© Georg Thieme Verlag KG Stuttgart · New York
Surgical management of an esophagotracheal fistula as a severe, late complication of repeated endoscopic stenting treatment
08. Januar 2008 (online)
An acquired, nonmalignant esophagotracheal fistula is an uncommon and difficult problem in clinical management. A few reports      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.
- 1 Baisi A, Bonavina L, Narne S. et al . Benign tracheoesophageal fistula: results of surgical therapy. Dis Esophagus. 1999; 12 209-211
- 2 Freire J P, Feijo S M, Miranda L. et al . Tracheo-esophageal fistula: combined surgical and endoscopic approach. Dis Esophagus. 2006; 19 36-39
- 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
- 4 Reed M F, Mathisen D J. Tracheoesophageal fistula. Chest Surg Clin N Am. 2003; 13 271-289
- 5 Wang M Q, Sze D Y, Wang Z P. et al . Delayed complications after esophageal stent placement for treatment of malignant esophageal obstructions and esophagorespiratory fistulas. J Vasc Interv Radiol. 2001; 12 465-474
R. Ladurner, MD
Department of General, Visceral, and Transplant Surgery
University Hospital Tübingen