Bronchoesophageal fistula (BOF) is a rare but severe complication following Ivor-Lewis esophagectomy, often leading to aspiration pneumonia and acute respiratory distress syndrome (ARDS), creating significant diagnostic and management challenges. We report a case of a man who developed BOF 26 days postoperatively, initially diagnosed as hospital-acquired pneumonia. Rapid respiratory deterioration led to intensive care unit (ICU) admission, where persistent air leaks prompted bronchoscopic confirmation of BOF. Despite endoscopic stenting and lung-protective ventilation, severe ARDS necessitated interim veno-venous extracorporeal membrane oxygenation (vv-ECMO). Unfortunately, the patient developed multiorgan failure and succumbed after 34 days on ECMO. This case underscores the importance of early diagnosis, multidisciplinary management, and balancing ventilatory strategies to support both ARDS treatment and fistula healing. BOF should be suspected in postesophagectomy patients with respiratory symptoms, even with initially negative contrast studies, and managed promptly with customized ventilation, early fistula repair, and timely ECMO support to optimize outcomes.

Broncho-esophageal fistula (BEF) is a severe yet relatively rare connection between the bronchus and esophagus usually caused by esophageal and pulmonary malignancies. We present a case report of a 49-year-old man diagnosed with terminal lung carcinoma who developed a BEF. The thoracic computed tomography scan detected a mass in the left bronchi that partially covers and disrupts the bronchial contour in certain regions and extends to the esophageal wall. After thoroughly evaluating alternative treatment approaches, we opt for the stenting procedure due to the advanced stage of the tumor and the significantly diminished quality of life. The treatment involves the use of a partially covered metal stent that is known to exhibit lower potential to migrate. The treatment is highly successful, resulting in a significant enhancement of the patient's quality of life, a lengthening in his survival, and the ability to pursue additional palliative treatment options. In contrast to the typical prosthesis implantation, our procedure uses a direct endoscopic visualization for the proximal deployment of a partially covered stent, offering a cost-effective and radiation-free alternative that can be particularly beneficial for BEF patients in facilities without radiology services.

(1) Background: Esophago-airway fistula after esophageal resection is a rare, life-threatening complication associated with a high postoperative mortality rate. Managing this condition is challenging, and the prognosis for patients is uncertain. The results and our own approach to treatment are presented. (2) Material and Methods: We present a retrospective analysis of a group of 22 patients treated for an esophago-airway fistula between 2012 and 2022, with 21 cases after esophageal resection and one during the course of Hodgkin's disease. (3) Results: Twenty-two patients were treated for an esophago-airway fistula. Among them, a tracheobronchial fistula occurred in 21 (95.4%) patients during the postoperative period, while 1 (4.5%) was treated for Hodgkin's disease. Of these cases, 17 (70.7%) patients underwent esophageal diversion with various treatments, including intercostal flap in most cases, greater omentum in one (4.5%), latissimus dorsi muscle in two (9%), and greater pectoral muscle in one (4.5%). Esophageal stenting was performed in two patients (9.0%), and one (4.5%) was treated conservatively. Unfortunately, one patient (4.5%) died after being treated with bronchial stenting, and two (9.5%) experienced a recurrence of the fistula. (4) Conclusions: The occurrence of an esophago-airway fistula after esophagectomy is a rare but life-threatening complication with an uncertain prognosis that results in several serious perioperative sequelae.

Esophagobronchial and esophagotracheal fistulas are rare but complex diseases with a heterogeneous spectrum of underlying etiologies. Common causes are locally advanced tumors of the esophagus and larynx, traumatic perforation from the esophageal or tracheal side as well as postoperative fistulas. The management of esophagotracheal and esophagobronchial fistulas always involves different health care providers and in most cases patients require a multidisciplinary treatment on the intensive care unit. The therapeutic concept primarily depends on the underlying cause, localization and size of the fistula but decision making is also influenced by the severity of the course of sepsis and the extent of the respiratory dysfunction. Endoscopic management with esophageal and/or tracheobronchial stenting is the most common treatment. Surgical reconstructive procedures are predominantly reserved for patients with a treatment refractory fistula or a septic multiple organ failure. The prognosis is particularly influenced by the underlying disease.

A tracheoesophageal fistula is the formation of an abnormal communication between the airway and the esophagus. Acquired tracheoesophageal fistulas can be benign or malignant. The management is either surgical or endoscopic depending on the etiology, size and anatomy of the fistula as well as on the patient's performance status. The interventional treatment of choice is endoscopic stent implantation. In general, tracheoesophageal fistulas in patients with benign conditions are managed surgically. If the patient is unfit for surgery silicone stents should be used because they can be more easily removed after a longer indwelling time compared to metal stents. Malignant fistulas are associated with very limited life expectancy of only a few weeks or months. In this situation fully covered self-expandable metal stents (FC-SEMS) are recommended, whereas surgical treatment approaches can only be considered in individual cases. Depending on the location of the fistula and the presence of an airway stenosis, tracheal stenting, esophageal stenting or parallel stenting of the trachea and the esophagus is carried out. Successful stent placement leads to immediate palliation of symptoms, such as cough or aspiration and results in a higher quality of life. Potential complications are stent migration, bleeding of the upper gastrointestinal tract, arrosion of neighboring organs and vessels with esophageal stents as well as secretion retention and obstruction with displacement of the airway with tracheobronchial stents.

Esophagotracheal and esophagobronchial fistulas are pathological communications between the airway system and the digestive tract, which often lead to major pulmonary complications with a high mortality. Endoscopic treatment is the primary therapeutic approach; however, in cases of failure early surgical treatment is obligatory.

This article describes the clinical course of patients with esophagotracheal and esophagobronchial fistulas treated in this hospital over a period of 10 years. Patients were retrospectively analyzed with respect to the etiology of fistulas, management, in particular to the operative procedures, complications and outcome.

Between 2009 and 2019, a total of 15 patients with esophagotracheal and esophagobronchial fistula were treated in this hospital. Of these 12 underwent an endoscopic intervention, of which 5 were successful. In total, eight patients needed surgical intervention, six of the eight surgically treated patients recovered fully, one had a recurrent fistula, which was successfully treated by subsequent endoscopy after surgery and one patient died.

Management of esophagotracheal and esophagobronchial fistulas is challenging. This retrospective analysis reflects the published data with a success rate of endoscopic treatment in approximately 50%. Surgical intervention should be carried out after unsuccessful endoscopic treatment or if endoscopic treatment is primarily not feasible. Direct closure with resorbable sutures or reconstruction with alloplastic or allogeneic material should be preferred. For larger defects or high proximal esophagotracheal fistulas local transposition of muscular flaps or free muscular flaps play a major role. During operative closure of high intrathoracic or cervical fistulas, intraoperative neuromonitoring can be useful to prevent nerve damage.