A 56-Year-Old Man with Dysphagia and Necrotizing Pneumonia

Abstract

A 56 year-old man was admitted with productive cough, fever, and progressive dyspnea. The patient had a long history of tobacco and alcohol dependency. He was noted to have progressive dysphagia to solids, intermittent hoarseness, and a 30 lb. weight loss over the preceding 6 months. Plain films demonstrated necrotizing right upper lobe pneumonia raising concerns for pulmonary tuberculosis. Chest CT showed circumferential irregular esophageal wall thickening in the mid-distal esophagus in addition to supraclavicular, mediastinal, and hilar lymphadenopathy. Pulmonary tuberculosis was subsequently excluded. Upper endoscopy confirmed a partially obstructing circumferential mass extending from 20 to 27 cm measured from the incisors. A small fistula was visualized at 22 cm that produced bubbles with provocative measures suggesting direct communication with either the pleural space or tracheobronchial tree. Biopsies revealed poorly differentiated squamous cell carcinoma. A 120 mm long, 18 mm Polyflex stent was placed under fluoroscopic guidance across the entire tumor length covering the fistula. The patient recovered uneventfully and was discharged. Six months later the patient returned to the hospital with 6 days of progressive dysphagia to solids. In the interval period he had gained over 25 pounds with good appetite and no limitation of daily activities. Repeat upper endoscopy under general anesthesia revealed distal displacement of the Polyflex stent and proximal tumor overgrowth causing high-grade obstruction. The stent was removed under manual traction uncovering a 4cm by 1cm tracheoesophageal fistula. The endotracheal tube and carina were clearly visible through the large fistula. A 120 mm long, 18 mm Ultraflex stent was then placed under fluoroscopic guidance but did not cover the entire length of the fistula. Therefore, a 90 mm long, 21 mm Polyflex stent was placed within the previously placed Ultraflex stent. The fistula appeared fully covered with the proximal end of the stent just below the UES. The patient was extubated and able to tolerate full liquid diet 24 hours later. This case illustrates management of one of the major complications that may occur with advanced esophageal cancer. New technical devices such as the Polyflex and Ultraflex esophageal stents allow occlusion of tracheoesophageal fistulas with improved quality of life in patients who otherwise may suffer early demise from respiratory complications related to these fistulas.