Miscommunication: A Case of Catastrophic Esophageal Stent Rupture Causing Complete Tracheal Occlusion

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INTRODUCTION: Esophageal self-expanding metal stents (SEMS) are often used for palliation of dysphagia caused by malignant esophageal obstruction due to unresectable tumor that has recurred or failed to respond to chemoradiotherapy. Reported success rates are greater than 95%, however, stent-related complications can occur in 45-60% of patients, including stent migration and tissue ingrowth. Stent-related esophago-respiratory fistula is a rare life-threatening complication that can be seen in 4-9% of patients. We present a fatal case of tracheoesophageal fistula (TEF) due to esophageal stent rupture into the distal trachea. CASE PRESENTATION: A 52-year-old female with stage IV non-small cell lung cancer and a large subcarinal mass was admitted for dyspnea, productive cough, and acute hypoxemic respiratory failure due to aspiration pneumonia. She had previously undergone placement of an esophageal fully-covered SEMS for palliation of dysphagia related to a 25 mm malignant TEF involving the proximal esophagus.CTA chest showed mass effect and partial obstruction of the posterior tracheal wall by the esophageal stent (Figure 1). She was transferred to the MICU and intubated. Despite initial stabilization, her ICU course was complicated by sudden hypoventilation, hypoxemia, and an inability to advance the endotracheal in-line suction. Emergent bronchoscopy revealed complete rupture of the esophageal stent through the posterior wall of the trachea, with the stent abutting the anterior endotracheal wall causing near-total occlusion of the tracheal lumen (Figure 2). The main carina was partially visualized 1 cm distally, but the bronchoscope was unable to traverse the obstruction. There was no feasible surgical or endoscopic intervention that could be offered and the obstruction was too distal for an emergent tracheostomy. The patient remained in extremis, and her family opted to pursue comfort-focused measures shortly before her death. DISCUSSION: Management of malignant TEF can include stenting of the esophagus, airway, or both. Rates of fistula closure following placement of esophageal covered SEMS range from 80-100%. Double stenting of both the airway and esophagus is the preferred strategy for malignant TEF involving the mid-to-proximal esophagus, in order to avoid potential airway compromise; this is also associated with improved survival when compared to airway stenting alone. However, data guiding the treatment of TEF that occurs as a complication of an esophageal stent encroaching into a nonstented airway is lacking, likely due to the paucity of cases and associated high mortality. Use of a tracheal (or tracheobronchial) stent to seal the defect is not routinely performed and rarely described in case reports. CONCLUSIONS: Further investigation into the prevention and minimally-invasive treatment of this life-threatening stentrelated complication is needed to improve future patient outcomes.




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Chest Annual Meeting 2023, October 8-11, 2023, Honolulu, HI