Malignant tracheoesophageal fistula*

TEF: tracheoesophageal fistula.
* Initial general measures that should be undertaken include eliminating oral intake, keeping the head of the bed elevated at 45 degrees or greater, administering anti-reflux therapy, frequent oral suctioning, treating pulmonary infection/aspiration pneumonia, supplemental oxygenation (if indicated), removal of nasogastric tubes and hyperalimentation either with a jejunostomy tube or total parenteral nutrition. If patients are receiving mechanical ventilation, extubation is preferable but is not always feasible. Efforts targeted at treating the underlying cause should be simultaneously undertaken (eg, radiation or chemotherapy).
¶ The location of the TEF will dictate whether double stenting of both the esophagus and airway is required. Stenting TEFs in the proximal or mid esophagus can result in airway compromise, so TEFs in those locations typically require double (esophageal and airway) stenting. TEFs in the distal esophagus can often be treated with a single esopageal stent because TEFs in the distal esophagus are not associated with airway compromise.
Δ For patients with concomitant airway stenosis, double stenting with both esophageal and an airway stent is also appropriate. If an esophageal stent is not feasible, an airway stent alone may be placed.
◊ In the event that either an airway or esophageal stent is not feasible, an esophaegeal or airway stent may be placed alone, understanding that therapy is not optimal and that complications may occur (eg, airway compromise due to an esophageal stent).
§ Local therapies include endoscopic clipping, tissue adhesive, and fibrin glue. Choosing among local therapies is dependent upon local expertiseand is less successful in malignant lesions when compared with benign lesions.