Successful closure of intractable tracheoesophageal fistula using a combination of a modified silicon stent and metallic stents
A 70-year-old man with hepatocellular carcinoma (HCC) underwent surgical resection, transarterial chemoembolization (TACE), percutaneous ethanol injection therapy (PEIT), and radiofrequency ablation (RFA). Although the primary tumor responded well, follow-up computed tomography (CT) scan demonstrated new pulmonary nodules.\nCT-guided biopsy confirmed pulmonary metastases from the HCC. Surgical treatment and radiotherapy was precluded by the multiple metastases within the right lung. Thus, local treatment was performed with bronchial arterial infusion (BAI) of epirubicin (30 mg), mitomycin (6 mg), and cisplatin (25 mg) via the right bronchial artery. One month later, a second BAI was given. Measurement of “protein induced by vitamin K absence or antagonist-II” (PIVKA-II) levels showed a decrease in the normal range.\nOne week after the second BAI, the patient developed back pain, chest pain, sputum production, and paroxysms of coughing after eating or drinking. Chest CT scan revealed a TEF between the mid-esophagus and the tracheal carina, and bronchoscopy demonstrated a fistula 1 cm in diameter located at the membranous portion of the carina (Fig. ).\nThe patient was established on total parenteral nutrition (TPN) and treated conservatively. Repeat examination revealed that the wall of the fistula had completely epithelialized. The patient declined surgical management, and thus, a silicon tracheobronchial tube stent (Dumon Y-stent, Novatech, La Ciotat, France; 110 mm in length and 16 mm in outer diameter [OD] for trachea, 50 mm in length and 13 mm in OD for each bronchus, cut to 30 mm for trachea and 20 mm for right bronchus and 30 mm for left bronchus in length) was placed in the carina using a rigid scope under general anesthesia on four months after the final diagnosis. However, the stent did not fit the carina adequately, and the fistula remained patent.\nAfter retrieving the tracheobronchial stent, further treatment was attempted through the use of metallic coils and cyanoacrylate glue (n-butyl cyanoacrylate [NBCA], Histoacryl-Blue, Braun, Melsungen, Germany), but these measures were also unsuccessful because the esophagus had dilated focally with a large diverticulum communicating directly with the carina without having a defined tract (Fig. ). Thus, application of any occlusive or adhesive would subsequently fall into the bronchial or esophageal lumen.\nFifteen months after the final diagnosis, the next attempt at treatment consisted of a retrievable and fully covered esophageal stent (16 × 140 mm Niti-S Esophageal Covered Stent; Taewoong Medical, Seoul, Korea) which was fixed externally to prevent migration. This was achieved by a transcervical approach in which the stent was fixed into place by tying the distal end of the stent to the dermis of the neck. Again, the fistula remained patent because of a gap between the stent wall and the dilated diverticulum-like esophageal wall. During these failures to close the fistula, the patient experienced recurrent aspiration pneumonia.\nTwo years after the final diagnosis, the esophageal stent was retrieved, and airway stenting was attempted using a combination of a modified silicon stent (TM Y-stent, Fuji Systems, Tokyo, Japan; 100 mm in length and 16 mm in OD for the trachea; 50 mm in length and 13 mm in OD for each bronchus, cut to 30 mm for trachea and 20 mm for right bronchus and 30 mm for left bronchus in length) and two bare metallic stents (Gianturco Z-stent, Cook Inc., Bloomington, IN, USA; 20 mm in diameter). A modified Y-shaped silicon stent was constructed by creating a longitudinal center cut to fit the tracheal and the bronchial lumens. The tube stent was introduced into the trachea by a rigid scope under general anesthesia and was placed at the carina so that the center cut faced forward. Next, two bare metallic stents were placed within the tube stent to expand its lumen (Fig. ). This technique resulted in close approximation between the silicone tube stent wall and the tracheobronchial wall, successfully covering the fistula. No immediate or short-term complications were noted.\nFollowing this procedure, aspiration remitted, and there was no leakage through the fistula by esophagography. Following swallowing-training by a qualified therapist, the patient began to eat a soft diet and was discharged. However, he died of HCC four months after the final procedure. During the follow-up period, there were no findings of aspiration pneumonia.