Management of aero-digestive fistulas in adults: the bronchoscopist’s perspective

Abstract

Aero-digestive fistulas (ADFs) are pathologic connections between the airways and gastrointestinal system. These most commonly occur between the central airways and esophagus. Fistulas may develop congenitally or be acquired from a benign or malignant process. Most fistulas presenting in adulthood are acquired, with similar rates of benign and malignant etiologies. Symptoms may severely impact a patient’s quality of life and result in dyspnea, cough, and oral intolerance. ADFs have been associated with increased mortality, often related to pneumonias and malnutrition. Management is multifaceted and includes a multidisciplinary approach between the pulmonologist, gastroenterologist, and thoracic surgeon. While definitive management can be achieved with surgery, this is typically reserved for benign causes as surgical repair is often impractical in patients with advanced malignancies. With malignant causes, less invasive endoscopic and/or bronchoscopic interventions may be indicated. Stenting is the most common non-surgical invasive intervention performed. Stents can be placed in the esophagus, airway, or both. There is limited data that suggests outcomes may be better when esophageal stenting is performed with or without airway stenting. Airway stents are indicated when there is airway compromise, inadequate sealing of the fistula with an esophageal stent alone, or when an esophageal stent cannot be placed. This review will provide an overview of approaching ADFs from the bronchoscopist’s perspective.

A Successful Treatment of Broncho-Esophageal Fistula with Esophageal Stenting Using Direct Endoscopic Visualization

“…Malignancy-associated broncho-esophageal fistulas may occur due to tumor infiltration and subsequent rupture, or as a result of radiation, laser therapy, chemotherapy, pre-existing stents (particularly esophageal stents), or a combination of these factors [3]; however, compared to tracheoesophageal fistulas, they are much rarer, with very few cases reported in the medical literature, which makes their diagnosis either delayed or inaccurate [4]. Additional causes of delayed diagnosis are the nonspecific and common symptoms such as cough, dysphagia, signs of aspiration, chest pain, or gastroesophageal reflux that may, however, severely impact the patient's quality of life [5]. Most malignant broncho-esophageal fistulas develop as a complication of esophageal cancer, being present in 5-10% of affected patients; in lung cancers, this complication is much less frequently encountered and develops mainly for squamous cell carcinomas [4].…”