SESSION TYPE: Airway Cases II
PRESENTED ON: Tuesday, October 23, 2012 at 11:15 AM - 12:30 PM
INTRODUCTION: Tracheoesophageal fistula (TEF) is a complication of malignancies of the esophagus and airway and its treatment. We describe a case of esophageal cancer with esophageal stent erosion into the trachea.
CASE PRESENTATION: A 68 year-old female was diagnosed with esophageal stricture due to a squamous cell carcinoma of the upper esophagus which was deemed unresectable. She underwent placement of an uncovered esophageal self-expanding metal stent (SEMS) for palliation and symptom control. Subsequently, she underwent chemotherapy and radiation therapy, in addition to having a PEG tube placed. Few months later, the patient developed progressive productive cough associated with oral intake, and recurrent aspiration pneumonias for which she was then evaluated at our institution. She underwent a chest CT which revealed a possible defect/TEF located at the proximal portion of the esophageal stent. Barium swallow showed a small amount of contrast in the left main stem bronchus consistent with aspiration versus TEF. Upper endoscopy revealed epithelialization of the stent into the esophagus, but no obvious evidence of TEF or tumor recurrence. Argon plasma coagulation was used to treat a narrowing at the distal portion of the stent and biopsies taken from this area were consistent with granulation tissue. Subsequently, rigid bronchoscopy showed large posterior tracheal wall erosion with exposure of the uncovered esophageal stent into the trachea. Surgical closure was not considered feasible and the decision was made to proceed with parallel covered tracheal and esophageal stenting. A covered tracheal metal stent (20x60 mm) was placed and was externally fixed to the neck using a button. Repeat upper endoscopy was performed and a fully covered esophageal stent (23x100 mm) was placed into the existing uncovered SEMS. Follow-up barium swallow study did not reveal any evidence of fistula or aspiration, and her productive cough significantly improved.
DISCUSSION: Self-expanding esophageal stents are commonly used to palliate malignant esophageal strictures. Their placement can be complicated by the development of a TEF due to erosion into the posterior tracheal wall. Patients often develop persistent coughing and recurrent aspiration pneumonia. Our patient is thought to have developed a TEF/erosion from the combination of mechanical pressure of the stent and radiation therapy, rather than direct malignant invasion. Stenting of the trachea and covered esophageal stent placement within the existing uncovered stent resulted in the sealing of the defect and resolution of aspiration.
CONCLUSIONS: Surgical repair of TEF is associated with relatively high morbidity and mortality, and endoscopic approach with parallel placement of covered esophageal and tracheal stents is considered to be the first line therapy.
1) Herth FJ, et al. Combined airway and esophageal stenting in malignant airway-esophageal fistulas: a prospective study. Eur Respir J. 2010 Dec;36(6):1370-4.
DISCLOSURE: The following authors have nothing to disclose: Ali Khodabandeh, Ryan Chua, Ali Ashraf, Hisashi Tsukada, Bhavesh Shah, Samaan Rafeq
No Product/Research Disclosure InformationDivision of Pulmonary, Critical Care, and Sleep Medicine, St. Elizabeth’s Medical Center, Tufts University School of Medicine, Boston, MA