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Ann Thorac Surg 1999;67:830-831
© 1999 The Society of Thoracic Surgeons

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Case Reports

Tracheoesophageal fistula caused by a self-expanding esophageal stent

^a Genesis Healthcare System, Zanesville, Ohio, USA

Accepted for publication August 6, 1998.

Address reprint requests to Dr Schowengerdt, 1246 Ashland Ave, Zanesville, OH 43701
e-mail: schowe{at}msmisp.com

	Abstract

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A patient is presented who had previously undergone an esophagectomy for an adenocarcinoma of distal esophagus. He experienced repeated strictures at the esophagogastric anastomosis at 22 cm. After multiple dilatations, a self-expanding metal stent was placed. Four months later the upper edge of the stent eroded through the esophagus into the trachea, forming a tracheoesophageal fistula. Muscle flap repair was successful.

	Introduction

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Both covered and noncovered self-expanding metal stents are now widely used for the treatment of dysphagia secondary to esophageal carcinoma as well as for the treatment of malignant tracheoesophageal fistula. The success rate of these stents is reported to be high and the complication rate low. The use of these stents has recently been expanded to include treatment of proximal esophageal stenoses [1]. Causation of a tracheoesophageal fistula has not been one of the recognized complications of these stents.

A 64-year-old man presented in 1992 with a past history of severe ulcer disease and, on screening laboratory studies, a low iron level. He had smoked for 40 years and had also used chewing tobacco. He was taking an oral hypoglycemic for control of diabetes and a hydrocodone-acetaminophen preparation for control of back pain. An aortobifemoral bypass graft had been performed in the past for control of claudication.

Barium swallow demonstrated a large filling defect in the distal esophagus. Endoscopy revealed an anterior tubal mass at 35 cm extending down to 40 cm. It did not extend into the stomach. Multiple biopsies revealed the presence of a mucinous adenocarcinoma. Computerized tomography of head, chest, and abdomen as well as bone scan did not show any evidence of metastatic disease. A transhiatal esophagectomy with pyloroplasty and jejunostomy was performed in January 1993, transposing the stomach to the neck to reconstitute gastrointestinal continuity. Pathologic specimens showed a moderately differentiated adenocarcinoma of esophagogastric junction extending into the muscularis. Six nodes were negative for metastases.

Postoperatively stenoses occurred repeatedly at the esophagogastric anastomosis in the neck. On nine separate occasions during the next 10 months, balloon, bougie, or Savary dilatations were necessary to correct a severe stenosis. The patient thereafter was able to maintain his weight without significant dysphagia until July 1997, at which time extraction of a meat foreign body was performed. Additional balloon and bougie dilatation was done. After an additional episode of stenosis, an esophageal coated stent was placed in August 1997 (Wallstent, Schneider, Inc, model 44010, diameter 20 mm, length 10 cm) The upper edge of the stent was placed in the cervical esophagus at 20 cm, 2 cm above the stenosis at 22 cm, and below the upper esophageal sphincter.

The patient was thereafter able to eat well and gained weight until presenting in January 1998 with a 2-month history of dysphagia and weight loss. He had a 2-week history of shortness of breath and severe coughing spells. Esophagogastroduodenoscopy revealed a functional upper esophageal sphincter and a patent stent from 23 to 33 cm. Moderate bile reflux gastritis was present. Bronchoscopy revealed extension of the upper edge of the esophageal stent through the cervical esophagus and posterior membranous wall of the trachea forming a tracheoesophageal fistula (Fig 1). A nasogastric tube was endoscopically guided and a subclavian catheter placed. Decompression and parental nutrition were performed. A right thoracotomy was then used to extract the esophageal stent through a gastrotomy, dissect the fistula free, repair the transposed stomach, and close the tracheal defect with a latissimus muscle flap. The patient was discharged eating well and has subsequently had no further dysphagia.

View larger version (110K): [in this window] [in a new window]   Fig 1. Anterior upper edge of stent eroding through posterior membranous wall of upper trachea.

	Comment

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The transposed stomach represents additional risk of perforation from a self-expanding stent. The wall is thinner, with more questionable vascular supply. There is additional risk in the anatomic area where trachea and esophagus are adjacent, particularly at the flanged tip of a self-expanding wire prosthesis.

Although placement of a self-expanding stent may be possible in the proximal esophagus without complication, it may be extremely hazardous to bridge a stenosis between the cervical esophagus and transposed stomach.

	References

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1. Gislasen G.T., Pasricha P.J. Crossing the upper limit: esophageal stenting in the proximal esophagus. Dysphagia 1997;12:84-85.[Medline]
2. Song H., Do Y., Han Y., et al. Covered, expandable esophageal metallic stent tubes: experiences in 119 patients. Radiology 1994;193:689-695.[Abstract/Free Full Text]
3. Kozarek R.A., Raltz S., Brugge W.R., et al. Prospective multicenter trial of esophageal Z-stent placement for malignant dysphagia and tracheoesophageal fistula. Gastointest Endosc 1996;44:562-567.

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This Article Abstract Full Text (PDF) Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Author home page(s): Carl G. Schowengerdt Permission Requests Citing Articles Citing Articles via HighWire Citing Articles via Google Scholar Google Scholar Articles by Schowengerdt, C. G. Search for Related Content PubMed PubMed Citation Articles by Schowengerdt, C. G.