Self-Expanding Bifurcation Stent for Malignant Esophagotracheobronchial Fistula
Joerg Lindenmann, MD,
Nicole Neuboeck, MD,
Udo Anegg, MD,
Veronika Matzi, MD,
Alfred Maier, MD,
Freyja Maria Smolle-Juettner, MD
Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Graz, Austria
Joerg Lindenmann, MD, Tel: + 43 316 385 3302, Fax: + 43 316 385 4679, Email: jo.lindenmann{at}meduni-graz.at, Division of Thoracic and Hyperbaric Surgery, Medical University Graz, Auenbruggerplatz 29 8036, Graz, Austria.
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ABSTRACT
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A 60-year-old man with esophageal carcinoma in the upper 3rd underwent palliative treatment including photodynamic therapy, brachytherapy, external beam irradiation, and esophageal stenting. He developed a symptomatic malignant esophagotracheo-bronchial fistula that could not be closed by telescope-stenting in the esophagus. Implantation of a self-expanding, covered metal, tracheal bifurcation stent by flexible bronchoscopy resulted in immediate closure of the fistula with an uneventful recovery.
Key Words: Bronchoscopy • Esophageal Fistula • Esophageal Neoplasms • Stents
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INTRODUCTION
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Prevention of aspiration and restoring both the ability to swallow and unimpaired respiratory function are the mainstays of treatment for malignant esophagotracheo-bronchial fistula not amenable to surgery. Esophageal stenting alone is not always sufficient to seal the leakage. Additional self-expanding covered tracheal or bronchial stents have shown excellent results in lesions localized to the trachea or well within a main bronchus. If the fistula involves the carinal region, a tracheal bifurcation stent is necessary. This is the first report of implantation of a self-expanding, covered nitinol, tracheal bifurcation stent after esophageal stenting in pre-carinal esophagotracheobronchial fistula.
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CASE REPORT
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A 60-year-old male alcohol and tobacco user, with functionally non-resectable squamous cell carcinoma of the esophagus between 18 and 28 cm (cT3, N1, M0; G3), underwent palliation with photodynamic therapy, self-expanding metal stenting (Ultraflex; Boston Scientific), and subsequent endoluminal brachytherapy and external radiation. Due to his poor general condition with significantly reduced cardiopulmonary functional capacity, esophagectomy and reconstruction by gastric pull-up was not recommended, and palliative tumor therapy was initiated. Six months after diagnosis, the patient reported coughing after swallowing, dyspnea and fever. Fiberesophagoscopy, fiberoptic bronchoscopy, and fluoroscopy with contrast swallow confirmed a 10-mm fistula at the level of the tracheal bifurcation, adjacent to the lower rim of the esophageal stent (Figure 1
). A second self-expanding covered metal stent (Ultraflex; Boston Scientific) was inserted into the esophagus in a "telescoping" manner, covering the fistula. After 24 h, contrast swallow showed the stent fully expanded, yet a persistent leak of contrast medium into the tracheobronchial tree was documented. Obviously, esophageal double-stenting was not sufficient to seal the fistula, although neither esophageal stent was dislocated. Thus a self-expanding, completely covered, nitinol tracheal bifurcation stent (MicroTech, Nanjing, Jiangsu, China) was used in addition (Figure 2A). Stent insertion was performed fluoroscopically, controlled by flexible bronchoscopy under general anesthesia and jet ventilation. Correct placement was ensured by inserting a guidewire into each main bronchus (Figure 2B). Because full expansion of the esophageal stent requires an interval of 24 h, oral intake was stopped until the effectiveness of leak occlusion had been documented by fluoroscopy with a water-soluble contrast medium the following day. The patient recovered uneventfully. Physiotherapy, inhalation treatment, and mucolytic medication were applied to ease expectoration and prevent clogging of the tracheal bifurcation stent. Computed tomography of the thorax and mediastinum confirmed that the 2 esophageal stents and the tracheal bifurcation stent were fully expanded (Figure 3). The patient was discharged to outpatient care on the 9th day after bifurcation stenting. Two months after this intervention, he was doing well.
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Figure 1. Bronchoscopic view of the malignant esophago-tracheobronchial fistula at the level of the tracheal bifurcation.
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Figure 2. (A) Self-expanding, covered nitinol, tracheal bifurcation stent. (B) Bronchoscopic view after deployment of the bifurcation stent. Note the sealed esophagotracheobronchial fistula visible through the silicon cover, and the lower rim of the bifurcation stent located in the right main bronchus.
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Figure 3. Thoracic computed tomography after successful triple stenting. Note the 2 esophageal stents and fully expanded, covered nitinol, tracheal bifurcation stent sealing the malignant esophagotracheobronchial fistula.
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DISCUSSION
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The essential goals of treatment for malignant esopha-gotracheobronchial fistula are prevention of aspiration and restoration of both the ability to swallow and unimpaired respiratory function. Esophageal stenting alone is usually sufficient but may also provoke further problems: in some cases, the stent thrusts the esophageal tumor against the membranaceous wall, causing secondary tracheobronchial stenosis. Especially in the presence of gross necrosis, the expanding stent may enlarge the fistula and cause secondary leakage. Occasionally, particularly in the presence of a large fistula, closure of the fistula is initially insufficient.
For tracheal or bronchial lesions, self-expanding covered metal stents for tracheal or bronchial use, respectively, have shown good results.1–7 In fistulas involving the carinal region, a bifurcation stent is necessary. Wallstents of the Freitag type are effective in treating bifurcation stenosis secondary to involvement of esophageal carcinoma; yet they are not useful for closure of a leak, and carry the additional problem of a comparatively narrow lumen. For insertion, rigid bronchoscopy is required. The self-expanding MicroTech nitinol tracheal bifurcation stent is biocompatible, tolerant to erosion, and inserted by fiberoptic bronchoscopy. The effectiveness of leak occlusion and functionality depends on the size of the device which must closely adapt to the wall when fully expanded. The rims of the stent are pliable and smooth, which reduces the tendency for granulation tissue to form. The flexible texture of the bifurcation stent causes hardly any local discomfort. Once the stent has been successfully inserted, care must be taken to provide physiotherapy, inhalational and mucolytic medication to prevent clogging of the device. Discharge is not indicated before the patient is able to expectorate sufficiently.8 Endoscopic insertion of a self-expanding covered nitinol bifurcation stent represents a safe and effective approach for closure of malignant esophagotracheobronchial fistula not manageable by esophageal stenting alone.
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REFERENCES
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Asian Cardiovasc Thorac Ann 2009;
17:79-81
© 2009 by SAGE Publications
DOI: 10.1177/0218492309102527
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ABSTRACT
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