Management of tracheo-oesophageal fistula in adults

Abstract

Tracheo-oesophageal fistula (TOF) is a pathological connection between the trachea and the oesophagus that is associated with various underlying conditions including malignancies, infections, inhalation injuries and traumatic damage. As the condition spans multiple organ systems with varying aetiologies and acuities, TOF poses unique diagnostic and management challenges to pulmonologists, gastroenterologists and thoracic surgeons alike. Although stents have been a cornerstone in the management of TOF, there exists a large gap in our understanding of their efficacy and precise methodology, making stenting procedure both art and science. TOFs relating to underlying oesophageal or tracheal malignancies require advanced understanding of the airway and digestive tract anatomy, dimensions of the fistula, stent characteristics and types, and the interplay between the oesophageal stent and the airway stent if dual stenting procedure is elected. In this review article, we review the most up-to-date data on risk factors, clinical manifestations, diagnostic approaches, management methods and prognosis. Consequently, this article serves to evaluate current therapeutic strategies and the future directions in the areas of 3D-printed stents, over-the-scope clipping systems, tissue matrices and atrial septal closure devices.

FIGURE 1

A case of malignant tracheo-oesophageal fistula (TOF) after a surgical resection of oesophageal cancer followed by radiation treatment. a) Oesophagogram showing the contrast leak in right upper lobe airways (arrowhead); b) computed tomography scan of the chest showing the defect at the level of right mainstem bronchus (arrowhead); c) bronchoscopic view of the TOF at the posterior wall of proximal right bronchus intermedius; d) oesophageal endoscopic view of the same TOF showing the fistula and mucosal abnormalities; e) TOF closure utilising Alloderm (*) and self-expanding metallic stent in the trachea.

FIGURE 2

A case of malignant tracheo-oesophageal fistula (TOF) from metastatic oesophageal cancer after radiation treatment followed by oesophageal self-expandable metallic stent placement: a) computed tomography scan of the chest showing TOF (arrowhead) at the level of proximal end of the oesophageal stent; b) bronchoscopic view showing muscosal abnormality obscuring the view of the fistula at the posterior wall of the trachea. c) A close-up bronchoscopic view of TOF; the oesophageal stent can be seen at the bottom of TOF (arrowhead). d) A case of iatrogenic TOF: closure with Alloderm (*) and covered, self-expandable metallic stent in trachea.

FIGURE 3

Management algorithm for acquired tracheo-oesophageal fistula (TOF).