Treatment Options for Bronchoesophageal Fistula

The placement of an esophageal and/or tracheo-bronchial stent constitutes the standard treatment for bronchoesophageal fistulas. 1

Diagnostic Approach

CT imaging is the primary diagnostic tool for suspected bronchoesophageal fistula, helping to identify the fistulous communication, extension to adjacent structures, and guide initial therapy 1
Diagnostic endoscopy is useful in patients with suspected fistula and doubtful CT findings, but should be performed with caution due to risks of enlarging the perforation 1
The presence of periaortic gas bubbles in an at-risk patient is suggestive of the diagnosis, even when a definite fistulous communication is not visible 1
Angiography or bronchoscopy may demonstrate a fistula but must be performed with extreme caution, as they could potentially dislodge a clot and induce massive hemorrhage 1

Secure the airway with a single-lumen endotracheal tube in patients with large volume hemoptysis 1
Administer broad-spectrum antibiotics covering aerobic and anaerobic bacteria 1
Keep patients nil per os and initiate proton pump inhibitor therapy 1
Early introduction of nutritional support by enteral feeding or total parenteral nutrition is essential for healing 1

Endoscopic stenting (esophageal and/or airway) is the treatment of choice 2
- Fully covered self-expandable metal stents (FC-SEMS) are recommended 2
- Depending on the location of the fistula and presence of airway stenosis, tracheal stenting, esophageal stenting, or parallel stenting of both may be required 2
Surgical intervention is rarely advisable due to advanced malignancy and poor performance status 3

Surgical management is generally preferred for benign fistulas in patients fit for surgery 2, 4
- Options include:
  - Resection of fistula with primary repair 4
  - Pneumonectomy and repair of leak (for extensive lung involvement) 4
  - Esophagectomy with reconstruction in complex cases 4
For patients unfit for surgery, silicone stents should be used as they can be more easily removed after healing compared to metal stents 2
Endoscopic approaches may be considered in select cases:
- Endoscopic laser therapy combined with stenting has shown success in some cases 5
- Endoluminal vacuum therapy represents a promising alternative treatment 1

For aortobronchial fistulas (a rare variant), thoracic endovascular aortic repair (TEVAR) may be considered preferable to open surgical therapy 1
For patients with late presentation or non-endoscopic fistulas, endoscopy as first-line therapy may be considered, though caution is warranted 1
Non-operative management can be considered in stable patients with early presentation, contained disruption, and minimal contamination if highly specialized surveillance is available 1

After stent placement, patients should be monitored for:
- Stent migration
- Bleeding of the upper gastrointestinal tract
- Secretion retention and obstruction 2
Lifelong suppressive antibiotic therapy may be considered when a foreign body (stent) is placed in an infected area 1
Regular follow-up is essential to monitor for recurrence of the fistula 1

Successful stent placement leads to immediate palliation of symptoms such as cough or aspiration and results in higher quality of life 2
Untreated fistulas have a mortality rate approaching 100% 1
Recurrence rates after endovascular treatment range from 9-60% depending on the etiology and whether the device is eventually explanted 1

Diagnostic procedures like bronchoscopy must be performed with extreme caution as they could potentially dislodge a clot and cause fatal hemorrhage 1
Stent migration is a common complication that may require reintervention 2
The presence of a fistula should be suspected in patients with underlying risk factors who present with sepsis and hemoptysis 1
A high index of suspicion is vital for accurate and prompt diagnosis 1