Tracheoesophageal Fistula as a Complication of Esophageal Stent Placement

Abstract

INTRODUCTION: Increased placement of esophageal stents for the palliative management of malignant esophageal strictures has resulted in increased complications. We report a case of tracheoesophageal fistula formation from esophageal stent erosion and subsequent tracheal and esophageal double stenting with good clinical outcome. CASE PRESENTATION: A 41-year old female with metastatic cervical cancer, gastritis, and recent placement of esophageal stent presented with sudden onset respiratory failure. Pt was diagnosed with stage II B cervical cancer and treated with chemo and radiation therapy. She had reoccurrence of disease a year later with metastasis to liver, retroperitoneum, and thoracic spine. Pt had increasing dysphagia and EGD done 7 days prior showed almost complete esophageal obstruction with stricture 30 cm from incisors. A 60mmx18mm esophageal stent was placed during EGD and Pt was recovering well when sudden respiratory failure occurred. Despite direct laryngoscopy intubation, Pt remained hypoxic with 100% inspired oxygen and 14cm PEEP. Exam showed hyperresonance over epigastrim with poor chest excursion. On bronchoscopy, a tracheoesophageal fistula was seen in the distal trachea (Fig.1) where the proximal end of the esophageal stent (Fig.2) was observed eroding through the posterior tracheal wall. Pt had esophageal stent removed and a longer 18mmx160mm stent was deployed across the defect with a second 14x40mm tracheal stent placed at the distal trachea. She was extubated 2 days later and subsequently discharged home in stable condition. DISCUSSION: Esophageal stents have proven useful in the management of esophageal strictures despite complications approaching 30-35% including prosthesis migration, new stricture formation, and esophageal erosion with fistula formations. Most tracheoesophageal fistulas present more than a week after stent placement with unrepaired defects leading to poor nutrition, repeat aspirations, and recurrent pneumonia followed by rapid clinical deterioration and death. Studies have examined management of malignant tracheoesophageal fistulas with combined airway and esophageal stenting leading to increased quality of life. Early recognition of stent complication and fistula formation provides a window of opportunity through which satisfactory clinical outcome can be attained. CONCLUSIONS: Tracheoesophageal fistulas should be considered in acute respiratory compromise following esophageal stent placement where early recognition can lead to immediate and improved patient outcome.