New Cufflink-Shaped Silicon Prosthesis for the Palliation of Malignant Tracheobronchial-Esophageal Fistula

Abstract

Malignant tracheoesophageal fistula (MTEF) account for more than 50% of all acquired aerodigestive fistulae. It mainly arises from esophageal and lung cancers, and always represent a therapeutic dilemma. The main objective of therapy is minimization of tracheobronchial contamination maintaining appropriate nutrition. To achieve these goals, many palliative measures are available. We present a case of a patient with a MTEF who was successfully treated with a cufflink-shaped silicon prosthesis designed to occlude both orifices of the MTEF. We believe that this prosthesis offers a new treatment option and has potential in the management of MTEF.Key Words: tracheoesophageal fistula, palliative treatment, cufflinkshaped silicon prosthesis (J Bronchol 2005;12:207-209) M alignant tracheoesophageal fistula (MTEF) is a serious complication of cancer arising in the esophagus, lung, or tracheobronchial tree. Approximately 77% of MTEF are related to esophageal cancer, whereas approximately 16% are originated from a primary lung neoplasm. Other tumors represent only a small percentage of this problem: malignant mediastinal node disease, thyroid and laryngeal carcinoma.Poor nutrition, repeated aspiration to the airway, and episodes of pneumonia lead to rapid deterioration and death if this condition is left untreated.Treatment is usually palliative and involves restoration of the swallowing mechanism and prevention of aspiration. In most cases, treatment is individualized and includes esophageal stenting, tracheobronchial stenting, simultaneous stenting of both the trachea and esophagus, esophageal exclusion, esophageal bypass, fistula resection and repair, and radiation therapy. 1,2 Prosthesis placement is considered to be appropriate for most patients with MTEF. A variety of stents have been used for this purpose; silicon and both covered and uncovered selfexpandable metallic prosthesis are commonly indicated. Because insertion of a single device may be insufficient for palliation, parallel stenting of the airway and esophagus is the preferred treatment by many physicians. The procedure is usually well tolerated by debilitated patients, it avoids more aggressive procedures, and it generally results in appropriate closure of the fistula and improvement of dyspnea, dysphagia, cough, and episodes of aspiration pneumonia. [2][3][4][5][6][7][8][9] Results, however, are temporary and complications such as wall erosion, bleeding, perforation, mediastinitis, pneumothorax, and vascular fistulas may develop. 2-4,6-9 We have designed a new cufflink-shaped soft silicon prosthesis directed to occlude the aerodigestive connection (Fig. 1). The prosthesis (DJ silicon prosthesis, Barcelona, Spain); can be safely placed under direct vision using a rigid bronchoscope and an alligator forceps.The DJ prosthesis is made of soft silicone in the shape of a cufflink. It comes in different sizes: 2, 3, 4, and 5-mm diameter for the central axis, whose length is also variable (3, 4, and 5-mm long). The lateral wings are 2 or 3 cm in diameter. The s...