Perspective on airway stenting in inoperable patients with tracheoesophageal fistula after curative-intent treatment for esophageal cancer

Silicone stent versus fully covered metallic stent in tracheoesophageal fistula: a single-center retrospective study

BACKGROUND

In cases of tracheoesophageal fistula (TEF), closure of the fistula by tracheal stent implantation is an effective treatment. In this study, we investigated the efficacy and complications of silicone and metallic tracheal stents for TEF.

METHODS

We retrospectively reviewed all patients who underwent tracheal stent insertion for TEF between January 2021 and April 2024 at our institution. Complications were assessed bronchoscopically.

RESULTS

Metallic stents were placed in 21 patients (18 men, 85.7%) and silicone stents in 17 patients (14 men, 82.4%). No differences were observed between the two groups in terms of age, gender, location or size of fistula, primary disease, symptoms or comorbidities. A total of 26 fistulas were found in the metallic stent group, and 19 fistulas were found in the silicone stent group. Stent insertion was successful in all cases. The differences in efficacy and complications after stent placement were not statistically significant between the two groups. Mucus retention was the most frequent complication (P = 0.221), followed by granulation tissue (38.1% with metallic stent and 29.4% with silicone; P = 0.734) and migration (14.3% with metallic stent and 29.4% with silicone; P = 0.426).

CONCLUSIONS

Silicone and metallic stents are viable clinical options for treating TEF. Both are equally effective and safe and have acceptable complication rates in TEF.

Endoluminal Wound Vacuum Therapy: A Paradigm Shift in Managing Esophageal Bronchial Fistula

Esophageal bronchial fistula after Ivor Lewis esophagectomy is a challenging complication. Surgical treatment is definitive, but it carries high morbidity and mortality, whereas esophageal stents have been shown to be temporary measures. We highlight the case of a patient who was treated with endoluminal wound vacuum therapy. The fistula healed after 9 days of therapy. The likely reason for success was the presence of an omentum between the esophagus and the bronchus that was placed during esophagectomy and that provided adequate tissue to close the fistula. In a patient with appropriate anatomy, esophageal bronchial fissure can be successfully treated with endoluminal wound vacuum therapy.

Efficacy of airway stenting and nasogastric tube insertion in airway-esophageal fistula patients with airways compromised by advanced malignancy

INTRODUCTION

Whether airway-compromised airway-esophageal fistula (AEF) patients should undergo combined airway and esophageal stenting is controversial. This study was designed to evaluate the survival prognosis and poststent interventions in AEF patients with airways compromised by advanced malignancy with or without airway stents.

METHODS

A retrospective analysis of the medical records, survival times, and poststent interventions of 17 patients with or without airway stents was performed.

RESULTS

The causes of AEF were esophageal cancer (11/17, 64.7%), lung cancer (6/17, 29.4%), and thyroid cancer (1/17, 5.9%). All patients received a nasogastric tube (n = 12) or underwent gastrostomy (n = 5) to resume enteral nutrition. Thirteen patients underwent airway stent insertion (13/17, 76.5%), whereas four patients did not. Four patients with a high risk of stent migration received external stent fixation to the trachea. Three of the patients with stents suffered severe granulation tissue formation and needed repeated bronchoscopy interventions. In the stented group, none of the patients developed stent migration, and the overall median survival time was 9 months, compared with 1.25 months in the nonstented group (P = 0.04). Cox proportional hazards regression revealed that stent insertion, nasogastric tube insertion, and transcatheter bronchial artery chemoembolization were protective factors against death, whereas surgery-related fistula, fistula larger than 2 cm, continued chemotherapy, and age were risk factors for poor survival (P < 0.05).

CONCLUSION

In airway-compromised AEF patients, airway stents and nasogastric tubes are probably the preferred treatments. Airway stenting is tolerable, and routine weekly poststent bronchoscopy is needed in the first month and depending on respiratory symptoms thereafter.

Palliative management of a malignant tracheoesophageal fistula using repeat endobronchial laser debridement and esophageal stenting

A 71-year-old female presented with progressive dysphagia and unexplained weight loss. Computed tomography and esophagogastroduodenoscopy (EGD) revealed invasive esophageal squamous cell carcinoma, which was initially treated with local radiation and esophageal stenting. Over the next year, the patient experienced multiple symptoms and hospital admissions consistent with a malignant tracheoesophageal fistula, despite negative findings on imaging, bronchoscopy, and EGD. Prophylactic antibiotics were initiated based on symptomatology to prevent septic episodes. Stent erosion into the membranous trachea was eventually observed. Neodymium-yttrium-aluminum-garnet laser bronchoscopy was used periodically to debulk the invading tumor around the stent. A percutaneous endoscopic gastrostomy tube was also inserted to facilitate enteral nutrition and avoid aspiration pneumonia. The patient reported significant improvements in respiratory symptoms following each laser debridement and has progressed well beyond the life expectancy associated with malignant tracheoesophageal fistula.

Clinical evaluation the success rate and complications of fluoroscopically guided removal of tracheal tube metallic stents

BACKGROUND

Long-term placement of airway stents has a high probability of restenosis of the airway due to granulation tissue hyperplasia, and it is difficult to remove the stent. Our aim is to evaluate the success rate and complications of removal of tracheal tube metallic stents under fluoroscopic guidance, and to compare the difference between uncovered stent and covered stent.

METHODS

We retrospectively reviewed 45 cases (31 males and 14 females; age, 12-71 years) of tracheal metallic stent removal performed at our center between January 2014 and December 2019. Covered stents were applied in 36 cases, and uncovered stents were applied in 9 cases. In the covered stent group, 15 patients presented with granulation tissue at both ends; 3 cases, with stent fracture; and 2, with stent intolerance due to severe airway foreign body sensation. In the uncovered stents group, all patients presented with granulation tissue formation; 2 patients, with stent fracture; and 1 patient, with stent intolerance.

RESULTS

A total of 41 (91.1%) stents were successfully removed (34 [94.4%] in the covered stent group and 7 [77.8%] in the uncovered stent group). The average duration of stent placement was 3.2 ± 0.7 and 2.5 ± 1.2 months in the covered stent group and uncovered stent group, respectively. With regard to the complications, hemoptysis occurred in 4 cases (average blood volume lost, 100 ml), tracheal mucosa tear occurred in 5 cases, tracheal collapse requiring emergency airway stent placement occurred in 1 case, and tracheal rupture requiring emergency surgical suture occurred in 1 case. No procedure-related deaths occurred in either group.

CONCLUSIONS

It is safe to remove the metal stent of the tracheal tube under the guidance of fluoroscopy, with low complications, and can avoid the long-term placement of the airway stent.