Palliative management of a malignant tracheoesophageal fistula using repeat endobronchial laser debridement and esophageal stenting

Abstract

A 71-year-old female presented with progressive dysphagia and unexplained weight loss. Computed tomography and esophagogastroduodenoscopy (EGD) revealed invasive esophageal squamous cell carcinoma, which was initially treated with local radiation and esophageal stenting. Over the next year, the patient experienced multiple symptoms and hospital admissions consistent with a malignant tracheoesophageal fistula, despite negative findings on imaging, bronchoscopy, and EGD. Prophylactic antibiotics were initiated based on symptomatology to prevent septic episodes. Stent erosion into the membranous trachea was eventually observed. Neodymium-yttrium-aluminum-garnet laser bronchoscopy was used periodically to debulk the invading tumor around the stent. A percutaneous endoscopic gastrostomy tube was also inserted to facilitate enteral nutrition and avoid aspiration pneumonia. The patient reported significant improvements in respiratory symptoms following each laser debridement and has progressed well beyond the life expectancy associated with malignant tracheoesophageal fistula.

Figure 1

(A–D) EDG images showing circumferential esophageal mass with friable mucosa and ulcerations. (E) CT chest showing marked soft tissue thickening with luminal narrowing in the upper esophagus, which extended to a level below the carina.

Figure 2

(A) CT image from January 2021 showing severe narrowing of the lumen of the esophagus proximal to the stent. (B) EDG from February2021 showing response to balloon dilation of a stricture proximal to the indwelling stent.

Figure 3

Bronchoscopic evidence of tumor growth into the trachea with evidence of stent erosion (August 2022).

Figure 4

Bronchoscopic view of the endobronchial obstruction. Invasion of the esophageal malignancy can be seen, as well as erosion of the esophageal stent into the lumen of the trachea.