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Editorial
. 2019 May;11(5):2165-2174.
doi: 10.21037/jtd.2018.12.128.

Perspective on airway stenting in inoperable patients with tracheoesophageal fistula after curative-intent treatment for esophageal cancer

Udit Chaddha  1 , D Kyle Hogarth  1 , Septimiu Murgu  1
Affiliations
Editorial

Perspective on airway stenting in inoperable patients with tracheoesophageal fistula after curative-intent treatment for esophageal cancer

Udit Chaddha et al. J Thorac Dis. 2019 May.
No abstract available

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Conflict of interest statement

Conflicts of Interest: The authors have no conflicts of interest to declare.

Figures

Figure 1
Figure 1
Patient with esophageal cancer who underwent esophageal stenting for a stricture and TEF following chemoradiotherapy. Six months later the esophageal stent had migrated caudally and eroded into the posterior tracheal wall causing a mass-like granulation tissue that obstructed 90% of the tracheal lumen (A). Electrosurgery (notice the white, coagulated color of the granulation tissue) and debulking was performed using CoreCath 2.7S (Medtronic Advanced Energy LLC; Portsmouth, NH) (B) to relieve the obstruction (C). There was a proximal esophageal stenosis (D) that permitted passage of only the pediatric endoscope, though which the esophageal stent was pulled up into optimal position (E) and balloon dilated. There was no contrast dye leak into the trachea on an esophagram and the patient had a significant improvement in symptoms. Bronchoscopy 1 month later showed continued coverage of the TEF by the fully expanded esophageal stent (F) with small granulation tissue (yellow arrow).
Figure 2
Figure 2
Patient with TGF (yellow arrow; evidenced by secretions leaking into the trachea) after an esophagectomy and gastric pull up surgery for esophageal cancer (A). The fistula was successfully covered by a tracheal fully covered SEMS (Merit Endotek) (B). One months later, the stent was removed as the fistula had completely healed (white arrow pointing at scar tissue) (C). TGF, tracheo-gastric fistula.
Figure 3
Figure 3
Patient with a high tracheal TEF (yellow arrow) 3 cm below the vocal cords (A). Esophageal stenting caused severe airway compression which could not be resolved optimally by stent resizing or repositioning, so the stent was removed. Given the proximity of the fistula to the subglottic region, a fully covered rather than partially covered tracheal SEMS (Merit Endotek) was placed to cover the fistula (B). The next day, the stent migrated caudally, protruding into the TEF posteriorly (as evidenced by the ridge of mucosa, i.e., posterior membrane; white arrow) (C). TEF, tracheoesophageal fistula.
Figure 4
Figure 4
Patient with esophageal cancer who following chemoradiotherapy developed a 2 cm TEF in the distal trachea extending into the proximal left main bronchus (A). Due to concern for airway compression from planned esophageal stenting, an airway stent was inserted as the first step. A silicone Y Duman stent was chosen due to the location of the fistula (B).
Figure 5
Figure 5
Patient with esophageal carcinoma treated with chemoradiotherapy, complicated by an upper tracheal TEF (A, white arrow) for which she received a partially covered SEMS (Ultraflex, Boston Scientific; Natick, MA, USA) that covered the fistula (B, white arrow). Esophageal stent could not be placed due to a severe proximal esophageal stenosis. Patient had significant initial improvement in symptoms. Inspection bronchoscopy 6 weeks later showed stable stent position and TEF occlusion with no granulation tissue (C, white arrow).
Figure 6
Figure 6
Patient with esophageal carcinoma who developed a TEF (white arrow) several months after chemoradiotherapy (A). Due to unsuccessful attempts at esophageal stent placement, a straight studded silicone stent was inserted in the trachea (B). Axial (C) and sagittal (D) CT scan 1 month later demonstrated stable stent position (yellow arrow) covering the TEF (white arrow). TEF, tracheoesophageal fistula.
Figure 7
Figure 7
Algorithm to manage patients with TGF post esophagectomy and TEF post chemoradiotherapy for esophageal cancer. *, Decision to insert a silicone, fully covered SEMS or partially covered SEMS will depend on presence or absence of obstruction, degree of obstruction, and location of fistula; **, if a clinician suspects airway compromise post esophageal stenting, a flexible bronchoscopy or computed tomography scan is recommended to detect the degree of airway compromise. In case a patient develops symptoms of airway obstruction, either revision of the esophageal stent or insertion of an airway stent should be performed. Occasionally the clinician may predict airway compromise post esophageal stenting, in which case an airway stent may be inserted as a first step. This is uncommon post chemoradiotherapy as there is no tumor to compress the airway; ***, stent inserted but did not deploy optimally, or insertion was not possible due to concurrent esophageal stricture; ****, bronchoscopic or endoscopic persistent fistula despite stenting, or stent migration; *****, this practice poses the risk for enlargement of the fistula and is not recommended in patients who may become surgical candidates.
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