Bronchoscopic Stenting of a Tracheoesophageal Fistula

A gentleman in his 60s with advanced oesophageal cancer (cT4bN1M0) and extensive nodal disease developed a malignant tracheoesophageal fistula (TEF). Due to the presence of the fistula, he was not a candidate for radiotherapy given the high risk of exacerbating the defect. 

He completed five cycles of 5-fluorouracil (5-FU)-based chemotherapy and was on maintenance pembrolizumab administered every six weeks. Clinically, he presented with a persistent cough, aspiration during swallowing, and recurrent chest infections, which were consistent with a symptomatic TEF. 

Given the severity of airway contamination and respiratory compromise, a decision was made to proceed with bronchial stenting for airway protection. 

Indications for Airway (Bronchial) Stenting:

Bronchial stenting in the context of malignant TEF is indicated for: 

• Airway protection from ongoing aspiration  

• Symptomatic relief of cough and respiratory distress  

• Prevention of recurrent aspiration pneumonia  

• Maintenance of airway patency in cases of concomitant airway compression  

• Palliative management in advanced malignancy  

In this case, airway stenting was prioritized due to significant respiratory symptoms and the risk of ongoing pulmonary contamination. 

Contraindications to Bronchial Stenting Include:

• Inability to safely access or deploy the stent bronchoscopically  

• Extensive airway necrosis or destruction precluding stent anchorage  

• Severe, uncontrolled coagulopathy  

• Extremely limited life expectancy where intervention would not provide symptomatic benefit  

• Active, uncontrolled infection without stabilization  

This patient was deemed suitable for bronchial stenting given persistent symptoms and reasonable functional status. 

Procedure Overview 

The procedure was performed under bronchoscopic guidance. The fistula was identified within the airway, and the involved bronchial segment was assessed. 

A guidewire was introduced, followed by the deployment of a covered self-expanding bronchial stent across the fistulous opening. The stent was positioned to fully cover the defect while preserving airflow to the distal lung segments. 

Care was taken to ensure optimal expansion and apposition to the airway wall, effectively isolating the fistula from the bronchial lumen. A final bronchoscopic assessment confirmed appropriate positioning and adequate sealing. 

Brief Discussion 

Malignant tracheoesophageal fistula represents a life-threatening complication due to continuous airway contamination. While esophageal stenting is often considered, airway stenting plays a critical role when respiratory compromise predominates or when airway involvement is significant. 

Bronchial stenting provides immediate protection of the airway, reduces aspiration, and improves respiratory symptoms. In selected cases, it may be used alone or in combination with esophageal stenting, depending on the anatomy and clinical priorities. 

A multidisciplinary approach is essential to determine the optimal strategy and improve patient outcomes in this challenging condition. 

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