How is acquired malignant tracheoesophageal fistula (TEF) treated surgically?

Updated: Nov 07, 2018
  • Author: Sat Sharma, MD, FRCPC; Chief Editor: Vinay Kumar Kapoor, MBBS, MS, FRCS, FAMS  more...
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Answer

More than 75% of the patients with TEFs secondary to tracheal intubation require tracheal resection because of circumferential damage to the trachea. Mechanical ventilation following tracheal reconstruction is contraindicated because of excessive risk of tracheal dehiscence.

In patients who present within 2-3 days after onset and are in good general condition, offer gastric bypass with esophageal exclusion. Esophageal exclusion may be performed by cervical esophagostomy and gastrostomy, with closure of the esophagus above and below the fistula. This procedure may still not prevent pulmonary sepsis and death in many individuals.

Esophageal endoprosthesis

Note the following:

  • Placement of an esophageal endoprosthesis has been used to palliate patients with malignant TEFs. A variety of stents are currently available; these include plastic stents (eg, Medoc, Atkinson, Celestin) and covered self-expanding metallic stents (SEMS). [19] Some authors have proposed the esophageal stents as the first line of therapy for malignant strictures associated with a TEF.

  • The placement of an endoprosthesis may be complicated by an inability to see the endoprosthesis well, enlargement of the TEF, and ongoing contamination of the respiratory tract. Other complications associated with esophageal stents include migration, obstruction, ulceration, esophageal necrosis, and delayed perforation. Insertion of plastic stents requires aggressive dilatation.

  • Airway stents are also being placed to prevent contamination of the respiratory tract.


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