Management of aero-digestive fistulas: the gastroenterologist's perspective, a narrative review

Abstract

Background and objective: Esophagorespiratory fistulas (ERFs) are pathologic communications between the esophagus and respiratory tract that may be congenital or acquired, and benign or malignant. ERFs can lead to significant respiratory compromise and increased mortality through recurrent respiratory infections. As the condition spans multiple organ systems, ERFs pose unique diagnostic and management challenges to pulmonologists, gastroenterologists, and thoracic surgeons. The aim of this manuscript is to provide an up-to-date review of the management of aero-digestive fistulas from the gastroenterologist's perspective.

Methods: Relevant studies regarding the management of ERFs through August 2022 were identified and data was extracted based on the relevance to the topic of the manuscript.

Key content and findings: Endoscopy has a pivotal role in the management of these patients. Multiple endoscopic options are currently available that involve either closure, covering, or draining techniques. Studies evaluating strategies for the management of ERFs are limited to small retrospective studies while head-to-head studies comparing different endoscopic options are lacking. Therefore, a standardized evidence-based algorithm for the management of this challenging pathology is not available. Selection of the management strategy depends on operator preference, location and size of the fistula, viability of the surrounding tissue, and patient's comorbidities.

Conclusions: Successful management of ERFs requires a tailored and multidisciplinary approach including surgery, pulmonology, gastroenterology, and oncology. Future studies comparing the effectiveness of different endoscopic strategies for the management of ERFs could help standardize management and potentially improve patient outcomes.

Keywords: Esophagorespiratory fistula (ERF); endoscopic suturing; esophageal stenting; over-the-scope clip (OTSC); tracheoesophageal fistula (TEF).

Figure 1

Patient with history of lung cancer treated with chemoradiation, currently in remission, presented with recurrent aspiration pneumonia. (A) An esophagram demonstrated evidence of a tracheoesophageal fistula; the black arrow indicates the fistula site; (B) upper endoscopy showed the fistula in the middle third of the esophagus; the yellow arrow indicates the opening of the tracheoesophageal fistula; (C) a fully covered esophageal self-expanding metal stent was deployed over the fistula site.