Esophageal stent migration into the trachea

Acquired Adult Aerodigestive Fistula: Classification and Management

BACKGROUND

Acquired aerodigestive fistulae (ADF) are rare, but associated with a high mortality rate. We present our experience of the diagnosis, management and outcomes of patients with ADFs treated at a tertiary centre. Utilising our findings, we propose an anatomical classification system, demonstrating how specific features of an ADF may determine management.

METHODS

A clinical database was searched and 48 patients with an ADF were identified. A classification system was developed based on anatomical location of the ADF and differences in clinico-pathological features based on this categorisation were performed, with the chi-squared test used for inferential analyses and Kaplan-Meier curves with log-rank test to assess survival.

RESULTS

Twenty (41.6%) patients developed an ADF secondary to malignancy, with previous radiotherapy (18.7%), post-operative anastomotic dehiscence and endotherapy (14.6% each) representing other causes. Thirty-one patients were managed with tracheal and/or oesophageal stents and eight underwent surgical repair. The classification system demonstrated benign causes of ADF were either proximally or distally sited, whilst a malignant cause resulted in mid-tracheal fistulae (p = 0.001), with the latter associated with poorer survival. ADFs over 20 mm in size were associated with poor survival (p = 0.011), as was the use of previous radiotherapy. Proximal and distal ADFs were associated with improved survival (p = 0.006), as were those patients managed surgically (p = 0.001).

CONCLUSION

By classifying ADFs, we have demonstrated that anatomical location correlates with the size, history of malignancy, previous radiotherapy and aetiology of ADF, which can affect management. The proposed classification system will aid in formulating multi-modality individualised treatment plans.

Migrated esophageal stent posing a challenge for ventilation

Self-expandable esophageal stents are being commonly used for palliative treatment in advanced esophageal cancer patients to relieve dysphagia, prevent tracheoesophageal fistula, and facilitate symptomatic betterment. The modern covered stents reduce the ingrowth of the tumor but have seen an increase in the incidence of stent migrations. We report a rather complicated presentation of an esophageal stent for esophageal dilatation and a challenging management of a difficult tracheostomy.

Large tracheobronchial fistula due to esophageal stent migration: Let it be!

We report tracheal-bronchial migration of a covered esophageal self-expanding metal stent used to relieve dysphagia in a patient with advanced esophageal cancer. The stent eroded the trachea and completely occluded the main left bronchus. Surgery was contraindicated due to her poor clinical condition, and insertion of another stent in the trachea, esophagus, or both was contraindicated due to extension of the fistula. Esophageal exclusion with a combination of cervical esophagostomy and an enteral feeding tube was the only feasible treatment to minimize spoilage by aspirated saliva and provide enteral nutrition.