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J Thorac Cardiovasc Surg 1994;108:595-596
© 1994 Mosby, Inc.

LETTERS TO THE EDITOR

Treatment of malignant tracheoesophageal fistula with an endotracheal silicone prosthesis in a patient with lymphoma

Thoracic Surgery Service^a

To the Editor:

The treatment of malignant tracheoesophageal fistula (TEF) must be as conservative as possible because aggressive methods yield poor results. This is important in patients with active mediastinal lymphoma, because TEF may develop during the treatment of the disease. We report the case of a 15-year-old boy who experienced this complication.

A 15-year-old boy was seen in another center because of a mediastinal mass observed on a roentgenogram and a thoracoabdominal computed tomographic scan. A biopsy was performed and the anatomopathologic diagnosis was Hodgkin's disease (the nodular sclerosing variety). Treatment with polychemotherapy and radiotherapy was begun.

During this treatment the patient began having fever, coughing related to food intake, regurgitation of food, nausea, and weight loss. Computed tomography of the chest showed a large TEF in the middle third posterolateral wall of the trachea. An examination with a fiberoptic bronchoscope showed a 15 mm TEF and distal tracheal stenosis. The boy was then switched to parenteral nutrition.

An endotracheal silicone prosthesis (Dumon type) was inserted with the aid of a rigid bronchoscope. Two days later an oral soluble contrast medium was administrated and leakage was not observed. Normal nutritional intake was begun and the patient did not have any symptoms. Five weeks later a barium swallow showed no sign of leakage of barium into the trachea. At present the patient has progression of Hodgkin's disease into the mediastinum and lungs, but he can eat normally. The TEF is not anatomically closed, but the endotracheal prosthesis allows mechanical closure between the esophagus and the trachea.

The prognosis for patients with TEF complicating malignant disease of the thorax is poor. In a 1970 report from the Memorial Sloan-Kettering Cancer Center, the immediate cause of death in 95 (85.6%) of 111 patients was pulmonary or esophageal aspiration pneumonia and poor food intake. ⁴ Pulmonary or esophageal carcinoma frequently causes this serious complication.

A review of the literature suggests that patients with lymphoma and TEF have a better prognosis than those with carcinoma of the esophagus or lung. Patients with Hodgkin's disease can expect to have a complete remission rate of greater than 80% with radiation or chemotherapy or a combination of the two. ⁵

An aggressive surgical approach to TEF gives poor results in carcinoma, and it is not clearly indicated in active Hodgkin's disease. The treatment must be individualized in these patients. Small fistulas without repeated aspiration pneumonia do not require immediate surgical repair ³ and therefore may be treated with radiation or chemotherapy, with the expectation that many will close.

An important aspect in this disease is long-term nutrition. Resolution of the TEF by gastrostomy, jejunostomy, or with a catheter has been proposed. However, these surgical treatments are sometimes aggressive, both physically and psychologically, particularly in young people. On the other hand, functional and mechanical closure of the TEF by means of several options has been proposed, with an important morbidity and mortality. ³ The endotracheal prosthesis provides two important function: the functional diversion of the TEF and, in our case, the treatment of the associated tracheal stenosis. Natural nutrition can be started quickly and parenteral nutrition can be withdrawn, decreasing the risk of associated infection. The use of an endotracheal silicone prosthesis is, in our opinion, a good alternative in the treatment of patients with lymphoma and TEF.

References

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2. Zenny JC, Grenier PH, Favier H, Bernard JF, Nahum H. Fistule oeso-tracheale revelatrice d'une maladie de Hodgkin. J Radiol 1981;62:191-5.[Medline]
   
3. Perry R, Rosenberg R, Pass H. Tracheoesophageal fistula in the patient with lymphoma: case report and review of the literature. Surgery 1989;105:770-7.[Medline]
   
4. Martini N, Goodner JT, D'Angio GJ, Beattie EJ Jr. Tracheoesophageal fistula due to cancer. J THORAC CARDIOVASC SURG 1970;59:319-24.[Medline]
   
5. Longo D, Young R, Wesley M, et al. Twenty years of MOPP therapy for Hodgkin's disease. J Clin Oncol 1986;4:1295-1306.[Abstract/Free Full Text]
   

This Article Alert me when this article is cited Alert me if a correction is posted Services Email this article to a friend Similar articles in this journal Similar articles in PubMed Alert me to new issues of the journal Add to Personal Folders Download to citation manager Permission Requests Citing Articles Citing Articles via Google Scholar Google Scholar Articles by Pac-Ferrer, J. Articles by Vara, F. Search for Related Content PubMed PubMed Citation Articles by Pac-Ferrer, J. Articles by Vara, F.