1775 Tracheoesophageal Fistula Managed With Double Stenting of Bronchus and Esophagus

Abstract

INTRODUCTION: Malignancy is responsible for 5-15% of acquired tracheoesophageal fistulas (TEF). Such patients have a short survival and management of these fistulas is a challenge. We present a case of TEF secondary to esophageal malignancy that was managed with double stenting of the bronchus and esophagus. CASE DESCRIPTION/METHODS: The patient is a 56 year old black female with no known past medical history who presented to our emergency department with complaints of chest pain, shortness of breath and a productive blood tinged cough. She had been recently discharged from another facility for a diagnosis of bronchitis, however symptoms had not abated. She reported a fifty-pound weight loss with poor oral intake. Her vital signs and labs on arrival were stable. Initial imaging in the ER was consistent with pneumonia of the right middle and lower lobes. She underwent a CT Neck, which showed esophageal wall thickening and a mass suspicious for an esophageal neoplasm. Due to concern of her recurrence of pneumonia and esophageal mass, she underwent an esophagram, which showed a stricture of the middle third of the esophagus with a fistula from the esophageal tumor to the right lower lobe bronchus. Due to concern of airway collapse with upper endoscopy, Pulmonology was consulted. The patient first underwent a bronchoscopy in which a Novatech Y-stent was deployed stabilizing the airway. The patient then underwent an endoscopy in which an esophageal stent was placed. Both procedures were successful and she tolerated oral intake well thereafter. She was discharged in stable condition to palliative hospice services. DISCUSSION: The case has relevance from both an interesting initial clinical presentation as well as management of this patient from both a technical and procedural aspect. This patient had continual infections from continuous overspill of esophageal contents into the respiratory tree. Although her prognosis to begin with was quite poor, these interventions allowed the patient some quality of life. This case also commands procedural respect. The patient’s left mainstem bronchus was extremely friable and actually ruptured during the initial course of balloon dilation. The stent in position did not completely cover the TEF however it did keep the central airway open. A long esophageal stent was placed by gastroenterology, which did completely cover the fistula. This patient’s case highlights potential difficulties in double stenting and anticipatory management by utilization of other services.