Tracheomediastinal Fistula (TMF) is uncommon and has never, to our knowledge, been reported as a complication of mediastinal lymph node excisional biopsy. We report such a case and its successful management using a Self Expandible Metallic Stent (SEMS).
A 69 year old female with a history of breast cancer requiring radiation in 1982, non-small cell lung cancer requiring left upper lobectomy in 1989, and small cell lung cancer requiring right lower lobectomy in 1996 developed PET scan positive subcarinal lymphadenopathy. Left thoracotomy and excisinal biopsy was performed; however, during the surgery a communication between left main stem bronchus (LMB) and mediastinum was noted. Following an attempt at intercostal muscle flap repair she was transferd to our institutuion. On examination she was hemodynamically stable with diffuse subcutaneous emphysema requiring 40% FIO2 via mechanical ventilation. Flexible bronchoscopy (FB) revealed dehiscence of the carina with TMF involving both main stem bronchi (figure 1). The left and right main stem bronchi were 80 and 50% detached from the carina, respectively. The FB was passed through the defect in to the mediastinum and a large amount of mucopurulent material was evacuated, the culture of which grew Pseudomonas aeruginosa. 14x40 mm and 12x20 mm uncovered Ultraflex stents were placed in the left and right main stem bronchi respectively. The patient was excubated the next day and discharged five days later. FB, 5 and 10 weeks after the stent placement, revealed dramatic healing of the fistulae. At 13 weeks the RMB stent was removed using FB revealing complete closure of the fistula on the right. A small medial defect was still present on the left hence only the portion of the stent extending above the carina was removed using laser. Presence of fresh granulation tissue around the fistula suggested that the area was still healing and the defect would close (figure 2). The patient is alive and well one year post incidence.
Bronchomediastinal fistula has been described in association with mediastinal tuberculous lymphadenitis (1), necrotic mediastinal lymphadenopathy from metastatic oral cancer (2), mediastinitis after esophageal perforation (3), and with brachytherapy (4). Review of the English-language literature did not reveal any information regarding TMF fistula as a complication of mediastinal lymph node excision. The factors contributing to fistula formation in our patient likely were many. First, some event during the biopsy may have created a rent in one or both mainstem bronchi. Second, previous radiation therapy for breast cancer may have altered the bronchial architecture, weakening the integrity of the bronchus. Finally, and likely much more importantly, the presence of an infected fluid collection below the carina may have caused direct tissue destruction.
Self Expandable Metallic Stents (SEMS), by promoting the formation of granulation tissue, are efficacious in the treatment of TMF. This case is notable because the patient, even with severely distorted airway architecture, demonstrated a quick response to treatment with SEMS, with notable improvement on the first surveillance bronchoscopic visualization and near complete fistula closure by three months. This case demonstrates that large airway fistula can be treated with SEMS, obviating the need for invasive surgical approaches.
J.L. Ranes, None.