Malignant tracheoesophageal fistula: diagnosis and management

Abstract

: Tracheoesophageal fistula (TEF) refers to a pathological connection between the tracheo-bronchial tree and esophagus, and may be found in 5–15% of esophageal and 1% of tracheo-bronchial malignancies. Individuals with such advanced malignancy resulting in TEF, are usually at terminal stages of disease. They are often burdened with intolerance to feeding and are subject to frequent pulmonary infections secondary to respiratory contamination. Presentation varies from mild coughing to florid sepsis due to aspiration pneumonia. Diagnosis can usually be made by bronchoscopy and esophagoscopy. In cases where the TEF is small and cannot be visualized by these methods, fluoroscopic swallow evaluation may be useful. The primary aims of treatment are to initiate broad spectrum antibiotics when sepsis is present, to separate the esophagus from the respiratory tree preventing soilage, and to ensure enteral nutrition. In order to determine the approach to management, patients may be categorized into those who present with TEF without a diagnosis of a malignancy, those who present with TEF during oncological treatment with chemotherapy and/or radiation, and those in remission after treatment with definitive chemotherapy and/or radiation, and have developed TEF as a complication. The mainstay of therapy is endoscopic stenting of the esophagus and/or airway. Definitive surgical intervention is usually reserved for patients who are tumor free and involves take-down of the fistula with interposition of a muscle flap. Although therapy is mainly palliative in most circumstances, a systematic approach to this disease may provide patients with a better quality of life.