INTRODUCTION: Benign fistulae between the central airways and the neo-esophagus are a rare complication of esophagectomy. The subsequent recurrent bronchopneumonia can be life-threatening. There is no standardized therapy for post-esophagectomy fistulae. Reports of management range from observation to stenting to resection of the neo-esophagus.
CASE PRESENTATION: A 69-year-old man was referred to the interventional pulmonology service for evaluation of tracheo-esophageal fistula. The patient had been diagnosed with adenocarcinoma of the esophagus 14 months earlier and had undergone primary radiation and chemotherapy followed 6 months later by transhiatal esophagectomy. Four months after surgery he was admitted for aspiration pneumonia. Computed tomography (CT) scan of the chest at that time revealed a fistula between the right mainstem bronchus (RMB) and the neo-esophagus. Adequate esophagoscopy could not be performed because of a stricture at the cervical anastamosis. Flexible bronchoscopy revealed a 6mm fistula track in the medial wall of the RMB at the level of the right upper lobe bronchus. The surrounding mucosa appeared normal with no suggestion of recurrent malignancy or necrosis. The fistula was traversed, confirming a direct communication with the neo-esophagus. Initial treatment was attempted with an uncovered self-expandable metallic stent (Ultraflex®) with the anticipation that the stent would induce the formation of granulation tissue resulting in closure of the fistula. Follow-up bronchoscopy one month later revealed appropriate stent position with inflammatory changes at the fistula opening in the RMB but no change in diameter of the fistula. Several weeks later the patient developed right lower lobe (RLL) pneumonia with associated respiratory failure and septic shock. Flexible bronchoscopy revealed continuous leakage of secretions from the fistula into the airways of the RLL. Once hemodynamically stable, the patient underwent rigid bronchoscopy. The metallic stent was removed. An Amplatzer® Septal Occluder with an 18mm distal (neo-esophageal) disk, a 6mm waist and a 16mm proximal (bronchial) disk was deployed across the fistula. After deployment, all airways were patent and no further bronchial contamination from the fistula was visualized. The patient was subsequently liberated from the ventilator and discharged home. Several weeks later, the patient was readmitted with altered mentation after dilation of the upper esophageal stricture. He was diagnosed with Streptococcus milleri bacteremia and multiple brain abscesses. During treatment, he developed aspiration pneumonia and subsequent respiratory failure requiring mechanical ventilation. Repeat flexible bronchoscopy at that time (five weeks after initial placement) revealed good position of the Amplatzer® device with no evidence of leaking at the fistula site. The patient was subsequently transitioned to comfort-focused care and died two weeks later.
DISCUSSIONS: The Amplatzer® Septal Occluder is a biocompatible dual-disk device composed of nitinol metal and polyester fabric. It is designed for percutaneous deployment in the closure of atrial septal defects. The variety of sizes available and established efficacy make the Amplatzer® device suitable for use in the airways. Advantages of this device are the complete mechanical seal that it produces over the defect and the induction of tissue granulation to facilitate long-term closure. Our review of the literature yielded two case reports of using Amplatzer® devices in the airways: to close a post-surgical bronchopleural fistula and an esophagorespiratory fistula. We describe what we believe to be the first use of rigid bronchoscopy to deploy an Amplatzer® device for closure of an acquired fistula between the airways and digestive tract. Rigid bronchoscopy enabled direct visualization of deployment as well as confirmation of cessation of airway contamination once the fistula was closed.
CONCLUSION: The Amplatzer® Septal Occluder can be deployed via rigid bronchoscopy for closure of benign fistulae between the central airways and the digestive tract.
DISCLOSURE: David Green, No Financial Disclosure Information; No Product/Research Disclosure Information