Surgical management of an esophagotracheal fistula as a severe, late complication of repeated endoscopic stenting treatment

An acquired, nonmalignant esophagotracheal fistula is an uncommon and difficult problem in clinical management. A few reports [1] [2] [3] [4] [5] describe various clinical examples and treatment solutions to the problem, but due to the rarity of the problem, guidelines for effective management have not been established.

In 1977, a 29-year-old woman with a thyroid carcinoma underwent thyroidectomy, neck dissection, radioiodine therapy, and telecobalt radiation. In 1997 she presented with dyspnea and dysphagia due to a retrolaryngeal stenosis. She underwent tracheostomy, repeated balloon dilation, and argon plasma coagulation therapy. The tracheostomy could then be removed 1 year later. However, in 2001 the stenosis relapsed, and placement of a tracheal stent was necessary. In 2003, esophagotracheal fistula and bilateral recurrent laryngeal nerve palsy were first described for this patient. Despite tracheostomy and an esophageal stent, a percutaneous gastrostomy was necessary to enable enteral nutrition. Recurrent overgrown stents were treated by overstenting, but in November 2005 recanalization was no longer possible. Beyond it, a wide esophagotracheal fistula developed with necrosis of the posterior wall of the whole trachea ([Fig. 1 ] a, b). The stent showed a broad coating defect, with the tracheal lumen compressed to 20 % ([Fig. 1 ] c). Recurrent scabs and mucus of the respiratory tract with dyspnea indicated the necessity for surgery, after recurrence of thyroid cancer was ruled out.

Fig. 1 a, b View through the tracheostoma showing the complete necrosis of the posterior wall of the trachea and the esophageal stent with the broad coating defect. c Compression to 20 % of the tracheal lumen by the protruding esophageal stent.

The larynx and trachea were resected and replaced with a tracheal T-tube. After extraction of the esophagus stent, and the resection of the esophagus, the sternoclavicular joints, and the manubrium sterni, the thoracic inlet was then closed with a pedicled sternocleidomastoid muscle, and a retrosternal interposed end-to-side pharyngogastrostomy was performed ([Fig. 2 ] a, b). The cervical skin defect was closed with a mesh graft ([Fig. 2 ] c).

Fig. 2 a, b Reconstruction with a pharyngogastrostomy and a temporary T-tube in the trachea. c Closure of the cervical skin defect with a mesh graft.

Acute, postoperative bleeding from the right carotid artery, caused by stent remnants, was stopped by interventional placement of a coated endovascular stent. The T-tube in the trachea was removed 29 days postoperatively, and the patient was discharged on day 42.

Endoscopy_UCTN_Code_CPL_1AH_2AD

References

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• 3 Mathisen D J, Grillo H C, Wain J C. et al . Management of aquired non-malignant tracheoesophageal fistula.  Ann Thorac Surg. 1991;  52 759-765
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