○Įntire tracheobronchial tree to be examined and cultures sent to guide antibiotic therapy ○ ○īiopsies of membranous wall of the trachea should be performed if malignancy is suspected. Documention of the measurements in the bronchoscopy note are important for future comparison and for evaluation of possible operative intervention (resection or stenting). Measurements should be taken of fistula and remaining normal airway (distance from the vocal cords to the TEF, diameter of the TEF, and the distance from the TEF to the carina). Rigid bronchoscopy provides complete inspection of airway ○ In ventilated patients, flexible bronchoscopy can be performed through endotracheal tube (tube pulled back under direct vision) ( Fig. This includes bleeding, migration, erosion, and further progression of the fistula, leak, and occlusion.Įssential in the diagnosis and management of tracheoesophageal fistula ▪īronchoscopy most valuable to locate fistula and determine extent ○ Although well tolerated, patients should be counseled on the complications of esophageal and airway stenting, from minor to devastating. The placement of self-expanding stents, whether in the esophagus or airway, can be safely accomplished with minimal intravenous sedation and the use of topical or nebulized anesthetic. Typically treated with an esophageal stent alone, these peripheral fistulas may also be managed with the addition of a tracheobronchial stent. Likewise, fistulas to the lobar or segmental bronchi are difficult to seal via bronchial stenting because there is a lack of healthy tissue proximally and distally. In such cases, a definitive tracheostomy tube with inflatable cuff to protect the distal airways may be placed. This technique decreases the incidence of tracheal narrowing from initial esophageal stenting.įor fistulas located at or above the cricopharyngeus, the placement of a stent is not recommended because a foreign body in the pharynx or larynx results in significant patient discomfort and the inability to swallow. In some cases, tracheal stents may also be needed and should be placed under bronchoscopic vision before the esophageal stent. These stents are typically placed under direct endoscopic guidance with the assistance of bedside fluoroscopy. Most malignant TEF may be sealed using a self-expanding covered or partially covered metal or plastic esophageal stents.
Pulmonary sepsis should be treated with antibiotics, mechanical ventilation should be weaned as allowed, and nutrition should be optimized. Preoperative imaging, including barium swallow, should be obtained to determine the anatomy and level of the fistula. The principals of preoperative planning in benign TEF also apply to patients with malignant disease. Either individual or a combination of stents across the fistula is placed to prevent further spillage of enteric contents across the fistula, thus minimizing pulmonary contamination and alleviating the symptoms of chronic aspiration and pulmonary sepsis.
In cases of incurable disease, airway and esophageal stenting has emerged as a viable option to achieve palliation. For these reasons, outcomes from radical and palliative surgery to address malignant TEF result in significant rates of morbidity and mortality. Furthermore, these patients are often significantly deconditioned and malnourished as a result of their disease burden, systemic chemotherapy, and local radiation. Surgery, in many of these cases, is not within the initial oncologic principles of management. As opposed to benign TEF, where surgical interventions restore the integrity and continuity of the airway and intestine, malignant fistulas represent the sequelae of advanced metastatic esophageal or bronchogenic carcinomas. The management of malignant TEF is aimed at palliation.
Cameron MD, FACS, FRCS(Eng)(hon), FRCS(Ed)(hon), FRCSI(hon), in Current Surgical Therapy, 2020 Management of Malignant Tracheoesophageal Fistulas
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