The incidence of esophageal carcinoma in the United States is estimated at 3.2 / 100,000 (1). With tumor involvment of the proximal esophagus, bronchoscopy is recommended, as case series have shown that esophago-bronchial fistulae will be present approximately 5% of the time (23). Additionally, fistulae will occur in up to 12 % of patients at some point during treatment (12). If esophageal-bronchial fistulae develop, the patient will suffer with continuous coughing, exhaustion, and recurrent aspiration pneumonia. Without sealing of the fistula tract, death can frequently be expected within several days time (4).
A 62 year old man diagnosed with locally advanced esophageal cancer had been treated with radiation therapy and successive cycles of chemotherapy, including carboplatin and 5-fluorouracil followed by taxotere. Because of progressive dysphagia, he then received esophageal dilation treatments. For two weeks prior to presentation he suffered from persistent cough, worse with swallowing, and was maintained on antibiotics for aspiration pneumonia. A cine-esophogram revealed 1.2 cm fistula tract to the left mainstem bronchus. Attempted esophageal stent placement was unsuccessful because of inability to pass the endoscope due to high-grade obstruction and non-localization of the fistula. After the patient swallowed 10 cc of methylene blue dye, fiberoptic bronchoscopy was performed under conscious sedation. The fistula was easily located in the posterior wall of the left mainstem bronchus approximately 2 cm from the main carina. After estimation of airway diameter and lesion length, a self-expanding, covered nitinol stent (14 mm diameter x 6 cm length) was placed under direct visualization. The patient’s symptoms of cough and sputum production resolved, and with repeated esophageal dilations he has been able to enjoy eating a regular diet and attending a family vacation. A recent, 2-month follow-up visit confirmed continued response.DISCUSSION: Esophageal cancer usually presents in an advanced and incurable stage with a poor prognosis—the 5-year survival rate remains dismally low, around 5% (1). A major goal of therapy is maintaining a patient’s ability to swallow thus preserving quality of life. Combined radiation and chemotherapy are frequently employed treatment regimens, with locally delivered palliative measures used as necessary (1). When esphago-bronchial fistulae occur, they signal an ominous prognostic sign and are challenging to manage. Treatment of these fistulae in the past has focused on esophageal stenting; however, acute, total airway obstruction as a complication from posterior membrane compression has occurred (56). Therefore, for patient safety, a dual stenting approach should always be attempted. Combined airway and esophageal stenting has been evaluated using the silicone and dynamic Y-stent models in the tracheobronchial tree (45). The increased radial force of self-expanding metal stents, may help seal the fistula tract and improve outcomes in these patients.
Airway covered, self-expandable metal stents can seal esophago-bronchial fistula and prevent persistent aspiration by themselves. This should always be considered as a combined procedure with esophageal stenting to prevent airway occlusion, and as a single procedure if the esophageal stent cannot be placed.
J.B. Hales, None.