped around the repaired part of the esophagus (Figure 4). A drainage tube was placed in the mediastinum. The total operative time was 371 min, with a laparoscopic phase time of 163 min and a thoracoscopic phase time of 208 min. The total volume of blood loss was 20 ml (Video S1). No perioperative complications or recurrences were observed.
Oral intake was initiated 2 weeks after the operation. Postoperative esophagoscopy and esophagography revealed that the fistula was closed. The patient was discharged 27 postoperation days (POD). At the 8-month follow-up, the patient fully recovered with a normal diet.

| DISCUSSION
We performed combined laparoscopic and thoracoscopic omentoplasty, which was effective for refractory esophago-mediastinal fistulae. When we planned this surgery, it was predicted that it would be difficult to cure the fistula by suturing alone, due to continuous administration of hydrocortisone. We considered it necessary to add a procedure that reinforces the sutured site. We selected the use of a greater omental flaps for various reasons. 3 First, we aimed to perform minimally invasive surgery for this benign disease. From this viewpoint, reinforcement using the intercostal muscle, pericardium, and latissimus dorsi flap required thoracotomy with a relatively large stress. Additionally, we empirically understand the usefulness of the greater omental flap. 4 Moreover, we were convinced that sufficient omentum with moderate thickness will be harvested according to the physique and preoperative CT imaging.
In this surgery, the laparoscopic techniques allow easy preparation of the omentum without enlargement of the incision, and wrapping the omentum to the sutured site of the lower esophagus can be performed using the thoracoscopic technique. The puncture of the mediastinum and the insertion of the harvested omentum to the right pleural cavity through the punctured pleura was possible because of the transhiatal dissection of the lower mediastinum, thus allowing subsequent thoracoscopic wrapping manipulation to be performed smoothly. Although dissection around the fistula was difficult, owing to hard fibrosis, an endoscopically inserted guidewire was helpful in locating the fistula. Barbed sutures seemed safe for closing the fibrotic esophageal wall, which leaks easily.
However, this technique has several disadvantages. First, it requires changing the patient's position when converting from the laparoscopic to the thoracoscopic phase; therefore, it may be difficult to perform in cases with unstable vital signs. Second, because it requires an appropriate amount of omental tissue, it may be difficult to apply this technique in lean patients. Third, thoracoscopic suturing is relatively difficult. A narrow view of the operative field, limitation of motion at the instrument tips, and the risk of injury to surrounding organs make this technique more stressful. In the near future, robotic surgery will be helpful for such diseases due to its functional stability. 5 This time, we selected a laparoscopic and right thoracoscopic approach. In addition, the mediastinoscopic or left thoracoscopic approach may be available for similar cases. As for the mediastinoscopic approach, it may have the advantage that it does not require changing position, and shortening the operation time as a result of that. However, the surgical field may not be adequate to suturing in the narrow mediastinum, especially in the higher mediastinal position. On the other hand, the left thoracoscopic approach will be convenient for the perforation in the lower left side, such as Boerhaave syndrome. However, it must be unfit for the right side or higher position because of the existence of the descending aorta and stronger heartbeat than that of the right thoracic cavity. Therefore, these two approaches must be limited.
Although we performed a literature search using MEDLINE (1968-2022) with search terms including "esophageal fistula," "esophageal rupture," "esophageal perforation," "esophageal foreign body," "press through package," "omental flap," "thoracoscopic," and "laparoscopic," there was no report similar to our case. However, the number of patients with esophageal foreign body perforation requiring surgical intervention may increase with the advancement of an aging society. 6 Although there is a report about fully covered esophageal stents for benign esophageal disease, including fistulae, 7 the risk of stent migration is quite high in patients without stricture. 8 Recently, although there have been some reports about methods to prevent migration, they seem to be imperfect. 9,10 Additionally, esophageal stents for benign diseases are out of the application range of insurance in Japan. We believe that this surgery is an effective treatment option for benign esophageal fistulae.

| CONCLUSION
To our knowledge, this is the first case report of combined laparoscopic and thoracoscopic omentoplasty for refractory esophago-mediastinal fistula. This method may be useful for esophago-mediastinal fistulae.

AUTHOR CONTRIBUTIONS
Kazuyuki Kojima contributed to study conception and design. The first draft of the article was written by Shuhei Takise, Masanobu Nakajima suggested this operation method and helped to draft the article. Hiroto Muroi was the main surgeon in this operation. Tsukasa Kubo and Shotaro Matsudera were the team members of this operation. All authors have read and approved the final article.

ACKNOWLEDGMENTS
The authors declare no conflicts of interest. Informed consent was obtained from all the patients. The surgical procedure was conducted in accordance with the principles of the Declaration of Helsinki. Ethics Committee approval was not required for this case report.

DATA AVAILABILITY STATEMENT
Data sharing is not applicable to this article as no new data were created or analyzed in this study.