Asian Cardiovasc Thorac Ann 2005;13:178-180
© 2005 Asia Publishing EXchange Ltd
Silicone Airway Stent for Treating Benign Tracheoesophageal Fistula
Yun-Hen Liu, MD,
Po-Jen Ko, MD,
Yi-Cheng Wu, MD,
Hui-Ping Liu, MD,
Ying-Huang Tsai, MD
Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
For reprint information contact: Po-Jen Ko, MD Tel: 886 3 328 1200 Fax: 886 3 328 5818 Email: pjko{at}cgmh.org.tw, Division of Thoracic and Cardiovascular Surgery, Chang Gung Memorial Hospital, 5 Fu-Hsing Street, Kweishan, Taoyuan, Taiwan.
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ABSTRACT
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We used a silicone tracheal stent successfully to seal a huge benign tracheoesophageal fistula and restore airway patency after treatment with double metallic stenting of the trachea and esophagus failed. The patient was weaned from the ventilator 16 days after the procedure and after 7 months of ventilatory support.
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INTRODUCTION
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Tracheoesophageal fistula is a serious and life-threatening condition. It can be benign: caused by prolonged endotracheal intubation, or malignant: due to primary esophageal or bronchogenic carcinomas. Treatment of malignant tracheoesophageal fistula is palliative and involves restoration of the ability to eat and drink without coughing.1,2 Management of benign tracheoesophageal fistula involves curative resection of the fistula and reconstruction of the airway and alimentary tract to re-establish continuity.3 We report our successful experience with the use of a silicone tracheal stent to seal a huge benign tracheoesophageal fistula after double metallic stenting of the trachea and the esophagus failed.
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CASE REPORT
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An 80-year-old female with respiratory failure, who had been on mechanical ventilation through a tracheostomy for 80 days, was transferred to our hospital because of recurrent pneumonia. Under local anesthesia, her airway was inspected using a flexible bronchoscope introduced through the tracheostomy tube. A 3 cm tracheal defect over the posterior membrane was noted 3 cm above the carina, and the esophageal lumen contained a nasogastric tube. The lesion was consistent with a tracheoesophageal fistula. To prevent further aspiration and pulmonary infection, a 16 mm x 8 cm metallic tracheal stent (Boston Scientific, Natick, MA, USA) was introduced through a flexible bronchoscope 3 days after admission. Twenty days later, an 18 mm x 12 cm metallic esophageal stent (Boston Scientific, Natick, MA, USA) was inserted to seal the fistula and restore alimentary continuity. However, the patient experienced persistent air leak from the fistula, preventing ventilator weaning. Furthermore, bronchoscopy revealed migration of the airway stent and distortion of the stent mesh, hampering removal of airway secretion. The airway stent was removed with forceps via a flexible bronchoscope 71 days after admission. Ventilation was maintained with an adjustable tracheostomy tube (Bivona, Gary, IN, USA) passed through the stoma and bypassing the fistula into the distal trachea.
On day 95 after admission, the patient was referred to our team for further management owing to difficulty in clearing airway secretions and inability to phonate with the Bivona tracheostomy tube. Under general anesthesia, a rigid bronchoscope was introduced via the tracheal stoma. With adequate ventilation provided via the bronchoscope, the trachea and main bronchi were explored and manipulated. A 3 cm tracheal defect over the membranous portion with a huge tracheoesophageal fistula was located 3 cm above the carina. To prevent recurrent pneumonia, an 18 mm x 7 cm (size 18) silicone stent (Hood Laboratories, Pembroke, MA, USA) was inserted via the tracheal stoma to seal the fistula. The proximal end of the silicone stent was placed 2 cm below the tracheal stoma, and there was a 2 cm distance between the distal end of the stent and the carina as measured with a bronchoscope following the procedure. A size 8 cuffed tracheostomy tube (Shiley, Mallinckrodt, St. Louis, MO, USA) was incorporated into the proximal end of the stent. The patient regained respiratory function immediately after surgery, and no air leak from the fistula occurred. The new combined airway had good patency, and the patient was weaned from the ventilator 16 days after the procedure. She was transferred to an ordinary ward with a tracheostomy mask to maintain ventilation 125 days after admission.
Chest radiographs of the patient taken before and after placement of the various stents are presented in Figure 1
. The trachea as seen on bronchoscopy before and after silicone stenting and incorporation of the Shiley tracheostomy tube are shown in Figure 2.
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Figure 1. Chest radiographs showing (A) tracheostomy tube in the trachea (day 1), (B) metallic stent in the trachea (day 3), (C) airway and esophageal stent (day 23), and (D) silicone stent and tracheostomy tube in place (day 95).
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Figure 2. Bronchoscopic views of (A) tracheoesophageal fistula with posterior membrane defect and (B) patent airway after silicone stenting. (C) Silicone stent incorporated into the tracheostomy tube. (D) Shiley tracheostomy tube in place and Bivona tracheostomy tube removed.
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DISCUSSION
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In treating tracheoesophageal fistula, the gold standard is resection of the fistula and reconstruction of the airway and alimentary tract. When surgery is not suitable (as in malignant cases or benign cases with a very high operative risk), endoscopic procedures provide adequate improvement of respiratory performance.2,4,5
Both metallic and silicone stents have their benefits and drawbacks. Silicone stents have the advantage of good flexibility, easy removal, and allowing further reconstructive surgery. Metallic stents, on the other hand, are easy to insert but difficult to remove. Replacement of the metallic tracheal stent by a silicone stent offered some advantages in our patient. It is a safe means of providing a patent airway. The proximal end of the silicone stent can be easily incorporated into the tip of a tracheostomy tube to provide sufficient ventilation. The fistula was tightly sealed after silicone stent deployment, and no air leaked from the nasogastric tube immediately after completion of the procedure. Although migration is the main limitation of silicone stents, it did not occur in our patient, probably because of accommodation between the metallic interstices and the stud of the stent.
Silicone stents are usually introduced via a rigid scope. In our patient, a size 18 silicone stent was required to maintain airway patency and to seal the fistula. We inserted the stent directly and smoothly through the tracheal stoma. The position of the stent was then confirmed and manipulated under rigid bronchoscopy.
Conventional resection of the tracheoesophageal fistula and reconstruction of the airway and esophagus may not be suitable for our patient because persistent infection unresponsive to conservative treatment, long-term ventilator dependence, and poor nutritional status may slow healing after reconstruction.6 Moreover, the tracheal defect was so huge that resection may lead to excessive anastomotic tension, devascularization, and slow anastomotic healing. As a result of a favorable outcome in our patient, we believe that this technique may be a useful option in the treatment of tracheoesophageal fistula, as an alternative to double metallic stenting.
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REFERENCES
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