Stent Stunts: Use of Telescoping Tracheal Stents to Tamponade a Tracheoesophageal Fistula Complicated by a Wandering Esophageal Stent

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INTRODUCTION: Malignant tracheoesophageal fistula (TEF) can be a major source of morbidity and mortality in patients with esophageal or lung cancer. Surgery with curative intent is generally not recommended nor feasible for malignant TEF. These patients are instead treated palliatively with endoscopic stenting of the esophagus, airway, or both. Rarely, placement of selfexpanding metal stents (SEMS) can lead to severe and life-threatening complications, including the creation of a new fistula, or expansion of an existing defect. We present a case of telescoping tracheal stents used to protect the airway against a wandering esophageal SEMS. CASE PRESENTATION: A 49-year-old female with a history of esophageal squamous cell carcinoma presented with dyspnea, fever, and dysphagia, and was admitted for aspiration pneumonia. Upper endoscopy revealed a completely obstructing proximal esophageal mass, and a 10 mm TEF. A fully-covered SEMS was deployed across the mass and TEF. She continued her radiation therapy but suffered persistent symptoms. An esophagram revealed contrast leakage from the proximal end of the esophageal stent into the left mainstem bronchus (Figure 1). A repeat upper endoscopy showed extension of the TEF to 25 mm and esophageal stent exchange was performed. Progressive hypoxemic respiratory failure and new onset stridor ensued, requiring intubation. Bronchoscopy revealed a large TEF of 40 mm with esophageal stent rupture into the trachea, causing moderate obstruction (Figure 2). She underwent rigid bronchoscopy for deployment of two telescoping tracheal SEMS with resultant airway patency and a completely covered TEF (Figure 3). The patient was subsequently extubated to supplemental oxygen. She ultimately elected to pursue hospice care after continued discussions. DISCUSSION: Stent-related TEF with airway encroachment is a rare and catastrophic delayed complication of esophageal SEMS placement, with an increased risk in patients who receive radiation after stent placement. Literature describing the management of this highly fatal entity is limited to case reports detailing the deployment of airway stents in order to displace the esophageal stent and seal the defect – similar to the strategy used for our patient. Due to the significant mortality associated with this complication, double stenting of both the esophagus and the airway is considered to be a first-line preventative approach in patients with malignant TEF involving the mid-to-proximal esophagus. Though primarily intended for palliation, double stenting has been associated with improved survival when compared with airway stenting alone. CONCLUSIONS: To our knowledge, no studies to date have examined the safety and efficacy of airway stenting as a means to tamponade intrusive esophageal SEMS. Further investigation into this strategy is needed to improve future patient outcomes




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