Broncho-esophageal fistula: Successful surgical repair after failed esophageal stent

Introduction: Acquired broncho-esophageal fistulas are uncommon and typically malignant in origin. Because of their location, they are difficult to treat and involve complicated repairs with equivocal results. Prior treatment with self-expanding stents when not successful, makes the management even more complicated. Patients and methods: In a three-year period, three patients were seen with acquired broncho-esophageal fistulas of non-malignant origin. One of them was following trauma and erosion of a self-expanding plastic stent that was inserted for esophageal perforation. The second patient had tubercular lymphadenitis with erosion in to esophagus and left bronchus while the third followed long term impaction of a denture and a difficult endoscopic extraction. All the three had failed self-expanding stents as a treatment to bridge the fistula, over a varying period of time (three months to three years) and had expanded to 1.5 cm to 2.5 cm in diameter. All the fistulas were between the esophagus and left bronchus. Results: After the fistula was localized, the problem was addressed by a thoraco-laparotomy, direct incision over the stent, piece-meal removal of the self-expanding plastic stent that was in shreds and stapling the collapsed esophagus on either side of the fistula, leaving the esophageal remnant to bridge the communication. Following success of this manoeuvre, the same technique was applied primarily to the next two patients with successful results. At a follow-up of 1-3 years, all the three patients are symptom free. Conclusion: Long standing self-expanding stents used for benign esophageal fistulas may result in erosion to the bronchial tree or aggravation of the existing fistulas and require innovative management to avoid complicated repairs with high failure rates