SESSION TITLE: Bronchology Cases II
SESSION TYPE: Affiliate Case Report Slide
PRESENTED ON: Tuesday, October 29, 2013 at 07:30 AM - 09:00 AM
INTRODUCTION: Stenting for tracheoesophageal or bronchoesophageal fistulae is usually palliative in the setting of malignancy. Although tubular stents may be placed in the trachea or bronchi, and Y-stents at the main carina, the use of Y-stents in the secondary carina has not previously been described for this indication.
CASE PRESENTATION: A 64 year old woman with a history of metastatic renal cell carcinoma, diffuse large B-cell lymphoma, and other medical comorbidities previously had a partially covered esophageal stent placed for dysphagia due to a mid-esophageal stricture. She subsequently presented with uncontrollable cough, recurrent pneumonia, and a severely impaired quality of life due to an inability to tolerate oral intake. Evaluation demonstrated a bronchoesophageal fistula in the right mainstem bronchus (Figure 1). Bronchoscopy was performed demonstrating a defect along the right mainstem bronchus that extended to within 5 mm of the right hilum distally and 8 mm of the trachea proximally. Given that a tubular stent would not adequately cover the defect due to its proximity to the right hilum, and due to the high chance of migration in this area, a silicone Y-stent was configured. The 14 x 10 x 10 mm diameter stent was sized to include a 5 mm limb extending into the right upper lobe bronchus, a 16 mm limb in the bronchus intermedius and a 25 mm limb in the right mainstem bronchus. This completely covered the fistulous tract while maintaining patency of the bronchi and minimizing the chances of migration and granulation tissue formation.
DISCUSSION: Respiratory-digestive fistulae may result directly from cancer erosion, from treatment of malignancy with radiation or chemotherapy, and, as shown in this case, as a complication of primary esophageal stenting. In a study of 264 patients with malignant fistulae, 44% were present in the right mainstem bronchus.1 When these fistulae involve the right hilum, tubular stenting will not satisfactorily cover the defect. As such, the only feasible option is the use of a Y-stent at the secondary carina. Although Y-stents are placed less commonly, recent publications demonstrate feasibility.2
CONCLUSIONS: The treatment of tracheobronchial fistulae is complex, particularly in the setting of malignancy in which surgical repair is not typically feasible. When confronted with fistulae that involve the secondary carina, consideration should be given to Y-stent placement. Although described for post-transplant stenosis and malignancy, this is the first case to our knowledge of its utility for bronchoesophageal fistula.
Reference #1: Rodriguez, AN and Diaz-Jimenez, J.P. Malignant respiratory-digestive fistulas. Current Opinion in Pulmonary Medicine, 2010. 16:329-88.
Reference #2: Lee HJ, Puchalski J, et al. Secondary carina Y-stent placement for post-lung-transplant bronchial stenosis. J Bronchology Interv Pulmonol. 2012 Apr;19(2):109-14.
DISCLOSURE: The following authors have nothing to disclose: Christopher Erb, Margaret Pisani, Jonathan Puchalski
No Product/Research Disclosure Information