Multidisciplinary team approach on tracheoesophageal fistula in a patient with home ventilator

Abstract

A 68-year-old man was transferred to our tertiary hospital. Ten years ago, he received radiation therapy for tonsil cancer, and while there was no evidence of recurrence, he suffered from recurrent aspiration. We treated his aspiration pneumonia in the intensive care unit. Prior to his discharge, he received percutaneous dilatational tracheostomy (PDT) before he was transferred to a nursing hospital. Nine months later, he was readmitted owing to tracheoesophageal fistula (TEF). However, he was considered unsuitable for conservative intervention after a multidisciplinary team discussion. Esophageal stent insertion was impossible due to the high level of TEF in the esophagus. Additionally, the size of the TEF could not be covered by an endosponge and endoluminal vacuum therapy, and there was no tracheal stent that could cover his large trachea. The preceding percutaneous enteral gastrostomy (PEG) procedure was required for the primary closure operation of the esophagus; however, family's consent could not be obtained. After 1month, the patient and his family changed their minds and agreed to the procedure and we attempted to perform PEG procedure. However, we could not proceed with PEG owing to stenosis in the inlet of the esophagus. Then, the patient deteriorated clinically and died due to pneumonia with septic shock.

Keywords: Tracheoesophageal fistula (TEF); adult; death; malnutrition; pneumonia; ventilator.

Figure 1

Chest CT findings. (A) Chest CT shows no evidence of tracheoesophageal fistula (8 months after discharge). (B) Red arrows show the tracheoesophageal fistula 9 months after discharge. CT, computed tomography.

Figure 2

Chest radiograph and bronchoscopic findings. (A) Chest radiograph shows an endotracheal tube with maximum ballooning in the trachea; (B) bronchoscopic findings demonstrate the tracheoesophageal fistula in the trachea (blue arrow) and the black arrow indicates the nasogastric tube through the fistula.

Figure 3

The esophagogastroscopic finding and last chest radiograph. (A) Thinner esophagogastroscopy shows the balloon of the endotracheal tube in the esophagus; (B) chest radiograph reveals lobar pneumonia in the left upper lung field.