Aerodigestive fistula is a dreaded complication after treatment of esophageal carcinoma. The primary management method for patients with malignant disease is stenting in esophageus, airway or both. When technically feasible, surgery is the preferred treatment for benign disease. Herein, we report a case of bronchogastric fistula, occurring after esophagogastrectomy, managed with a combination of methods.
A 49 year old female presented with recurrent aspiration after placement of a metal esophageal stent for an esophageal stricture. She had a history of adenocarcinoma of the gastro-esophageal junction which was treated five years earlier with neoadjuvant chemoradiation and subsequent subtotal esophagectomy with Ivor-Lewis anastomosis. The patient developed an esophagogastric anastomotic stricture which required repeated dilatations. Despite multiple dilatations the patient remained symptomatic with solid dysphagia. She subsequently underwent placement of a 10 mm covered biliary stent. She tolerated that procedure well and continued to have improvement in her dysphagia. She then underwent removal of this stent and replacement by a larger 12 mm self expanding nonmetallic stent. The patient’s swallowing improved for a few months, but then she developed recurrent episodes of aspiration. Radiography revealed a fistula from her stomach to her left main bronchus. She then underwent bronchoscopy which revealed a 1 millimeter fistula in the posterior membrane of the left main bronchus 1 centimeter from the carina. Under rigid bronchoscopy a silastic stent was placed in the left main. She continued to experience aspiration after multiple replacements and revisions of the silastic stent. In February of 2009 she underwent rigid bronchoscopy with removal of the previously place silastic stent and placement of a 16 × 6 × 3 DJ (Diaz-Jimenez)® silicone prosthesis into the fistulous tract. That evening she unfortunately coughed forcefully which dislodged the DJ® silicone prosthesis. The following day she had replacement of the 16 × 6 × 3 DJ® silicone prosthesis and a 16 × 13 × 13 silastic Y-stent over the prosthesis to keep it in place. The patient had good palliation of her symptoms and no further episodes of aspiration. She has had no evidence of recurrence of her cancer.
The DJ® silicone prosthesis is a new cufflink shaped silicon prosthesis that is inserted from the airway to occlude (in a clamshell fashion) a fistulous tract and prevent gastric content aspiration. It has been used in malignant tracheoesophageal fistulas for palliation as a novel approach to sealing an aerodigestive fistula. We report the successful use of this prosthesis in a non-malignant gastropulmonary fistula. In this case however the prosthesis became dislodged due to the size of fistula and a Y-stent was placed over the DJ® silicone prosthesis to secure it in place. This resulted in excellent symptomatic control for the patient.
Stent migration is a frequent complication that can be difficult to manage. The DJ silicone aerodigestive prosthesis is a novel device used for closure of aerodigestive fistula. The combination of DJ stent and conventional airway stenting can be used to effectively and safely close fistula and prevent migration.
Jennifer Mattingley, No Financial Disclosure Information; No Product/Research Disclosure Information