Critical Care |

A Large Tracheal Defect Is Not a Contraindication to an Eloesser Flap FREE TO VIEW

Sean Goh, MD; James Lim, MD; Raja Flores, MD
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Singapore General Hospital, Singapore, Singapore

Chest. 2014;146(4_MeetingAbstracts):356A. doi:10.1378/chest.1991499
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SESSION TITLE: Surgery Student/Resident Case Report Posters

SESSION TYPE: Medical Student/Resident Case Report

PRESENTED ON: Tuesday, October 28, 2014 at 01:30 PM - 02:30 PM

INTRODUCTION: Indications for esophageal stents range from benign and malignant esophageal obstruction to esophageal perforations and tracheoesophageal (TE) fistulas. Unfortunately, these fistulas do not often close spontaneously and may require surgical intervention or stent placement. However, while several types of esophageal stents have been used to treat TE fistulas, complications such as migration, increased reflux and erosion may occur.

CASE PRESENTATION: Our patient is a 45 year-old male non-smoker with a history of laryngeal cancer (2004) and stage IIIA squamous cell carcinoma of the right lung that was treated with adjuvant chemotherapy, pneumonectomy and radiotherapy (2010). He developed a TE fistula (2012) secondary to radiation-associated esophagitis, which was subsequently managed with a covered metal stent. He later presented with chronic cough, increasing shortness of breath, fevers, tarchycardia, and expectoration of brown, foul smelling liquid while bending over. Chest X-ray showed interval development of air within the right pneumonectomy space suggestive of a communication with the esophagus (Fig 1). A CT scan further characterized an air-filled tract extending from the posterior aspect of the esophagus surrounding the stent into the right pneumonectomy cavity. Further examination showed pleural enhancement surrounding the right pneumonectomy space (Fig 2). A tracheo-esophageal-pleural fistula with post-pneumonectomy space empyema was diagnosed. Intraoperatively, while the defects in the airway and esophagus were identified, the difficult nature of his anatomy given his prior surgery and radiation precluded safely performing an esophageal diversion. Thus, the pleural space was debrided and an Eloesser flap created.

DISCUSSION: The management of esophageal stent erosions includes the placement of overlapping stents, covered metal stents into pre-existing uncovered stents, or replacement of an esophageal stent for an airway stent. Stent placement can be used in the palliative setting or, in the case of double stenting, used to alleviate dysphagia and airway contamination in cases of malignant TEF. Blood vessel involvement, while rare, involves a multidisciplinary management approach via angiography, endoscopic compression, and ligation.

CONCLUSIONS: We present the case of a 45-year-old man who had a stage III squamous cell lung cancer treated with a right pneumonectomy and chemoradiation, with his treatment course complicated by a TE fistula.

Reference #1: Katsanos K, Sabharwal T, Koletsis E, et al. Direct erosion and prolapse of esophageal stents into the tracheobronchial tree leading to life-threatening airway compromise. J Vasc Interv Radiol 2009;20:1491-5.

Reference #2: Vanden Eynden F, Deviere J, Laureys M, et al. Erosion of a retroesophageal subclavian artery by an esophageal prosthesis. J Thorac Cardiovasc Surg 2006;131:1183-1184 e1.

Reference #3: Ali AT, Kokoska MS, Erdem E, et al. Esophageal stent erosion into the common carotid artery. Vasc Endovascular Surg 2007;41:80-2.

DISCLOSURE: The following authors have nothing to disclose: Sean Goh, James Lim, Raja Flores

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