Document Type

Conference Proceeding

Publication Date

5-2-2025

Abstract

Tracheoesophageal fistula (TEF) is a pathological connection between the trachea and esophagus. It is a rare but serious complication following esophagectomy, particularly in patients who have undergone concurrent radiation therapy, with rates of 5-15%. TEFs often manifest with severe complications such as malnutrition, infections, and life-threatening bleeding, making them exceptionally difficult to manage. This case report highlights a rare presentation of TEF in a patient with esophageal adenocarcinoma treated with multimodal therapy. A 45-year-old male with stage III esophageal adenocarcinoma underwent concurrent chemoradiation, esophagectomy, and immunotherapy. Subsequent oligometastatic disease required further treatment, including radiofrequency ablation and Keytruda maintenance. The patient later presented with syncope, anemia, hypotension, and tachycardia. CT thorax was concerning for a contained esophageal perforation in the right paratracheal region with gas and food material. The patient subsequently developed severe hemoptysis and hematemesis, necessitating airway protection via intubation. Bedside bronchoscopy identified blood products in both airways but no active bleeding source. Mesenteric and thoracic angiography showed no evidence of an active bleed. Endoscopy revealed a large TEF approximately 20 cm from the incisors, located at the mid-trachea. Definitive surgical repair was deemed unfeasible due to the fistula’s size, location, and tissue fragility from prior treatments. Conservative measures included a tracheostomy with balloon placement distal to the fistula and strict NPO status to minimize further damage and allow time for potential spontaneous healing. Unfortunately, the tracheostomy tube dislodged into the fistula, causing hypoxia and bradycardia, requiring emergent reversal and endotracheal tube replacement. Despite repeated interventions, the patient experienced recurrent bleeding and airway compromise. Ultimately, catastrophic bleeding led to severe hypoxia and cardiac arrest, with the family opting for comfort measures, and the patient passed away shortly thereafter. Tracheoesophageal fistula (TEF) is a severe complication of esophagectomy and radiation therapy, with mortality rates reaching 40% due to due to sepsis, airway obstruction, and other complications. Early diagnosis is essential for preventing lifethreatening complications. In our case, diagnosis was confirmed via combination of bronchoscopy and endoscopy. Management of TEF focuses on stabilizing the patient and addressing the structural defect. Initial conservative measures, such as tracheostomy adjustments and parenteral nutrition, are implemented to minimize further damage and facilitate healing. However, definitive treatment often necessitates surgical intervention, including tracheal resection and esophageal closure using tissue flaps. Alternatively, stenting can offer symptom relief and improve quality of life. However, outcomes remain poor for patients with significant tissue damage or advanced malignancy. In our case, due to the patient's history of radiation, radiofrequency ablation, the location of the injury, and prior surgical repair, thoracic surgery determined that surgical intervention had a very low likelihood of success. A distal tracheostomy with balloon placement below the injury site, along with abdominal enteric feeding, was considered the best approach from a surgical perspective. Despite these measures, complications persisted, highlighting the limitations of current strategies. This case emphasizes the critical need for advancements in diagnostic tools, minimally invasive therapies, multidisciplinary approach and individualized treatment strategies to improve outcomes for patients with TEF.

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American College of Physicians Michigan Chapter and Society of Hospital Medicine Michigan Chapter Resident and Medical Student Day, May 2, 2025, Troy, MI

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