J Formos Med Assoc 2011;110(4):270–272
Contents lists available at ScienceDirect
Volume 110 Number 4 April 2011
Journal of the Formosan Medical Association
ISSN 0929 6646
Journal of the
Formosan Medical Association World Health Day 2011—Antimicrobial resistance: No action today, no cure tomorrow Pharmacotherapy of spasticity in children with cerebral palsy Etiology of peptic ulcer bleeding in southern Taiwan Brugada-type electrocardiogram in Chinese
Journal homepage: http://www.jfma-online.com
Formosan Medical Association Taipei, Taiwan
Case Report
Successful Treatment of Bronchoesophageal Fistula With Esophageal and Bronchial Stenting Cheng-Yi Wang,2,5 Chien-Hong Chou,2,6 Hsiu-Po Wang,3 Jin-Shing Chen,4 Peilin Lee1,2* Bronchoesophageal fistula is reported in 5–10% of patients with esophageal cancer. In most of these cases, the insertion of a single stent, either a tracheobronchial or an esophageal stent, is sufficient to seal off the fistula. In this case we describe a 67-year-old man with esophageal cancer and complications of bronchoesophageal fistula, which resulted in repeated pneumonia and acute respiratory failure. Initially, two expandable metallic membranous esophageal stents were placed to cover the fistula. However, the esophageal stent failed to stop the air leak and dislodged into the stomach. Thereafter, a bronchial stent was placed at the right intermediate bronchus and successfully stopped the air leak. The patient was then weaned from the ventilator 1 week after the insertion of a bronchial stent. In conclusion, stenting in both the esophagus and airways should be considered when both are severely invaded by malignancy, when the airway is compressed, or when the fistula is insufficiently sealed by an esophageal stent. Key Words: bronchoesophageal fistula, respiratory failure, stent
Case Report
Bronchoesophageal (BE) fistula can be palliated by stent insertion. In most cases, a single stent, either a tracheobronchial or an esophageal stent, is sufficient to overcome the fistula. However, in some cases, double stents are needed to seal off the BE fistula. In this case we describe a man with esophageal cancer-related BE fistula, which resulted in repeated pneumonia and acute respiratory failure. The BE fistula was successfully treated with two esophageal stents and one bronchial stent, which helped to wean the patient from mechanical ventilation.
A 67-year-old man had odynophagia, cough, and body weight loss for 6 months. Medical history showed a perforated peptic ulcer treated with truncal vagotomy and pyloroplasty 13 years ago, and medically-controlled hypertension and diabetes mellitus. Panendoscopy (PES) on June 3, 2005 showed an ulcerated esophageal tumor 32−40 cm below the incisors. Biopsy was performed and the pathologic report was squamous cell carcinoma. Therefore, the patient underwent
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1
Center of Sleep Disorder, 2Division of Pulmonary and Critical Care Medicine, 3Department of Internal Medicine, 4Department of Surgery, National Taiwan University Hospital, 5Department of Internal Medicine, Cardinal Tien Hospital, Fu-Jen Catholic University, Taipei, and 6Department of Internal Medicine, National Taiwan University Hospital Yun Lin Branch, Yun Lin, Taiwan. Received: August 18, 2008 Revised: January 10, 2009 Accepted: February 12, 2009
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*Correspondence to: Dr Peilin Lee, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan. E-mail:
[email protected]
J Formos Med Assoc | 2011 • Vol 110 • No 4
Esophageal and bronchial stenting for BE fistula
concurrent chemo-radiotherapy from June 30 to July 11, 2005. On July 21, 2005, the patient had right lower lobe (RLL) pneumonia that partially responded to antibiotic treatments. Bronchoscopy disclosed esophageal cancer invading the right intermediate bronchus without BE fistula. However, sudden massive hematemesis with respiratory failure occurred on August 3, 2005. Emergent endotracheal intubation was performed and mechanical ventilation support was given. A milk-like substance was aspirated from the endotracheal tube after enteric feeding on August 10, 2005. In addition, persistent air bubbles were drained from the nasogastric tube (NGT) and the ventilator showed a persistent air leak with 150cc tidal volume per breath. Follow-up chest radiography showed progression of the RLL pneumonia. The patient also needed a higher fraction of inspired oxygen. BE fistula was suspected and a left-sided double-lumen endotracheal tube was inserted to maintain better oxygen saturation. PES was performed on August 15, 2005 and showed a circumferential ulcerative lesion with luminal stenosis in the lower esophagus at 30–40 cm below the incisor. An expandable metallic membranous esophageal stent (Microvasive, Boston Scientific Corp., Boston, MA, USA) was placed at 28–40 cm below the incisors. There was a fistula over the upper-end of the esophageal stent, which was not covered by the stent membrane. Therefore, another stent (Microvasive) was placed at 24– 34 cm below the incisors to bypass the defect (Figure 1). The air leak did not improve after the insertion of the esophageal stents and chest radiography showed that the second stent dislodged into the stomach in the morning of August 16, 2005 (Figure 2). Emergency PES on August 16, 2005 also confirmed this observation. The second stent was extracted with a snare 22–23 cm from the incisors and was overlapped with the first stent at 32–33 cm from the incisor. However, the air leak persisted after revision on August 17, 2005. Bronchoscope was repeated and it revealed a fistula opening into the right intermediate bronchus around the orifice of the common basal bronchus. J Formos Med Assoc | 2011 • Vol 110 • No 4
Figure 1. Endoscopy-guided insertion of two covered expandable metallic esophageal stents to bypass the esophageal mucosal defect (arrow).
Figure 2. The esophageal stent (arrow) migrated to the stomach 1 day after insertion.
Therefore, on August 19, 2005, an expandable covered metallic 4-cm-long × 18-mm-diameter stent (Ultraflex, Boston Scientific Corp, Boston, MA, USA) was placed at the right intermediate bronchus near the orifice of the common basal bronchus to cover the defect. Thereafter, no air leak was detected (Figure 3). The RLL pneumonia was better controlled after the BE fistula was successfully bypassed with the bronchial stent. The patient was weaned from the ventilator on August 26, 2005.
Discussion BE fistula is a devastating complication reported in 5−10% of patients with esophageal cancer.1 271
C.Y. Wang, et al
Figure 3. Fluoroscopy showed the properly positioned esophageal stents (arrowheads) and right-intermediate bronchial stent (arrow).
Treatment should be prompt,2 with the goal of sealing off the fistula. In Burt’s study, the two most commonly associated primary tumors are esophageal (77%) and lung cancer (16%),3 and it is more likely to arise in locally advanced cancer.4 Diagnosis is difficult without the typical signs and symptoms. Recurrent cough is the most common symptom (56−65%), especially for those on a liquid diet.5,6 Aspiration (37%) and fever (25%) are next, often due to pneumonia.6 Barium esophagogram is usually the diagnostic study of choice.3 Esophagoscopy and bronchoscopy are also able to demonstrate the fistula.3 Most patients succumb to respiratory failure within 6 weeks of diagnosis if the fistula is not sealed.3 In 1990, Song et al7 reported their success with silicone-covered expandable esophageal stents, which lowered the rate of complications and mortality compared to conventional treatment. Stenting has since become the management of choice. In most cases, insertion of a single stent, either a tracheobronchial or an esophageal stent, is sufficient to seal off the fistula. A second stent is indicated if dyspnea or dysphagia is not relieved. Stenting in both the esophagus and airways should be considered when both are severely invaded by malignancy, when there is airway compression, or when the fistula is insufficiently sealed by an esophageal stent.8 272
Covered stents have a higher risk of displacement than uncovered ones, despite the higher effectiveness.9,10 After bronchial stent insertion, our patient rapidly recovered from both the pneumonia and air leak, and was weaned from ventilation. This supports other findings that the early recognition and management of BE fistula with BE stent improves outcome. In conclusion, we demonstrated that an esophageal cancer-related BE fistula was successfully treated with an esophageal and a bronchial stent. This procedure should be considered if a single stent, either an esophageal stent or a bronchial stent, fails to overcome the complications caused by BE fistula. Awareness of the possibility of BE fistula, prompt diagnosis, and immediate treatment are key factors in saving the lives of such patients.
References 1. Abadal JM, Echenagusia A, Simo G, et al. Treatment of malignant esophago-respiratory fistulas with covered stents. Abdom Imaging 2001;26:565–9. 2. Burt M. Management of malignant esophago-respiratory fistula. Chest Surg Clin N Am 1996;6:765–76. 3. Burt M, Martini N, Bains MS, et al. Malignant esophagorespiratory fistula: management options and survival. Ann Thorac Surg 1991;52:1222–9. 4. Little AG, Ferguson MK, Demeester TR, et al. Esophageal carcinoma with respiratory tract fistula. Cancer 1984;53: 1322–8. 5. Spalding AR, Burnery DP, Richie RE. Acquired benign broncho-esophageal fistulas in the adult. Ann Thorac Surg 1979;28:378–83. 6. Enzinger PC, Mayer RJ. Esophageal Cancer. N Engl J Med 2003;349:2241–52. 7. Song HY, Chung JY, Han YM, et al. Expandable esophageal metallic stents coated with silicone rubber: an experimental study in rabbits. J Korean Rad Soc 1990;26: 829–34. 8. Nam DH, Shin JH, Song HY, et al. Malignant esophagealtracheobronchial strictures: parallel placement of covered retrievable expandable nitinol stents. Acta Radiol 2006; 47:3–9. 9. Song HY, Lee DH, Seo TS, et al. Retrievable covered nitinol stents: experiences in 108 patients with malignant esophageal strictures. J Vasc Interv Radiol 2002;13:285–93. 10. Shin JH, Kim SW, Shim TS, et al. Malignant tracheobronchial strictures: palliation with covered retrievable expandable nitinol stent. J Vasc Interv Radiol 2003;14:1525–34.
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