Treatment of Postoperative Esophagorespiratory Fistulas with Dual Self-Expanding Metal Stents

Background  Fistulas between the esophagus and the respiratory tract can occur as a complication to anastomotic dehiscence after esophageal resection. The traditional therapeutic approach is to deviate the proximal portion of the esophagus and transpose the conduit into the abdominal cavity. With the introduction and development of self-expandable metal stents (SEMS), new therapeutic options have emerged for these severe complications. Methods  One hundred sixty-seven consecutive esophageal resections were reviewed to address the outcome of a stent-based therapeutic strategy in cases with esophagorespiratory fistulas. The patency of each anastomosis was checked only at the time of clinical suspicion of leakage but then radiology, endoscopy, and bronchoscopy were used together. Results  Seven patients developed esophagorespiratory fistula. All of these fistulas were diagnosed more than 1 week after the operation. Two patients (27%) died due to the fistula. Four could be successfully treated but in two of these we were forced to change strategy and either perform a colonic interposition or externalize the esophagus. One of these patients subsequently developed total respiratory failure and required extracorporal membrane oxygenation (ECMO) to recover. Conclusions  When an esophagorespiratory fistula is diagnosed, an attempt to close the fistula tract by SEMS from both the esophageal and the respiratory side is a feasible treatment option. This strategy has to be prolonged and aggressive with a commitment to repeatedly change stents and modify sizes and designs. Thereby a majority of these patients can be managed conservatively with prospects of a successful outcome.